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Lower systolic BP target for black patients may confer greater cognitive benefit

Patients aged older than 70 who were undergoing hypertension treatment and had a systolic BP target of 120 mm Hg or lower had significantly greater cognitive benefit compared with those aiming for a higher target, according to findings recently published in JAMA Neurology.

“...Cognitive outcomes have not yet been reported from [the Systolic Blood Pressure Intervention Trial],” Ihab Hajjar, MD, MS, from the department of medicine at Emory University, and colleagues wrote. “Target [systolic] BP guidelines have also not addressed the potential that black patients may have greater morbidity and mortality from hypertension, including cognitive outcomes, and hence may require a different set of targets ... Identifying the optimal treatment target in this population is of great necessity.

Researchers evaluated how the Systolic Blood Pressure Intervention Trial (SPRINT) systolic BP target of less than 120 mm Hg affected cognition among older adults undergoing treatment for hypertension, compared with the Eighth Joint National Committee (JNC-8) systolic BP target of less than 150 mm Hg. They also evaluated discrepancies by race.

Hajjar and colleagues used data from 1,657 cognitively intact older adults in the Health Aging and Body Composition study. Mental processes were evaluated using the Digit Symbol Substitution Test five times, and the Modified Mini-Mental State Examination four times. Before each test, participants were categorized as having a systolic BP level of 120 mm Hg or lower, 121 to 139 mm Hg, 140 to 149 mm Hg, or 150mm Hg or higher based on the mean systolic BP level of two seated readings.

Researchers found that when compared with white patients, black patients had a greater difference in cognition between the higher and lower systolic BP levels: adjusted differences between the group with levels of 150 mm Hg or higher and the group with levels of 120 mm Hg or lower were –0.05 in white patients and –0.08 in black patients for Modified Mini-Mental State Examinations (P = .03), and –0.07 in white patients and –0.13 in black patients for the Digit Symbol Substitution Test (P = .05).

In addition, there was a differential decrease in the Digit Symbol Substitution Test and Modified Mini-Mental State Examination scores by the systolic BP levels, with the greatest decrease in the group with systolic BP levels of 150 mm Hg or higher and the lowest decrease in the group with systolic BP levels of 120 mm Hg or lower (P < .001 for both).

“The lower targets may offer greater protection for older black adults with hypertension,” Hajjar and colleagues wrote. “Future guidelines need to consider this racial difference when reviewing or providing recommendations for management of hypertension.”

In a related editorial, Rebecca F. Gottesman, MD, PhD, of the department of neurology at Johns Hopkins School of Medicine, wrote that more information is forthcoming and needed to understand the link between BP and dementia.

“The MIND — memory and cognition in decreased hypertension — component of SPRINT, which is ongoing, will provide more direct data on the cognitive outcomes associated with intensive [BP] control,” she wrote. “It will be important to consider cognitive outcomes in this trial in older vs. younger adults, as well as in distinct racial groups, to evaluate whether tight [BP] control is equally safe in both age groups, and whether it is particularly effective in either racial group.”

Disclosure: Gottesman is an associate editor for Neurology. None of the other researchers reported any relevant financial disclosures.