1. Blood Pressure and Age in Controlling Hypertension
Michael A. Weber, MD
State University of New York
Downstate College of Medicine

2. Michael Weber, MD Disclosures
Consulting: Boston scientific, Medtronics, Ablative Solutions, ReCor, Novartis Research: Medtronics, Boston Scientific, ReCor, Ablative Solutions, Novartis, Boehringer Ingelheim

3. Coronary Heart Disease
CHD Rates by SBP and Age
120 mm Hg
140 mm Hg
160 mm Hg
180 mm Hg
256
128
Coronary Heart Disease
Mortality 64 32 16 8
For every 20 mm Hg systolic or 10 mm Hg diastolic increase in BP, there is a doubling of mortality from both ischemic heart disease and stroke.
Data from observational studies involving more than 1million individuals have indicated that death from both ischemic heart disease and stroke increases progressively and linearly from BP levels as low as 115 mm Hg systolic and 75 mm Hg diastolic upward. The increased risks are present in all age groups ranging from 40 to 89 years old. 4 2 1
50-59
60-69
70-79
80-89
40-49
Age
Adapted from Lewington et al. Lancet. 2002; 360:

4. Comparison of Event Rates According to Age in ACCOMPLISH
Outcome
Age ≥70 (Mean: 75) (n=4369)
Age <70 (Mean: 64)
(n=6336)
Odds Ratio (95% CI)
← More Events Age <70 Years
More Events → Age ≥70 Years
p-Value
Primary CV Outcome*
317 (7.26%)
264 (4.17%)
1.80 (1.52, 2.13)
<0.0001
Total MI
123 (2.82%)
140 (2.21%)
1.28 (1.00, 1.64)
0.0541
Total Stroke
139 (3.18%)
89 (1.40%)
2.31 (1.76, 3.02)
CV Mortality
124 (2.84%)
65 (103%)
2.82 (2.08, 3.81)
All-cause mortality
260 (5.95%)
154 (2.43%)
2.54 (2.07, 3.11)
* Primary outcome includes CV death or nonfatal MI or stroke
ACCOMPLISH, Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension; CV, cardiovascular; MI, myocardial infarction; CI, confidence interval
Odds Ratio
95% CI
Weber MA ,et al.  ACCOMPLISH. In preparation. 2016

5. Prevalence of High Blood Pressure in Adults by Age and Sex: NHANES 2005-2006 9 NHLBI.

6. The HYpertension in the Very Elderly Trial
N. Beckett, R. Peters, A. Fletcher, C. Bulpitt
on behalf of the HYVET committees and investigators
Beckett NS et al. NEJM 2008;358:1887
ClinicalTrials.gov: NCT

7. Baseline data Placebo (n= 1912) Active (n= 1933) Age (years) 83.5 83.6
Female
60.3%
60.7%
Blood Pressure:
Sitting SBP (mmHg)
173.0
Sitting DBP (mmHg)
90.8
Orthostatic Hypotension
8.8%
7.9%
Isolated Systolic Hypertension
32.6%
32.3%
Beckett NS et al. NEJM 2008; 358:1887

8. HYVET: Total Mortality
(21% reduction)
P=0.019

9. Systolic Hypertension in the Elderly Program (SHEP)
Multicenter, randomized, double-blind, placebo-controlled, patients ≥60 years, systolic BPs ≥160 mm Hg & diastolic BPs <90 mm Hg, using mg chlorthalidone + other drugs if needed (Starting SBP: 170 mm Hg; achieved SBP: Placebo 155 mm Hg, active treatment 143 mm Hg)
Placebo (n=2371)
Active treatment (n=2365)
Cumulative fatal and nonfatal stroke rate per 100 participants 10 8 6 4 2 72 36 12 60 24 48
Months ↓
36%
SHEP Cooperative Research Group. JAMA. 1991;265:

10. James PA. et al. JAMA. 2013 Dec 18. doi: 10. 1001/jama. 2013. 284427
James PA. et al. JAMA Dec 18. doi: /jama [Epub ahead of print].

