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Journal of Geriatric Medicine and Gerontology





DOI: 10.23937/2469-5858/1510020



What Should the Systolic Blood Pressure Treatment Goal be in Patients Aged 60 Years and Older with Hypertension in 2016?

Wilbert S Aronow*



Department of Medicine, Cardiology Division, New York Medical College, USA


*Corresponding author: Wilbert S Aronow, MD, FACC, FAHA, Professor of Medicine, Cardiology Division, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 141, Valhalla, NY 10595, USA, Tel: (914)-493-5311, Fax: (914)-235-6274, E-mail: wsaronow@aol.com
J Geriatr Med Gerontol, JGMG-2-020, (Volume 2, Issue 2), Editorial; ISSN: 2469-5858
Received: September 13, 2016 | Accepted: October 14, 2016 | Published: October 17, 2016
Citation: Aronow WS (2016) What Should the Systolic Blood Pressure Treatment Goal be in Patients Aged 60 Years and Older with Hypertension in 2016? J Geriatr Med Gerontol 2:020e. 10.23937/2469-5858/1510020
Copyright: © 2016 Aronow WS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



The Hypertension in the Very Elderly Trial (HYVET) randomized 3, 845 patients aged 80 years and older, mean age 83.6 years, with a systolic blood pressure (SBP) of ≥ 160 mmHg to indapamide plus perindopril if needed versus double-blind placebo [1]. The target SBP reached was 150 mmHg, and the lowest SBP reached was 143 mmHg. Median follow-up was 1.8 years. Compared to patients randomized to placebo, patients randomized to antihypertensive drug therapy had a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality, a 23% reduction in cardiovascular death, and a 64% reduction in heart failure [1].

On the basis of the available randomized clinical trial data including HYVET [1] and the Systolic Hypertension in the Elderly (SHEP) trial [2-4], the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) 2011 expert consensus document on hypertension in the elderly developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society for Preventive Cardiology, the American Society of Hypertension (ASH) , the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension recommended that the SBP be lowered to less than 140 mmHg in older persons younger than 80 years and to 140 to 145 mmHg if tolerated in adults aged 80 years and older [5].

The European Society of Hypertension/European Society of Cardiology 2013 guidelines for management of hypertension recommended lowering the SBP in older patients younger than 80 years with a SBP of 160 mmHg or higher to between 140-150 mmHg with consideration of a SBP less than 140 mmHg [6]. In patients older than 80 years with a SBP of 160 mmHg or higher, the SBP should be lowered to between 140-150 mmHg provided they are in good physical and mental conditions [6].

The 2013 Eighth Joint National Committee (JNC 8) guidelines for management of hypertension recommended lowering the SBP in patients aged 60 years or older to less than 150 mmHg if they did not have diabetes mellitus or chronic kidney disease and to less than 140 mmHg if they had diabetes mellitus or chronic kidney disease [7]. The minority view from JNC 8 recommended lowering the SBP goal in patients aged 60 years and older with hypertension to less than 140 mmHg [8].

The 2014 ASH/International Society of Hypertension guidelines recommended lowering the SBP to less than 140 mmHg in adults younger than 80 years [9]. In adults aged 80 years and older, these guidelines recommended lowering the SBP to less than 150 mmHg unless these patients have diabetes mellitus or chronic kidney disease when a goal of less than 140 mmHg can be considered [9].

The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study is an observational study of risk factors for stroke which includes 4,181 patients aged 55 to 64 years, 3,767 patients aged 65 to 74 years, and 1,839 patients aged 75 years and older (mean age 79.3 years) living in the stroke belt and stroke buckle regions of the United States and taking antihypertensive medication [10]. Median follow-up was 4.5 years for cardiovascular disease, 4.5 years for coronary heart disease, 5.7 years for stroke, and 6.0 years for all-cause mortality. Data from this study supported reducing the SBP to less than 140 mmHg in older persons [10].

The AHA/ACC/ASH 2015 guidelines on treatment of hypertension in adults with coronary artery disease guidelines recommended that the optimal SBP in adults with coronary artery disease should be less than 140 mmHg in older persons younger than 80 years and less than 150 mmHg in persons aged 80 years and older [11]. These guidelines also stated that a SBP goal of less than 130 mmHg may be appropriate in some patients with coronary artery disease [11].

