Abstract
BackgroundIn the very elderly, “the lower the better” hypothesis has constantly been contradicted by randomized control trials and various cohort studies, but inconsistency in results led to unclear blood pressure treatment targets. This study aimed to assess the relationship between baseline blood pressure (BP) and ischemic stroke, myocardial infarction, and all-cause mortality in very elderly people treated for hypertension.MethodsThis large population-based retrospective cohort study was based on the national claims database of the Korean National Health Insurance System, which covers the entire Korean population. 374,250 participants aged ≥ 75 years taking antihypertensive agents were recruited, excluding patients with a history of previous ischemic stroke or myocardial infarction.ResultsSystolic BP (SBP) followed a J curve for ischemic stroke and a U curve for all-cause mortality, with nadir ranges of 120 to 129 mmHg and 140 to 149 mmHg, respectively. While increasing diastolic BP (DBP) generally resulted in higher HRs for ischemic stroke, HRs for myocardial infarction and all-cause mortality significantly increased only when DBP was ≥ 80 mmHg and ≥ 90 mmHg, respectively. The SBP/DBP combination analysis showed that even with SBP < 130 mmHg, higher DBP ≥ 90 mmHg had higher HRs for all three outcomes compared to the reference group (130 to 149 / < 80 mmHg).ConclusionsThere were no further benefits or even harm below certain BP levels for ischemic stroke, myocardial infarction, and all-cause mortality in very elderly hypertensive patients.
Highlights
In the very elderly, “the lower the better” hypothesis has constantly been contradicted by randomized control trials and various cohort studies, but inconsistency in results led to unclear blood pressure treatment targets
This led to the American College of Cardiology/American Heart Association (ACC/AHA) hypertension treatment guidelines to be revised to a target blood pressure (BP) of 130/80 mmHg even for the elderly [16], raising some concerns among experts on how caution must be taken with this new target
While there was no additional consistent trend in ischemic stroke and myocardial infarction (MI), in terms of all-cause death, within the same diastolic BP (DBP) group, the highest hazard ratio (HR) lay in the systolic BP (SBP) groups < 130 mmHg. In this nationwide cohort of 374,250 very old Koreans treated for hypertension, our data showed that there was a relationship between baseline blood pressure and ischemic stroke, MI, and all-cause death, after adjusting for age, sex, body mass index (BMI), smoking, drinking, exercise, income status, diabetes mellitus, dyslipidemia, and chronic kidney disease
Summary
“the lower the better” hypothesis has constantly been contradicted by randomized control trials and various cohort studies, but inconsistency in results led to unclear blood pressure treatment targets. The J-curve observed in a Unites States (US) veteran cohort [8] and in the INVEST trial sub-study [9] illustrates an initial decline in the hazard ratio (HR) in octogenarians as SBP is lowered, but below 140 mmHg cardiovascular outcomes [9] and total mortality [8, 9] increase with an additional SBP decrease. In the SPRINT trial subgroup analysis of individuals 75 years or older, intensive treatment with a goal of SBP < 120 mmHg resulted in significantly lower rates of cardiovascular events, stroke, and all-cause mortality [15] This led to the American College of Cardiology/American Heart Association (ACC/AHA) hypertension treatment guidelines to be revised to a target BP of 130/80 mmHg even for the elderly [16], raising some concerns among experts on how caution must be taken with this new target
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