Jessica Weiss, MD, MCR; Michele Freeman, MPH; Allison Low, BA; Rochelle Fu, PhD; Amy Kerfoot, MD; Robin Paynter, MLIS; Makalapua Motu'apuaka, BS; Karli Kondo, PhD; Devan Kansagara, MD, MCR
Disclaimer: This article is based on research conducted by the Evidence-based Synthesis Program Center located at the Veterans Affairs Portland Health Care System, Portland, Oregon. The findings and conclusions in this article are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government. Therefore, no statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.
Financial Support: This research was funded by the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1754.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015017677. Statistical code: Available from Dr. Kansagara (e-mail, firstname.lastname@example.org). Data set: Supplementary data are available in the Supplement.
Requests for Single Reprints: Devan Kansagara, MD, MCR, Veterans Affairs Portland Health Care System, Mail Code RD71, 3710 SW US Veterans Hospital Road, Portland, OR 97239; e-mail, email@example.com.
Current Author Addresses: Dr. Weiss: Oregon Health & Science University, Mail Code SJH6, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
Ms. Freeman; Ms. Low; Drs. Kerfoot, Kondo, and Kansagara; Ms. Paynter; and Ms. Motu'apuaka: Veterans Affairs Portland Health Care System, Mail Code RD71, 3710 SW US Veterans Hospital Road, Portland, OR 97239.
Dr. Fu: Oregon Health & Science University, Mail Code CB669, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
Author Contributions: Conception and design: J. Weiss, A. Low, R. Paynter, M. Motu'apuaka, K. Kondo, D. Kansagara.
Analysis and interpretation of the data: J. Weiss, M. Freeman, R. Fu, A. Kerfoot, M. Motu'apuaka, K. Kondo, D. Kansagara.
Drafting of the article: J. Weiss, M. Freeman, R. Paynter, M. Motu'apuaka, K. Kondo, D. Kansagara.
Critical revision of the article for important intellectual content: J. Weiss, M. Freeman, A. Low, R. Fu, A. Kerfoot, M. Motu'apuaka, K. Kondo, D. Kansagara.
Final approval of the article: J. Weiss, M. Freeman, A. Low, R. Fu, A. Kerfoot, R. Paynter, M. Motu'apuaka, K. Kondo, D. Kansagara.
Statistical expertise: R. Fu.
Obtaining of funding: D. Kansagara.
Administrative, technical, or logistic support: M. Freeman, A. Low, R. Paynter, M. Motu'apuaka.
Collection and assembly of data: J. Weiss, M. Freeman, A. Low, R. Paynter, M. Motu'apuaka, K. Kondo, D. Kansagara.
Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, et al. Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis. Ann Intern Med. [Epub ahead of print 17 January 2017]:. doi: 10.7326/M16-1754
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Published: Ann Intern Med. 2017.
Recent guidelines recommend a systolic blood pressure (SBP) goal of less than 150 mm Hg for adults aged 60 years or older, but the balance of benefits and harms is unclear in light of newer evidence.
To systematically review the effects of more versus less intensive BP control in older adults.
Multiple databases through January 2015 and MEDLINE to September 2016.
21 randomized, controlled trials comparing BP targets or treatment intensity, and 3 observational studies that assessed harms.
Two investigators extracted data, assessed study quality, and graded the evidence using published criteria.
Nine trials provided high-strength evidence that BP control to less than 150/90 mm Hg reduces mortality (relative risk [RR], 0.90 [95% CI, 0.83 to 0.98]), cardiac events (RR, 0.77 [CI, 0.68 to 0.89]), and stroke (RR, 0.74 [CI, 0.65 to 0.84]). Six trials yielded low- to moderate-strength evidence that lower targets (≤140/85 mm Hg) are associated with marginally significant decreases in cardiac events (RR, 0.82 [CI, 0.64 to 1.00]) and stroke (RR, 0.79 [CI, 0.59 to 0.99]) and nonsignificantly fewer deaths (RR, 0.86 [CI, 0.69 to 1.06]). Low- to moderate-strength evidence showed that lower BP targets do not increase falls or cognitive impairment.
Data relevant to frail elderly adults and the effect of multimorbidity are limited.
Treatment to at least current guideline standards for BP (<150/90 mm Hg) substantially improves health outcomes in older adults. There is less consistent evidence, largely from 1 trial targeting SBP less than 120 mm Hg, that lower BP targets are beneficial for high-risk patients. Lower BP targets did not increase falls or cognitive decline but are associated with hypotension, syncope, and greater medication burden.
