Do the frail experience more adverse events from intensive blood pressure control? A 2-year prospective study in the Irish Longitudinal Study on Ageing (TILDA).

Patrick O'Donoghue,Roman Romero-Ortuno,Rose Anne Kenny,Aisling M O'Halloran

doi:10.1016/j.eclinm.2022.101304

Abstract

SummaryBackgroundThe 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for management of hypertension in adults aged ≥65 years recommend a blood pressure (BP) treatment target of 130–139/70–79 mmHg if tolerated. Randomised controlled trials have advocated for lower BP, but this may have adverse outcomes in the frail. Yet, definitions of frailty vary.MethodsUsing a prospective, observational study design, we compared two frailty classifications in their ability to predict short-term adverse outcomes associated with intensive BP control (<130/70 mmHg) in The Irish Longitudinal Study on Ageing (TILDA). Data from participants aged ≥65 treated for hypertension in Wave 1 (W1) between October 2009 and June 2011 were analysed. Frailty was identified by Frailty Phenotype (FP) and the Clinical Frailty Scale (CFS). We formulated 8 participant groups based on frailty-BP combinations. Outcomes at wave 2 (W2) in 2012–2013 were analysed with adjusted binary logistic regression models.FindingsOf 1920 W1 participants aged ≥65 and treated for hypertension, 1229 had full BP/FP and 1282 BP/CFS data. While the FP only identified risk of hospitalisation associated with intensive BP treatment, intensively treated frail-by-CFS participants had no increased or decreased risk of adverse outcomes, but those treated above the target had a higher risk of falls/fractures. In the non-frail by FP, intensive blood pressure treatment was associated with reduced risk of falls/fractures.InterpretationDifferent frailty classifications may have different prognostic implications for the purpose of the application of hypertension management guidelines. Our study had limited power due to low frailty prevalences, so further research is needed. Guidelines should specify the recommended frailty identification method/s. In the frail, therapy personalisation is needed.

Highlights

Hypertension is a proven risk factor globally for cardiovascular morbidity including ischaemic heart disease, heart failure, stroke and cardiovascular mortality.[1]
Randomised controlled trials have advocated for lower blood pressure (BP), but this may have adverse outcomes in the frail
None of the The Irish Longitudinal Study on Ageing (TILDA) Wave 1 participants were classified in the Clinical Frailty Scale (CFS) 8 or 9 categories, as noted elsewhere.[27]

Summary

Introduction

Hypertension is a proven risk factor globally for cardiovascular morbidity including ischaemic heart disease, heart failure, stroke and cardiovascular mortality.[1] In epidemiological studies, long-term treatment of hypertension has been shown to reduce both cardiovascular mortality and all-cause mortality.[2] the management of older adults who have hypertension is not clear-cut, as cohort studies have suggested that the cardiovascular benefits of treatment can be offset by the increased risk of adverse events from anti-hypertensive medication including hypotension, falls and associated injuries.[3]. For older adults with hypertension, frailty may add an extra layer of complexity to managing their cardiovascular risks. Frailty has been defined as a state of dysregulation of multiple physiological systems resulting in increased vulnerability to stressors.[4] Frailty is associated with reduced physiological regulation of various organ systems including blood pressure (BP) homeostasis.[5] The clinical characterisation of different BP levels in older people living with frailty is mixed in the literature. In the Lausanne 65+ population-based www.thelancet.com Vol 45 Month March, 2022

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