The new guidelines for the management of patients with hypertension will be strongly influenced by the results from the Systolic Blood Pressure Intervention Trial (SPRINT) [12,13]. SPRINT randomized 9,361 patients with a SBP of 130-180 mmHg and an increased cardiovascular risk but without diabetes mellitus, history of stroke, symptomatic heart failure within the past 6 months, a left ventricular ejection fraction of less than 35%, and an estimated glomerular filtration rate less than 20 ml/min/1.73 m2 to a SBP goal of less than 120 mmHg or less than 140 mmHg. The patients were aged 50 years and older with a mean age of 67.9 years. Of the 9,361 patients, 2,636 (28.2%) were aged 75 years and older (mean age 79.9 years). Of the patients aged 75 years and older, 30.9% were frail [13]. Median follow-up was 3.26 years for all patients [12] and 3.14 years in the group aged 75 years and older [13].

The primary composite outcome was myocardial infarction, other acute coronary syndrome, stroke, heart failure, or death from cardiovascular causes and was reduced 25% by intensive blood pressure treatment in the entire group [12] and by 34% in patients aged 75 years and older. All-cause mortality was reduced by 27% by intensive blood pressure treatment in the entire group [12] and by 33% in patients aged 75 years and older [13]. The number needed to treat to reduce the primary outcome in patients aged 75 years and older was 27. The number needed to treat to reduce all-cause mortlity in patients aged 75 years and older was 41 [13]. Heart failure was reduced by intensive blood pressure treatment 38% in the entire group [12] and by 38% in patients aged 75 years and older [13].

Serious adverse events were similar in both treatment groups [12,13]. In patient aged 75 years and older, the benefit of reducing the SBP to less than 120 mmHg was similar in frail and nonfrail persons [13].

Expert medical opinion will need to be used to decide what the optimal SBP goal should be in older persons with hypertension not included in the SPRINT trial. On the basis of data from the ACTION to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial [14-16], this author favors in older diabetics at increased cardiovascular risk a SBP goal of less than 130 mmHg or of less than 120 mmHg with more intensive monitoring for serious adverse events [17].


Conflict of Interest

Dr. Aronow has no conflicts of interest.


References
  1. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, et al. (2008) Treatment of hypertension in patients 80 years of age or older. N Engl J Med 358: 1887-1898.

  2. (1991) Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 265: 3255-3264.

  3. Perry HM Jr, Davis BR, Price TR, Applegate WB, Fields WS, et al. (2000) Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 284: 465-471.

  4. Kostis JB, Davis BR, Cutler J, Grimm RH Jr, Berge KG, et al. (1997) Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA 278: 212-216.

  5. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, et al. (2011) ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the AmericanCollege of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Developed in collaboration with the AmericanAcademy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 57: 2037-2114.

  6. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, et al. (2013) 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 34: 2159-2219.

  7. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, et al. (2014) 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 311: 507-520.

  8. Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR (2014) Evidence supporting a systolic blood pressure goal of less than 150 mmHg in patients aged 60 years or older: the minority view. Ann Intern Med 160: 499-503.

  9. Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, et al. (2014) Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 32: 3-15.

  10. Banach M, Bromfield S, Howard G, Howard VJ, Zanchetti A, et al. (2014) Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking antihypertensive medication. Int J Cardiol 176: 219-226.

  11. Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, et al. (2015) Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 65: 1998-2038.

  12. SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, et al. (2015) A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373: 2103-2116.

  13. Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, et al. (2016) Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: A randomized clinical trial. JAMA 315: 2673-2682.

  14. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, Goff DC Jr, et al. (2010) Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med 362: 1575-1585.

  15. Margolis KL, O'Connor PJ, Morgan TM, Buse JB, Cohen RM, et al. (2014) Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care 37: 1721-1728.

  16. Soliman EZ, Byington RP, Bigger JT, Evans G, Okin PM, et al. (2015) Effect of intensive blood pressure lowering on left ventricular hypertrophy in patients with diabetes mellitus: Action to Control Cardiovascular Risk in Diabetes Blood Pressure Trial. Hypertension 66: 1123-1129.

  17. Aronow WS (2016) Orthostatic hypotension in diabetics in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial. Hypertension 68: 851-852.

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