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Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older

TO THE EDITOR: As contributors to Hypertension Canada's clinical practice guidelines, we have concerns about Qaseem and colleagues' new recommendations on hypertension management in persons aged 60 years or older, which were developed by the American College of Physicians and the American Academy of Family Physicians (1). These recommendations were based on a systematic review by Weiss and associates, which evaluated the effect of more versus less intensive lowering of systolic blood pressure (SBP) on cardiovascular outcomes in this population and was published in the same issue. Weiss and colleagues' review, while well done, had notable limitations. Namely, data were pooled by strategy (that is, intensive vs. less intensive control) rather than specific targets, methods of blood pressure measurement were inconsistent across included studies, and the analytic approach to important subpopulations was inconsistent (trials of participants with and without diabetes were pooled, whereas trials in participants with stroke were analyzed separately). Furthermore, the overall results of the ACCORD (Action to Control Cardiovascular Disease in Diabetes) trial (2) were pooled despite evidence of an interaction between the SBP treatment and interventions for glycemic control. Notwithstanding these limitations, Weiss and associates showed a significant reduction in stroke with more intensive SBP lowering (relative risk, 0.79 [95% CI, 0.59 to 0.99]). The point estimates for all-cause mortality and cardiac events favored intensive SBP lowering, but the CIs were wide. A larger review (n= 42000) not considered in Qaseem and colleagues' new guideline showed unambiguous benefit with intensive blood pressurelowering strategies on cardiovascular outcomes among older (aged62 years) persons (3). Another meta-analysis of 123 hypertension trials noted a linear relationship between SBP lowering and cardiovascular risk reduction, with every 10-mm Hg reduction in SBP being associated with a 20%, 27%, and 13% decrease in cardiovascular events, stroke, and all-cause mortality, respectively (4). These meta-analyses suggest that lower SBP is associated with incrementally greater benefit, regardless of age. And among the elderly, SPRINT (Systolic Blood Pressure Intervention Trial) indicates that intensive SBP lowering (<120 mm Hg, measured by automated method) leads to significant reductions in cardiovascular outcomes when compared with standard SBP lowering (<140 mm Hg), especially in the elderly (5), thus providing high-quality evidence for a specific target in older adults. Safety concerns in older patients are understandable. Although institutionalized elderly persons and those with severe orthostasis were excluded, SPRINT supports lower SBP targets even in frail persons (5). Serious adverse events were higher overall in the elderly SPRINT subpopulation, but the adverse event rate did not differ by treatment assignment (intensive, 48.4%; standard, 48.3%) (5). Of note, Weiss and coworkers' review revealed no significant increase in falls, fractures, or adverse renal outcomes with intensive versus less intensive strategies. Compelling evidence supports lower SBP targets in older patients. Intensive treatment guided by accurate blood pressure measurement will reduce the risk for cardiovascular events and death in older patients more than in younger ones. We commend the American College of Physicians and the American Academy of Family Physicians for encouraging meaningful communication with patients and the promotion of patient-centered treatment goals, but the best available evidence should also inform decisions.