blood pressure in the very old

Introduction

In reference to patients at least 80 years of age.

Pathology

• older individuals have lower arterial compliance & increased vascular resistance
• pulse pressure is often increased in elderly
• older individuals have a greater variability in blood pressure & greater postural changes
• U-shape relationship of diastolic blood pressure & mortality
  • diastolic blood pressure < 70 mm Hg associated with higher mortality
  • U point may be > 70 mm Hg (also see diastolic blood pressure)

Complications

• elderly are susceptible to orthostatic hypotension if antihypertensive therapy is initiated or increased too rapidly
• lowering of blood pressure in the elderly may adversely affect cognitive function
• daytime systolic blood pressure < 130 mm Hg may be associated with faster cognitive decline in cognitively impaired elderly treated with antihypertensives

Management

• multiple blood pressure measurements are needed to assess blood pressure in the very old
• orthostatic blood pressures needed to assess likelihood of orthostatic hypotension
• treat the diastolic blood pressure
  • treat diastolic hypertension (> 90 mm Hg)
  • lower systolic blood pressure until < 160 mm Hg or diastolic blood pressure < 70 mm Hg
    • ref would allow diastolic blood pressure as low as 50 mm Hg (not evidence-based recommendation)
• MKSAP 16 Nephrology section & JNC 8 recommend treatment of systolic BP > 150 mm Hg regardless of diastolic BP
  • this recommendation would seem at odds with results of clinical trials (see Clinical-trials below)
• thiazide diuretics are the preferred first line agents
  • not an evidence-based recommendation
• similar rates of injurious falls & cardiovascular events after initiating any first-line antihypertensive in elderly with limited life expectancy
• a systematic review of blood pressure guidelines in the elderly

Clinical trials

[1] 85+

• Population-based propective study in very old people (>= 85 years) in Finland
• No randomized trials in this age group have been conducted
• Systolic blood pressure < 140 mm Hg significantly increases* mortality in the very old (> 85 years of age)
• Systolic blood pressure > 160 mm Hg does not.*

* Relative to systolic blood pressure 140-159 mm Hg

systolic blood pressure	hazard ratio
< 140 mm Hg	1.35
140-159 mm Hg	1.00
> 160	0.97

[2] 471 ambulatory veterans from 10 VA centers aged >= 80 with hypertension

• inverse relationship* of blood pressure with mortality
  • up to 139 mm Hg systolic
  • up to 89 mm Hg diastolic

* Veterans with higher blood pressure (up to 139 mm Hg systolic) & (up to 89 mm Hg diastolic) had lower mortality than veterans with lower blood pressure.

• hazard ratio for a 10 mm Hg increase in blood pressure
  • 0.82 up to 139 mm Hg (systolic)
  • 0.85 up to 89 mm Hg (diastolic)

• for systolic blood pressure > 140 mm Hg & diastolic blood pressure> 90 mm Hg, no association with blood pressure & mortality

The study did not control for antihypertensive therapy.

[3] No data, extrapolation

[4] 1283 patients >= 80 years of age, with BP 160-220/90-110

• target BP < 150/80, follow-up 13 months

• Treatment groups
  • diuretic (bendroflumethiazide)
  • ACE inhibitor (lisinopril)
  • no treatment
  • diltiazem added to treatment groups as needed

• Results:
  • treatment of blood pressure reduced risk of stroke, but increased risk of mortality & cardiovascular risk in general (it seems overall risk of stroke 3%)

[5] 65+, 85+

• men, 85+: higher systolic BP associated with better survival
• men, 65+: negative association of diastolic BP with mortality
• women, 65-85, increased systolic BP associated with increased mortality
• women, 85+ no association of systolic BP with mortality

[6] 75+

• inverse relationship between systolic BP & diastolic BP with mortality
• a U-shaped relationship was observed in the 75-80 group for diastolic BP, mortality least for BP 80-90 mm Hg

[7] 80+ years of age (review)

• treatment of HTN increases mortality in elderly > 80
• higher systolic BP & diastolic BP are associated with decreased mortality

[8] 60+ years, 15,693 patients with isolated systolic HTN

• follow-up (median) 3.8 years
• systolic BP positively associated with mortality, risk of stroke
• inverse association of diastolic BP with mortality
• treatment reduced mortality 13%, stroke 30%, acute coronary syndrome 23%
• number need to treat for 5 years to prevent 1 major cardiovascular event lower in men than women (18 vs 38) & >= age 70 (19 vs 39) & in patients with prior cardiovascular complications (16 vs 37)

