Treating Low Blood Pressure in Elderly Patients

Caution should be used in treating frail elderly patients with low systolic blood pressure (SBP), according to research published in JAMA Internal Medicine.

Researchers from Italy and France teamed up to evaluate the blood pressure (BP) in 1,127 elderly residents of nursing homes (greater than 80 years) over the course of a 2-year follow up period between 2007 and 2010. The researchers assessed the interaction between low SBP (<130 mm Hg) and the presence of combination anti hypertensive treatment on 2 year all cause mortality.

The participants’ BP was measured with assisted self measurements 3 times in the morning (between 8 am and noon) and 3 times in the evening (from 3 pm to 6 pm) over 3 consecutive days for an average total of 18 measurements. The researchers then compared patients with SBP less than 130 mm Hg and receiving combination anti hypertensive treatment to all other participants.

The researchers discovered a significant association between low SBP and treatment with 2 or more BP lowering agents, which resulted in a higher risk of mortality in patients with low SBP who had received multiple BP lowering medicines compared to the other participants. The researchers used 3 sensitivity analyses to compare patients with SBP lower than 130 mm Hg and receiving anti hypertensive treatment (exposed) versus all the other patients: 1) propensity score matched subsets; 2) adjustments for cardiovascular comorbidities; 3) and exclusion of patients without a history of hypertension who were receiving BP lowering agents.

There were other co-variables associated with mortality, the researchers discovered — age, male sex, low body mass index, Charlson Comorbidity Index score, and degree of disability (such as low activities of daily living score). After adjustment for these factors, the excess risk in patients with low SBP who were receiving multiple BP lowering agents persisted. After similar factors, the risk of death in the group with low SBP receiving multiple BP medicines did not change significantly.

Currently, the researchers noted, there are no clear recommendations regarding target BP level in the treatment of hypertension in elderly, frail patients. European guidelines recently recommended reducing SBP to between 140 mm Hg and 150 mm Hg for individuals older than 80 years whose SBP was 160 mm Hg or higher. However, the researchers continued that there was no clear indication that this strategy, or other recommendations, should be implemented when the SBP levels are lowered.

“The findings of this study raise a cautionary note regarding the safety of using combination antihypertensive therapy in frail elderly patients with low SBP (<130 mm Hg),” the authors concluded, noting that further clinical trials are required in order to develop standardized recommendations.