Intensive Blood Pressure Treatment May Not Be Appropriate for All with Hypertension

Intensive systolic blood pressure (BP) control may be appropriate for older adults with hypertension who have a life expectancy of greater than 3 years, but may not be suitable for those with less than 1 year, according to new findings.

Data show that in treating 100 older patients (≥60 years old) with hypertension for approximately 3 years, a single major adverse cardiovascular event (MACE) would be prevented.

“The summary TTB results of the present study provided a global estimate for prevention with intensive BP control; individual patients may be best served by focusing on TTB results from studies with similar intensive BP control interventions for patient characteristics,” wrote study author Chao Li, PhD, Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center.

Newer guidelines recommend a systolic BP target of less than 150 mm Hg or potentially 130 mm Hg for individuals aged ≥60 years. However, the large heterogeneity in cardiovascular risk requires clinicians to individually weigh benefits against potential risks, including syncope and fall.

Li and colleagues thus performed an analysis of individual data from randomized clinical trials to consider the TTB of more vs less intensive BP control. Trials were identified through PubMed until October 2021. If original study data were not available, investigators reconstructed them from the number of patients at risk and the Kaplan-Meier graph.

The primary outcome was defined as the time-to-first MACE, originally defined by individual trial as a composite of cardiovascular outcomes (myocardial infarction, stroke, and cardiovascular death), the investigators noted.

After identifying 85 trials from 7 systematic reviews, exclusions left a total of 6 trials in the analysis. There were a total of 27,414 participants, consisting of 56.3% women and having a mean age of 70 years.

Investigators observed intensive BP treatment with a systolic BP target below 140 mm Hg was significantly associated with a 21% reduction in MACE (hazard ratio [HR], 0.79; 95% CI, 0.71 - 0.88; P <.01).

Then, analyses to determine the TTB at various clinical thresholds found that 9.1 (95% confidence interval [CI], 4.0 - 20.6) months were needed to prevent 1 MACE per 500 patients with the intensive BP treatment (absolute risk reduction [ARR], 0.002).

Meanwhile, 19.1 (95% CI, 10.9 - 34.2) and 34.4 (95% CI, 22.7 - 59.8) months were estimated to avoid 1 MACE per 200 (ARR = .005) and 100 (ARR = .01) patients, respectively. Investigators noted the TTB to specific ARR threshold varied across different subgroups, with “little changes compared with the overall estimate.”

They found the TTB was consistently higher in the subgroup of target systolic BP less than 120 mm Hg vs the systolic BP less than 140 mm Hg compared with that of target SBP less than 130 mm Hg vs systolic BP less than 150/160 mm Hg.

“The degree to which an individual patient will benefit from intensive BP control will likely depend on their risk profile and potential harm,” Li concluded.

The study, “Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials,” was published in JAMA Internal Medicine.