U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO 2015: CRD42015017677)
Literature flow diagram.
* All databases were searched through 30 January 2015. The Ovid MEDLINE search was updated on 15 September 2016.
Table 1. Characteristics of Trials Included in the Meta-analysis
RRs for death, stroke, and cardiac events, with trials combined by mean baseline SBP ≥160 or <160 mm Hg.
RRs for death, stroke, and cardiac events in trials in which the intervention group had a target of SBP <140 mm Hg or DBP ≤85 mm Hg and the control group had a less strict target.
Table 2. Summary of the Evidence on More Versus Less Intensive Treatment for Hypertension in Elderly Adults
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Gulistan Bahat1, Birkan İlhan2, Asli Tufan3, Mehmet Akif Karan4
1 Associate Professor, M.D, Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey, firstname.lastname@example.org
February 6, 2017
Treatment of hypertension in frail, functionally limited older adults
We have read the article entitled “Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older” by Weiss et al. with great interest (1). In their valuable systematic review and meta-analysis, the authors reviewed a large number of studies regarding optimal management strategies of hypertension in older adults. We would like to give a few comments on this valuable review.Authors stated that in 2 trials (2,3), antihypertensive treatment effects did not differ according to frailty status. However, when we go into the second report of the SPRINT (2), primary composite cardiovascular outcomes and all-cause mortality was not better in subjects with frailty (p=0.06, 0.05; respectively) or slow gait speed (p=0.05, 0.28; respectively) when they get intensive treatment compared with standard treatment (4). In the other one HYVET trial (3), both the frailer and the fitter older adults with hypertension appeared to gain from treatment. Here frailty was evaluated by Frailty Index (FI) but there were about or less than 5% participants having limitation in walking and activities of daily living. Hence, in the HYVET study, the reported lack of modification of positive impact of antihypertensive treatment by FI, does not supply data on the older adults specifically having low gait speed and/or functional limitation. However, the specific investigation of the impact of antihypertensive treatment in the older adults having low gait speed and/or functional limitation would give a better view (4). In accordance with this argument, in 2016 the European Society of Hypertension (ESH) and the European Union Geriatric Medicine Society have published a common expert opinion article on the management of hypertensive very old, frail subjects and suggested that in these patients, therapeutic decisions should be preceded by accurate information on their functional capacity (5).Weiss et al. stated the lack of data to assess the risks and benefits of antihypertensive treatment among institutionalized elderly patients or those with multiple comorbidities. We would like to point out the PARTAGE study which assessed all-cause mortality in institutionalized individuals older than 80 years according to systolic blood pressure levels and number of antihypertensive drugs (6). They reported higher risk of mortality in patients with low systolic blood pressure (<130 mmHg) who were receiving multiple antihypertensive agents compared with the other participants. This longitudinal study gives weighty data regarding the harms of antihypertensive agent use in frail older adults.REFERENCES1. Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, Motu'apuaka M, Kondo K, Kansagara D. Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis. Ann Intern Med. 2017 Jan 17. 2. Williamson JD,Supiano MA,Applegate WB,Berlowitz DR,Campbell RC,Chertow GM et al;SPRINT Research Group.Intensive vs Standard Blood Pressure Control and Car-diovascular Disease Outcomes in Adults Aged ≥75 Years:A Randomized Clinical Trial.JAMA.2016Jun 28;315(24):2673-82.3. Warwick J,Falaschetti E,Rockwood K,Mitnitski A,Thijs L et al:No evidence that frail-ty modifies the positive impact of antihypertensive treatment in very elderly people:an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind,placebo-controlled study of anti-hypertensives in people with hypertension aged 80 and over. BMC Med 2015Apr 9;13:78.4. Bahat G, Ilhan B, Tufan A, Karan MA. Blood pressure goals in functionally limited elderly patients. The American Journal of Medicine 2017, in press.5. Benetos A, Bulpitt CJ, Petrovic M, Ungar A, Agabiti Rosei E, Cherubini A, Redon J, Grodzicki T, Dominiczak A, Strandberg T, Mancia G. An Expert Opinion From the European Society of Hypertension-European Union Geriatric Medicine Society Work-ing Group on the Management of Hypertension in Very Old, Frail Subjects. Hyperten-sion. 2016 May;67(5):820-5.6. Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F, Salvi P, Zamboni M, Manckoundia P, Hanon O, Gautier S. Treatment With Multiple Blood Pressure Medi-cations, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents: The PARTAGE Study. JAMA Intern Med. 2015 Jun;175(6):989-95.
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