Intensive blood pressure lowering in older people with hypertension: a systematic review and meta-analysis

Abstract

Hypertension is a prevalent chronic disease associated with increased risk of ischaemic heart disease, stroke, and heart failure, especially in older people. Recommendations on blood pressure target in older patients are not consistent among guidelines. While most guidelines suggested the target of systolic blood pressure (SBP) <140 mmHg or a more relaxing target of 150 mmHg in older people, several guidelines suggested a more intensive target of <130 mmHg or <120 mmHg.The objective of this study is to evaluate the benefits and adverse side effects of intensive blood pressure targets, defined as SBP <130mmHg, compared to standard blood pressure targets, defined as SBP <140mmHg, in older people with hypertension.We performed a systematic review and meta-analysis of randomised controlled trials comparing intensive blood pressure targets (SBP <130mmHg) with standard blood pressure targets in older people (aged≥60 years). Pooled odds ratios (ORs) and 95% Confidence Intervals (95%CI) were estimated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. The study outcomes include all-cause mortality, cardiovascular mortality, major adverse cardiac events (MACE), acute coronary syndrome, stroke, heart failure, and adverse side effects including hypotension, syncope, falls and acute kidney injury.A total of 485 articles were identified, of these, 4 studies were included in this analysis. These 4 trials randomised 12,456 patients to either intensive blood pressure targets or standard blood pressure targets. Intensive blood target was defined as SBP <120 mmHg in 2 trials, and as SBP <130 mmHg in 2 trials. The meta-analysis showed that intensive blood pressure control was associated with reduced MACE (OR 0.69, 95%CI 0.58-0.83), acute coronary syndrome (OR 0.70, 95% CI 0.55-0.90), heart failure (OR 0.55, 95% CI 0.37-0.80), and stroke (OR 0.65, 95% CI 0.49-0.86). Similar trend was observed with all-cause mortality (OR 0.81, 95%CI 0.64-1.01) and cardiovascular mortality (OR 0.67, 95%CI 0.44-1.02), although not statistically significant. In terms of adverse effects, intensive blood pressure control was significantly associated with increased hypotension compared to standard blood pressure targets: OR 1.32 (95% CI 1.06-1.65, p=0.01). However, there was no significant difference in falls, syncope, or acute kidney injury between the two groups.While the evidence base is limited, this analysis suggests that intensive blood pressure target may be a beneficial strategy in reducing the risk of cardiovascular events in the elderly population with hypertension. More studies are needed to evaluate the impact of this strategy on mortality and on the adverse side effects in older populations.Outcome: strokeOutcome: mortality