Hypertension in Older Adults in the Wake of the Systolic Blood Pressure Intervention Trial

H ypertension is the most common chronic condition that geriatricians and other physicians caring for older adults treat in clinical practice. Management of hypertension in this population is a conundrum for healthcare professionals, older adults, and their families. Several studies have shown a decrease in cardiovascular morbidity associated with treatment of hypertension in older adults. Nonpharmacological interventions for hypertension, such as a low-sodium diet that may make food less pleasurable in people with diminished taste sensation, and exercise, which may be limited because of musculoskeletal conditions, are often challenging for older adults. Pharmacological treatment is fraught with hazards in older adults, especially those with multiple morbidities. As practicing geriatricians have witnessed all too often, drugs with hypotensive effects are among the most common agents associated with adverse events resulting in hospitalization. Hypotension and related falls are also among the most common adverse events that occur in skilled nursing facilities. As with most clinical trials of pharmacological treatment for any condition in older adults, studies that have shown benefit from antihypertensive therapy have for the most part systematically excluded the types of people that geriatricians commonly see in practice, making evidence-based treatment decisions challenging. The Systolic Blood Pressure Intervention Trial (SPRINT) offers new data that can assist clinicians in treatment decisions for this common condition. SPRINT randomized 9,361 individuals aged 50 and older (28.2% 75) with systolic blood pressure of 130 to 180 mmHg to a blood pressure treatment target of less than 120 mmHg or to a target of less than 140 mmHg. The trial was terminated early after a median follow-up of 3.26 years because there was a 25% reduction in the primary composite outcome of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or cardiovascular death in the intensive treatment arm (1.65%/year event rate vs 2.19%/year; hazard ratio (HR)50.75, 95% confidence interval (CI)50.64–0.89, p<. 001). All-cause mortality was 27% lower (HR50.73, 95% CI50.60–0.90, p5.003). In individuals aged 75 and older (N52,686, mean aged 79.9, 37.9% women), the effect of intensive treatment on the primary outcome was at least as great as in younger adults (HR50.66, 95% CI50.51–0.85 vs HR50.80, 95% CI50.64–1.00, p-value for interaction5.32); all-cause mortality was lower as well (HR50.67, 95% CI50.49–0.91). Moreover, results were similar across predefined fitness levels (fit, less fit, frail) and in individuals with slow gait speed (<0.8 m/s). The beneficial effects of intensive blood pressure reduction in SPRINT occurred at a cost of higher rates of the serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure (but not injurious falls), with similar findings in individuals younger than 75 and 75 and older. In this issue of the Journal of the American Geriatrics Society, Sink and colleagues provide a more detailed analysis of 3 serious adverse events of particular concern to geriatricians and to all clinicians treating hypertension in older adults—syncope, hypotension, and falls. For this analysis, serious adverse events were defined as those that were “fatal or life-threatening, resulted in significant or permanent disability, required hospitalization, or that the investigators judged represented significant hazards or harm to the participant. ” The main findings were that, after extensive adjustment for numerous potential confounding variables, randomization to the intensive treatment arm was associated with significantly greater risk of hypotension (HR51.67, 95% CI51.21–2.32, p5.002) and possibly syncope (HR51.32, 95% CI50.98–1.75, p5.07) but not falls (HR50.98, 95% CI50.75–1.29) or injurious falls. Older age, frailty, and chronic kidney disease were also associated with greater risk of all three adverse events, but there was no interaction between age and treatment assignment with respect to any of the adverse events. In other words, the effect of intensive treatment on serious adverse events was similar in younger and older adults, including those aged 85 and older. SPRINT was a landmark trial, in part because it was the first major study to enroll individuals with systolic blood pressure in the range of 130 to 160 mmHg and to demonstrate that more intensive blood pressure reduction reduces major cardiovascular events and mortality, including in individuals aged 75 and older. Nonetheless, SPRINT has generated controversy and raised questions about the applicability of the study findings to older adults commonly encountered in routine clinical practice. SPRINT excluded individuals with diabetes mellitus, prior stroke, advanced kidney disease, a recent cardiovascular event, dementia, nursing home residence, life expectancy less than 3 years, and several other conditions (Table 1). Based on an analysis of data from the 2007 to 2012 National Health and Nutrition Examination Surveys (NHANES), only 34.6% of This editorial comments on the article by Sink et al. DOI: 10.1111/jgs.15326