11. Authors of JNC 8 Panel: Recommendation 1
In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at systolic blood pressure (SBP) of 150 mm Hg or higher or diastolic blood pressure (DBP) of 90 mm Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg.
Strong Recommendation – Grade A
Note: This recommendation – amazingly --replicated by ACP/AAFP Guideline in 2017

12. SPRINT Primary Outcome Cumulative Hazard
Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89)
Standard
(319 events)
Intensive
(243 events)
During Trial (median follow-up = 3.26 years)
Number of
Participants

13. Intensive Treatment (n=1317) Standard Treatment (n=1319)
Cardiovascular (CV) Outcomes by Treatment Group in SPRINT in Patients Aged >75 Years
Outcome
Intensive Treatment (n=1317)
Standard Treatment (n=1319)
H.R. (95% CI)
← Favors Intensive Treatment
Favors → Standard Treatment
p-Value
Primary CV Outcome*
102
148
0.66 (0.51, 0.85)
0.001
Myocardial infarction (MI) 37 53
0.69 (0.45, 1.05)
0.09
ASC not resulting in MI 17
1.03 (0.52, 2.04)
0.94
Stroke 27 34
0.72 (0.43, 1.21)
0.22
Heart failure 35 56
0.62 (0.40, 0.95)
0.03
CV disease mortality 18 29
0.60 (0.33, 1.09)
All-cause mortality 73
107
0.67 (0.49, 0.91)
0.009
Non-CV mortality** 55 78
0.69 (0.49, 0.99)
0.042
* Primary outcome includes nonfatal MI, ACS, nonfatal stroke, nonfatal acute decompensated heart failure, and CV death
** NOT part of original report.  Added by current presenter.
Hazard Ratio (H.R.)
95% CI
Williamson JD, et al. JAMA. 2016;315:2673

14. Frailty in the Aged Generally defined under major categories
Excessive weight loss (or low BMI)
Exhaustion (reporting of weakness/tiredness)
Low physical activity (by activity scale)
Slowness (measured by walking speed)
Weakness (measured by grip strength)
SPRINT utilized a 37 item Frailty Index to divide patients into:
Fit or Less Fit or Frail categories

15. Intensive Treatment (n=1317) Standard Treatment (n=1319)
Cardiovascular (CV) Outcomes and Mortality in SPRINT Patients Aged >75 Years by Frailty Status*
Outcome
Frailty Status*
Intensive Treatment (n=1317)
Standard Treatment (n=1319)
H.R. (95% CI)
← Favors Intensive Treatment
Favors → Standard Treatment
p-Value
p-Value for Interactn
Primary CV Outcome†
Fit
4/159
10/190
0.47 (0.13, 1.39)
0.20
Less fit
48/711
77/745
0.63 (0.43, 0.91)
0.01
0.84
Frail
50/440
61/375
0.68 (0.45, 1.01)
0.06
All-cause mortality
5/159
6/190
0.95 (0.27, 3.15)
0.93
26/711
52/745
0.48 (0.29, 0.78)
0.003
0.52
40/440
49/375
0.64 (0.41, 1.01)
0.05
Primary CV outcome plus all-cause mortality
8/159
11/190
0.71 (0.28, 1.69)
0.45
65/711
108/745
0.60 (0.44, 0.83)
0.002
0.88
69/440
84/375
0.67 (0.48, 0.95)
0.02
Classified using a 37-item frailty index (FI): fit (FI ≤0.10), less fit (FI >0.10 to 0.21), or frail (FI >0.21)
† Primary outcome: nonfatal MI, ACS, nonfatal stroke, nonfatal acute decompensated heart failure, and death from CV causes
Hazard Ratio (H.R.)
95% CI
Williamson JD, et al. JAMA. 2016;315:

16. Mean Patient Age at Baseline in Major Hypertension Outcomes Trials
General High Risk Trials
ACCOMPLISH
ACCORD
ALLHAT
ASCOT
CLARIFY
HOPE
INVEST
SPRINT
VALUE
Trials Targeted at Older Patients
HYVET
SHEP
SPRINT Older
Syst-EUR

17. Conclusions: Hypertension in Older People
Hypertension very common in elderly: about 80% prevalence at ages >75
Benefits of treatment shown at all ages, including > 80
Most obvious benefit is reduced mortality, CV & non-CV
If tolerated, SBP <140 mmHg or even <130 mmHg can be justified in older patients
Patients labeled as “frail” or “less fit” have benefits comparable to the “fit”
Older patients more susceptible to hypotensive symptoms and renal dysfunction, so caution warranted