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Lower systolic BP during antihypertensive treatment associated with more deaths in the elderly
Clinical Question
Is lower systolic blood pressure associated with better outcomes in elderly patients who take antihypertension medications?
Bottom line
In this small cohort study of patients older than 85 years, lower systolic blood pressure during treatment with antihypertensive medications is associated with higher death rates and greater cognitive decline. 1b-
Reference
Study design: Cohort (prospective)
Funding: Government
Setting: Population-based
Synopsis
Are you tired of all the ping-ponging, guideline-based blood pressure targets? Unfortunately, this study won't improve your fatigue. These researchers assembled a cohort of 570 residents of Leiden in the Netherlands who turned 85 years of age between 1997 and 1999. They excluded people who died within 3 months of enrollment and those who had no blood pressure measurement at baseline. At baseline, and periodically over the course of 5 years of follow up, the researchers collected all kinds of information: sociodemographics, medical diagnoses, medications, mental status, grip strength (as a proxy for frailty), blood pressure, and so forth. They assessed the main outcome—death from any cause—by using municipal records. Slightly fewer than half of the residents (44%) took antihypertensive medications at baseline; these patients were more likely to have other cardiovascular disorders than those not taking antihypertensive medications (62% vs 36%). During the 5 years of follow-up, 263 (46%) participants died. For those taking antihypertensive medications, all-cause mortality was significantly higher with decreasing systolic blood pressure (hazard ratio 1.29 per 10 mmHg lower systolic blood pressure; 95% CI 1.15 - 1.46). For the residents who were not taking antihypertensive medications, there was no significant correlation between systolic blood pressure and all-cause mortality. Additionally, the patients taking antihypertensives had more rapid cognitive decline with lower systolic blood pressure. Although many explanations for the differences in treatment thresholds are given by the various guidelines, one is how we value clinical trial versus observational data: The guidelines that promulgate lower blood pressure targets are more likely to value observational data. The data from this study are subject to many of the biases inherent in cohort studies, but they should moderate the enthusiasm for lower blood pressure targets.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
My target above 80 years old, no matter DM or CKD, <150/90.
Alleluia!
Finally. something I can use to justify my long-held belief that treating the elderly for hypertension is not only a waste of time but is actually harmful!
I am going print this off and hand out in my waiting room- thank you.
Good poem
leaning on guidelines is the worst way to practice medicine. Using your knowledge of your patient - especially the elderly - and common sense is far superior and will keep people alive longer.
I am not sure whether this will offer a tangible, clinical benefit, other than both patient and prescriber feeling more comfortable about being off antihypertensives at a later age. This may expose them to less risk of adverse effects, and lower pill burden, both of which seem like a good idea in a patient over 80 yrs old.
Most practitioners at the entry level of the health care system have been convinced that the measurement and pharmacologic manipulation of isolated readings blood pressure produces immense benefit and run a system predicated on this.This is a good financial model for those involved but delivers very poor returns. Various body measurements are taken as a surrogate marker for good health and manipulated with the one very strange exception of waist circumference.
We could expend our resources better.
Is it possible to identify post-Rx systolics in mm Hg to see if there is correlation between amount of lowering with the increased mortality and cognitive decline? That is, was Rx "too successful"?
Presumably there will be optimal upper and lower limits for BP for different ages and other factors. Hopefully more information will become available in future.
Je ne changerai pas ma conduite actuelle.