INVESTing in the question of BP goals for the elderly

An appropriate, risk-reducing goal for blood pressure (BP) in elderly hypertension patients is the heart of targets in a study that took recommendations by the 2014 Eighth Joint National Committee panel to task. The results were published in the Aug. 26 issue of the Journal of the American College of Cardiology.

The research team led by Sripal Bangalore, MD, MHA, of the New York University School of Medicine in New York City, questioned whether recommendations by the committee were aggressive enough. Instead of previously recommended goals of lowering hypertensive BP below 140 mm Hg, new committee recommendations suggested lowering below 150 to be sufficient.

Bangalore et al asked if this was optimal treatment for elderly patients whose BP was originally 150 mm Hg or higher and attempted to determine, using the INVEST (INternational VErapamil SR Trandolapril Study) data set, at what point patients had the most benefit from BP reduction therapies.

The team analyzed data from 8,354 patents in three groups: those who achieved a BP of less than 140 mm Hg, those who achieved BP between 140 and 149 mm Hg, and those whose BP was greater than or equal to 150 mm Hg after treatment, which ended up representing 57 percent, 21 percent and 22 percent of the total patient cohort, respectively.

Bangalore et al found that patients in the below 140 mm Hg treated BP group had lower rates for combined outcomes, death, MI and stroke compared to those with higher BP. However, they noted that there was a higher risk of cardiovascular mortality and stroke in the group between 140 and 149 mm Hg. These findings are similar to those reported in other research in recent weeks.

While they noted that there is less benefit to achieving a target between 140 and 149 mm Hg, per recommendations, than earlier recommendations of less than 140 mm Hg, there is still debate over what the target should be. As they wrote, Bangalore et al did not design the current analysis to investigate the “lower is better” statements of past work. Bangalore et al noted that in other analyses of the INVEST data, there were J-curves shown in relationship to BP and cardiovascular events.

Further, they noted that patients with lower BP in this analysis had “significantly fewer strokes and cardiovascular mortality.”

Meanwhile, Alan H. Gradman, MD, of Temple University School of Medicine in Philadelphia, wrote in a commentary that this study did not pick out a “sweet spot” either, especially noting that even if it were found, it is difficult to maintain any ideal BP in real-world patients. However, Gradman wrote that while the committee recommendations were reasonable for hypertensive  patients with coronary artery disease, other risks should be taken into consideration when recommending lower BP goals.

“For high-risk diabetic patients, the lower target of less than 140/90 mm Hg is recommended for patients regardless of age.” Further, Gradman noted that stroke risks, which are sensitive to BP, should be part of physician decision making.