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Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis.

Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis.
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Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, Motu'apuaka M, Kondo K, Kansagara D,


Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, Motu'apuaka M, Kondo K, Kansagara D, (click to view)

Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, Motu'apuaka M, Kondo K, Kansagara D,

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Annals of internal medicine 2017 01 17166(6) 419-429 doi 10.7326/M16-1754
Abstract
Background
Recent guidelines recommend a systolic blood pressure (SBP) goal of less than 150 mm Hg for adults aged 60 years or older, but the balance of benefits and harms is unclear in light of newer evidence.

Purpose
To systematically review the effects of more versus less intensive BP control in older adults.

Data Sources
Multiple databases through January 2015 and MEDLINE to September 2016.

Study Selection
21 randomized, controlled trials comparing BP targets or treatment intensity, and 3 observational studies that assessed harms.

Data Extraction
Two investigators extracted data, assessed study quality, and graded the evidence using published criteria.

Data Synthesis
Nine trials provided high-strength evidence that BP control to less than 150/90 mm Hg reduces mortality (relative risk [RR], 0.90 [95% CI, 0.83 to 0.98]), cardiac events (RR, 0.77 [CI, 0.68 to 0.89]), and stroke (RR, 0.74 [CI, 0.65 to 0.84]). Six trials yielded low- to moderate-strength evidence that lower targets (≤140/85 mm Hg) are associated with marginally significant decreases in cardiac events (RR, 0.82 [CI, 0.64 to 1.00]) and stroke (RR, 0.79 [CI, 0.59 to 0.99]) and nonsignificantly fewer deaths (RR, 0.86 [CI, 0.69 to 1.06]). Low- to moderate-strength evidence showed that lower BP targets do not increase falls or cognitive impairment.

Limitation
Data relevant to frail elderly adults and the effect of multimorbidity are limited.

Conclusion
Treatment to at least current guideline standards for BP (<150/90 mm Hg) substantially improves health outcomes in older adults. There is less consistent evidence, largely from 1 trial targeting SBP less than 120 mm Hg, that lower BP targets are beneficial for high-risk patients. Lower BP targets did not increase falls or cognitive decline but are associated with hypotension, syncope, and greater medication burden. Primary Funding Source
U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO 2015: CRD42015017677).

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