Managing Hypertension:
An Important Update

I just knew it—you know how you feel when you know something is true but you don’t have the evidence to back it up?

Back in 2015 we discussed the Eighth Joint National Committee (JNC 8) guidelines and their recommendations for relaxing requirements for blood pressure-lowering targets in elders. That worried me. We know three of every four persons over the age of 75 have hypertension. And it is clearly established that higher levels of systolic blood pressure (SBP) are related to more cerebrovascular events and development of heart failure. This finding is outlined in the editorial on The Systolic Hypertension in the Elderly Program, which demonstrated that lowering SBP to less than 150 mmHg in patients aged 60 and older with isolated systolic hypertension was beneficial in reducing stroke, and the Hypertension in the Very Elderly Trial, involving patients aged 80 and older with hypertension and an SBP treatment target of less than 140 mmHg, showed significant reduction in the incidence of stroke and heart failure with active as compared with placebo therapy.1

So why would treatment goals be relaxed? Among other issues, there was concern that, as per the adage, too much of a good thing ceases to be good. Physicians feared induced hypotension, falls, confusion, etc from inducing low blood pressure or orthostatic symptoms of overmedication; and both patients and clinicians sought to avoid polypharmacy. So the targets were relaxed, but a minority of the expert panel published their objection.

The JNC 8 guidelines recommend, in patients aged 60 and older, to start treatment in blood pressures >150 mmHg systolic or >90 mmHg diastolic and treat to under those thresholds.2

As noted by Wright et al in Annals of Internal Medicine in April 2014, a minority opined with caution and concern: “We, the panel minority, believed that evidence was insufficient to increase the SBP goal from its current level of less than 140 mmHg because of concern that increasing the goal may cause harm by increasing the risk for CVD [cardiovascular disease] and partially undoing the remarkable progress in reducing cardiovascular mortality in Americans older than 60 years.”

The recent update comes from the SPRINT trial—a randomized clinical open-label study of community-dwelling older adults with SBP in the 130 to 180 mmHg range in whom the effects of reducing SBP to less than 120 mmHg (intensive treatment group) were compared with those associated with SBP lowering to less than 140 mmHg (standard treatment group).3

While planned and powered for a five-year observation period for cerebrovascular events (eg, stroke, heart failure, acute myocardial infarction, or death), the study was stopped after just over two years when the results of individuals in the intensive treatment group were clearly better than the standard treatment arm.

Key findings include the following:

• Thirty percent to 35% lower risk of stroke, myocardial infarction, congestive heart failure, and death.
• Benefits extended even to those frail by evaluation of slow gait speed.
• No higher rates of falls.
• Ninety percent of medications used in the study were generic.
• On average, patients in intervention group required one more medication per day than standard care group.

An accompanying editorial is a succinct summary of the benefits of this research and espouses a new evidence-based stepwise approach in which clinicians move patients first to the goal of SBP <140 mmHg and then move toward 130 mmHg and, if possible, toward 120 mmHg. Certainly comorbidities and functional status may individually impact the desire for strict control, but when possible, we now have evidence of benefit without significant risk.

The findings of this study are important for all of us to work into our clinical practice patterns. Often research protocols, especially those involving elders, are so stringent the patients are vastly different from typical community-dwelling elders. SPRINT does have limitations in that the patients had few other comorbidities and were generally healthy and high-functioning elders. But we all have many of those patients. Help to spread this important clinical care update across your organization. Please pass this article along to all clinicians and/or consider updating flags in your EMR or having it recalibrated to identify patients who should be evaluated for this newer treatment goal. Let’s do what we can to help patients remain vital and active for as long as possible. Aging is tough enough as it is.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

References
1. Bulpitt C, Fletcher A, Beckett N, et al. Hypertension in the Very Elderly Trial (HYVET): protocol for the main trial. Drugs Aging. 2001;18(3):151-164.

2. James PA, Oparil S, Carter BL, et al. 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. 2014;311(5):507-520.

3. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315(24):2673-2682.