BACKGROUND AND PURPOSE: 

• It is unclear how much older patients benefit from blood pressure lowering pharmacological intervention, particularly when their blood pressure is not substantially increased 
• The Blood Pressure Lowering Treatment Trialists’ Collaboration (Lancet, 2021) compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline 

METHODS: 

• Systematic review and meta-analysis 
  • Individual participant-level data from randomized controlled trials 
• Study inclusion criteria 
  • Pharmacological blood-pressure-lowering vs placebo or other classes of blood-pressure-lowering medications 
  • More vs less intensive treatment strategies 
  • Exclusion: Previous history of heart failure 
• Study design 
  • Patients were categorized into  
    • Baseline age groups: <55 years, 55 to 64 years, 65 to 74 years, 75 to 84 years, and ≥85 years 
    • Blood pressure categories: In 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic 
• Primary outcome 
  • Composite: Fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischemic heart disease 
  • Heart failure causing death or requiring hospital admission 

RESULTS: 

• 358,707 participants | 51 randomized clinical trials 
  • Age range 21 to 105 years (median 65; IQR 59 to 75) 
    • Participants <55 years: 12.0% 
    • 55 to 64: 35.8% 
    • 65 to 74 years: 35.8% 
    • 75 to 84 years: 15.1% 
    • ≥85 years: 1.3% 
• Hazard ratios (HR) for risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure (adjusted p_interaction=0.050) 
  • <55 years: HR 0.82 (95% CI, 0.76 to 0.88) 
  • 55 to 64 years: HR 0.91 (95% CI, 0.88 to 0.95) 
  • 65 to 74 years: HR 0.91 (95% CI, 0.88 to 0.95) 
  • 75 to 84 years: HR 0.91 (95% CI, 0.87 to 0.96) 
  • ≥85: HR 0.99 (95% CI, 0.87 to 1.12) 
• Similar patterns of proportional risk reductions were observed per 3 mm Hg reduction in diastolic blood pressure 
• Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups 

CONCLUSION: 

• Pharmacological blood pressure reduction appears to have a sustained benefit into old age 
  • Risk reduction for major cardiovascular events did not vary by blood pressure levels at randomization, down to <120/70 mmHg 
• The authors conclude that age-related blood-pressure thresholds should be removed from international guidelines 
• The authors conclude 

…we found no evidence to substantiate the common approach of withholding antihypertensive treatment for older adults, in particular when their blood pressure is not highly elevated 

Therefore, pharmacological blood pressure reduction should be considered as an important treatment option for the prevention of cardiovascular events even in those aged 80 years or older and guidelines should be simplified to remove any differing blood pressure thresholds by age 

Learn More – Primary Sources: 

Age-stratified and blood-pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis 

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