[9] 85+ years of age

• mortality greatest in those with lowest systolic & lowest diastolic blood pressure
• mortality least in elderly with systolic BP >= 160 mm Hg & diastolic BP >= 90 mm Hg

[10] 80+ years of age, mean age 84 years (HYVET study)

• 3845 patients from Europe, China, Australasia, & Tunisia
• mean blood pressure 173/91 mm Hg treated with indapamide SA 1.5 mg or placebo + perindopril 2-4 mg or placebo as necessary to achieve BP of 150/80
• BP lower in treatment group, mean 15/6 mm Hg
• allegedly, mean BP achieved in treatment group 143/78
• 30% reduction in mortality from stroke in treated group (p=0.046) 12.4 vs 17.7 per 1000 patient years
• number need to treat to prevent 1 stroke in 2 years = 100
• 21% reduction in all-cause mortality (p=0.02) (10% vs 12%)
• 64% reduction in heart failure
• fewer adverse effects in the treatment group (358 vs 448)
• allegedly, only 2 serious adverse events, in the indapamide group (implausible per commentator)
• trial halted early because of ethical concerns
• sponsored by manufacturer of study drugs
• open label 1 year extension of trial
  • all patients treated with study drugs with target of 150/80
  • comparing patients previously treated with study drugs & those previously on placebo,
    • at 6 months BP difference between groups 1.2/0,7 mm Hg
    • no significant differences for stroke (n = 13; RR=1.92)) or cardiovascular events (n = 25; RR=0.78))
    • decrease total mortality (47 deaths; RR=0.48; P=0.02) & cardiovascular mortality (11 deaths; RR=0.19, P=0.03)

[11] 85+ years

• systolic blood pressure, diastolic blood pressure & pulse pressure were all inversely associated with mortality
• systolic blood pressure was the strongest predictor
• systolic blood pressure <120 mmHg correlated with greater 4-year all-cause mortality alone & when controlling for health status
• suggestion of a U-shaped mortality curve for the adjusted model, with systolic blood pressure of 164 mmHg associated with the lowest mortality.

[12] 85-90 years of age

• higher systolic blood pressure associated with better scores on MMSE & activities of daily living scale
• during 5 years of follow-up, higher baseline systolic BP was associated with less physical & cognitive decline

[13] 80+ years of age, meta-analysis

• treating hypertension in very old patients reduces stroke & heart failure with no effect on total mortality

[19] 80+ years of age

• systolic blood pressure < 135 mm Hg associated with increased mortality

[20] 80+ years of age (study in China)

• systolic blood pressure of 143.5 mm Hg conferred minimal risk
  • after adjustment for covariates minimum mortality risk for systolic blood pressure declined to 129 mm Hg
    • higher systolic blood pressure predicted a higher risk of death from cardiovascular disease
    • lower systolic blood pressure predicted a higher risk of death from non-cardiovascular causes

[21] mean age 88.6 years

• odds of gross brain infarcts & microinfarcts at autopsy were higher in older adults with higher average systolic BP
• a more rapidly declining systolic BP also associated with increased risk of infarcts
• association of higher systolic BP & neurofibrillary tangles
• 87% of study participants had used antihypertensive agent
• average systolic BP 134 mm Hg

[22] adults >= 80 years of age with hypertension but not diabetes intensive systolic BP control (target 120 mm Hg vs 140 mm Hg) lowers the risk of major cardiovascular events (RR=0.66), mild cognitive impairment (RR=0.70) & death (RR=0.67), with increased risk of changes to kidney function, without difference is rates of injurious falls or gait speed

[23] adults >= 80 years of age with hypertension, OPTIMISE randomized trial.

• deprescribing antihypertensive medications feasible 7 noninferior to usual care for geriatric patients
• benefits of lower blood pressure (BP) WITH multiple antihypertensives may not outweigh risks

[25] elderly > 75 years of age (up to age 95 years)

• lowest risk of dementia in elderly > 75 years is 158 mm Hg
• lowest risk of mortality in elderly > 75 years is 160 mm Hg

More general terms

• blood pressure (BP)

Additional terms

• systolic hypertension (hypertension in the elderly)