Abstract 68: Safety and Effectiveness of Intensive Blood Pressure Management in the Elderly: Findings From the Secondary Prevention of Small Subcortical Strokes Trial

Abstract

Background: Despite being at greatest risk for stroke, older adults are less likely to receive the same level of vascular risk factor management as younger adults. Our objective was to examine the safety and effectiveness of intensive systolic blood pressure (SBP) management in the elderly cohort of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial. Methods: SPS3 is an international trial that evaluated SBP targets (< 130 mmHg vs. 130-149 mmHg) for secondary stroke prevention in patients with recent lacunar stroke. Elderly were defined as ≥ 75 years at study entry and compared with patients < 75 years on adherence to SBP targets, presence of side-effects, and risk of recurrent stroke, cardiac events, and death. Interactions between age and SBP targets on outcomes were examined. Results: Of the 3020 participants in SPS3, 494 (16%) were ≥ 75 years (mean age 80 years). Mean achieved SBP across all follow-ups was similar (older and younger groups respectively, lower target: 125.2 (15.8) vs. 125.1 (14.4), p=0.62; higher target: 137.1 (14.6) vs. 137.1 (14.4), p=0.95). Adherence to medications and follow-up visits was similar. There was no difference by age group in rates of postural hypotension and serious complications of hypotension. There was no difference in the effect of the SBP intervention by age group on stroke (p=0.39), cardiac events (p=0.62), and all-cause mortality (p=0.29). There was a significant interaction for vascular death (p=0.049). While there was no association with SBP treatment group and vascular death in the younger group (HR: 1.17; 95% CI: 0.68-2.01), there was a significant reduction in vascular death for the elderly in those assigned to the lower target (HR: 0.42; 95% CI: 0.18-0.98). Conclusions: These results provide evidence that elderly (≥75 years) can safely tolerate lowering of SBP. In addition to similar benefit as their younger counterparts regarding stroke, cardiac events, and all cause mortality, elderly SPS3 participants had a decreased risk of vascular death. To decrease the growing stroke burden it is critical that age disparities in treatment are eliminated.