"Systolic Blood Pressure Intervention in Elderly Hypertensive Patients". The New England Journal of Medicine.

Clinical Question:

Does intensive treatment to lower systolic blood pressure decrease the incidence of cardiovascular events in older hypertensive patients as compared to standard treatment?

Bottom Line:

Intensive blood pressure control with a systolic target of 110 to less than 130 mm Hg led to fewer cardiovascular events in elderly hypertensive patients compared to standard treatment targeting 130 to less than 150 mm Hg.

Major Points:

Guidelines:

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Design:

- Multicenter, randomized, controlled trial
- Population: 8511 Chinese patients aged 60-80 years with hypertension
- Interventions:
- Intensive treatment: Target systolic blood pressure 110 to less than 130 mm Hg
- Standard treatment: Target systolic blood pressure 130 to less than 150 mm Hg
- Mean follow-up: 3.34 years

Population:

Inclusion criteria: Aged 60-80 years with hypertension and systolic blood pressure 140 to 190 mm Hg or on antihypertensive medication.
Exclusion criteria: History of ischemic or hemorrhagic stroke.

Interventions:

Patients were assigned to intensive or standard systolic blood pressure targets using antihypertensive drugs including olmesartan, amlodipine, and hydrochlorothiazide. Blood pressure was managed based on office and home measurements using a smartphone app.

Outcomes:

Primary outcome: Composite of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularization, atrial fibrillation, and death from cardiovascular causes.
Secondary outcomes: Individual components of the primary outcome, death from any cause, major adverse cardiac events (excluding stroke), and renal outcomes.
Safety outcomes: Adverse events such as hypotension, dizziness, syncope, and fracture.

Major Points:

The primary outcome occurred in 3.5% of patients in the intensive treatment group compared to 4.6% in the standard treatment group, with most secondary outcomes also favoring intensive treatment. The risk of death from any cause did not differ significantly between groups.

Criticisms:

The trial only included Han Chinese patients, limiting generalizability to other ethnicities. The use of the Framingham Risk Score, which was formulated primarily in white populations, may overestimate cardiovascular risk in Chinese adults.

Funding:

The trial was supported by grants to Dr. Cai from the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, Beijing Outstanding Young Scientist Program, and the National Natural Science Foundation of China. Drugs and blood pressure monitors were donated by companies with no role in trial design or data analysis.

Further Reading: