The Highs and Lows of Blood Pressure Targets in Elderly Adults and Other High-Risk Populations.

EDITORIAL The Highs and Lows of Blood Pressure Targets in Elderly Adults and Other High-Risk Populations “T he greatest obstacle to discovery is not ignorance —it is the illusion of knowledge.” —Daniel Boor- stin, 12th Librarian of the U.S. Congress Despite major public health efforts to reduce the prevalence and severity of hypertension, high blood pres- sure (BP) remains a pervasive and important risk factor for cardiovascular and related diseases, especially in elderly adults and racial and ethnic minorities. 1,2 One of the major challenges for providers is the inconsistency of rec- ommendations in the major clinical guidelines. The recent recommendations for the management of high BP by the panel members appointed to the Eighth Joint National Committee (JNC8) included raising the JNC7 recom- mended therapeutic target BP goal for persons aged 60 and older from 140/90 mmHg 1 to 150/90 mmHg. 3 Although many randomized controlled clinical trials have been conducted in older populations, differences in study design (e.g., inclusion and exclusion criteria), outcomes (e.g., differing BP goals and achieved BP levels), medica- tions, and participant characteristics make the creation of clinical guidelines using these heterogeneous studies an art rather than a science and complicating the application of the guidelines to a given person. A truly evidence-based recommendation generalizable to broader and more-speci- fic populations is much more difficult than is generally appreciated. An example of the challenge has been that most ran- domized controlled trials examining BP since the 1980s have compared the clinical outcomes of different pharma- cological therapies and not different BP targets. These studies usually targeted JNC6 or JNC7 BP recommenda- tions of 140/90 mmHg (or even lower targets in the pres- ence of diabetes mellitus or chronic kidney disease) for each arm of differing pharmacological intervention. 1,4 One recent example to better understand the role of BP levels in high-risk older persons was a post hoc analysis 5 per- formed on the International VErapamil SR Trandolapril (INVEST) study 6 cohort, which enrolled 8,354 individuals aged 60 and older (11.6% black, 39.6% Hispanic) with hypertension and coronary artery disease and baseline sys- tolic BP (SBP) of 150 mmHg or greater to atenolol with hydrochlorothiazide or verapamil sustained release (SR) with trandolapril. The INVEST study found similar mor- tality and morbidity in high-risk persons treated with cal- cium channel blockers or beta-blockers treated to JNC6 BP levels. 6 The post hoc analysis found a significantly DOI: 10.1111/jgs.13699 JAGS 63:2139–2141, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society greater graded risk for the unadjusted pooled occurrence of all-cause death, nonfatal myocardial infarction (MI), and nonfatal stroke with increasing levels of achieved BP (SBP <140 vs 140–149 vs ≥150 mmHg). 5 Moreover, in the multiple propensity score–adjusted model, achieving the current 2014 JNC8 panel–recommended SBP target of 140 to 149 mmHg was associated with a greater risk of cardio- vascular mortality (P = .04), total stroke (P = .002), and nonfatal stroke (P = .03) than with with SBP less than 140 mmHg. 5 Although this was a secondary analysis, it provides some limited evidence in the absence of random- ized trials designed to answer that specific question. Another major concern for older persons treated to a more-aggressive BP target is the risk of falls, but again, the data are conflicting. In one study of 406 participants aged 60–86, a higher BP medication dose was associated with more falls; 7 a similar association was observed in 4,961 community-living adults with hypertension aged 70 and older. 8 By contrast, another study found no difference in falls and fractures in a study of intensive BP control (SBP <120 vs < 140 mmHg) that included more than 3,000 individuals aged 40 to 79 with type 2 diabetes mellitus. 9 Finally, two recent metaanalyses found no greater risk of falls in persons aged 60 and older taking antihypertensive medication. 10,11 In this issue of the Journal of the American Geriatrics Society, Still and colleagues 12 provide an excellent review of current guidelines and recent trials for hypertension treatment in older adults, with a focus on African Ameri- cans, a population at especially high risk. 13 Their analysis finds a consistent pattern of BP guideline recommendations from national and international hypertension, cardiovascu- lar, nephrology, and endocrinology associations to target a goal of less than 140/90 mmHg for persons younger than 80 and 150/90 mmHg for those aged 80 and older, paying attention to symptoms or other factors that may mitigate aggressive BP lowering in a given individual aged 60–80. They conclude that there is insufficient evidence is to raise the SBP goal from its current level of less than 140 mmHg, particularly in African Americans or those with cardiovas- cular disease or multiple cardiovascular risk factors. The debate over a target BP of less than 140/ 90 mmHg versus one of 150/90 mmHg at age 60–79 focuses in large part on interpretation of data from differ- ent trials that various experts in the field may weigh differ- ently, but the real question seems to be not so much the difference in clinical outcomes, because there appears to