Wednesday, October 4, 2023
This activity is intended for primary care clinicians, cardiologists, nurses, pharmacists, and other clinicians who treat and manage older adults with hypertension.
The goal of this activity is to compare treatment strategies for the control of hypertension among older adults.
Upon completion of this activity, participants will:
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.
Medscape, LLC designates this enduring material for a maximum of 0.25
AMA PRA Category 1 Credit(s)™
. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.
Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-21-523-H01-P).
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of
continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the
time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the
valid credit period that
is noted on the title page. To receive
AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it.
Credits will be tallied in
your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as
the certificates from the
CME/CE Tracker.
*The credit that you receive is based on your user profile.
CME / ABIM MOC / CE Released: 10/29/2021
Valid for credit through: 10/29/2022, 11:59 PM EST
processing....
"How low is enough?" is a common question when prescribing medications to lower blood pressure, particularly among patients older than 70 years. There is concern that any benefit derived from more intensive hypertension management in this group would be offset by potential adverse effects of aggressive therapy.
SPRINT suggests otherwise. The final report of this randomized trial of adults with hypertension comparing target systolic blood pressure values of less than 120 mm Hg and less than 140 mm Hg found that more strict blood pressure targets were associated with lower risks for cardiovascular disease and overall mortality.[1] This result remained valid in a subgroup analysis of participants who were aged 75 years or older.
A more aggressive systolic blood pressure target was also associated with higher rates of hypotension, electrolyte abnormalities, syncope, and acute kidney injury. The current study again evaluates outcomes associated with tighter hypertension control among older adults, and it features measurement of blood pressure in the home.
Another large clinical trial has endorsed the approach of intensive blood pressure lowering, reinforcing the benefits of this approach seen in the previously reported SPRINT trial.
The STEP trial was conducted in China and involved patients older than 60 years who had hypertension. Intensive treatment with a systolic blood pressure target of 110 to less than 130 mm Hg produced a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than 150 mm Hg.
The intensive group showed a 26% reduction in cardiovascular events, a 33% reduction in stroke, a 33% reduction in acute coronary syndrome (ACS), and a 73% reduction in acute decompensated heart failure.
The intensive group achieved a systolic pressure of 127 mm Hg with an average of 1.9 medications vs 135 mm Hg with an average of 1.5 medications in the standard group.
However, unlike in the SPRINT trial,[2] the lower pressure in the intensive group was achieved without major tolerability issues in the STEP trial, which has been attributed to a healthier population of patients included.
The STEP trial was presented August 30 at the virtual European Society of Cardiology (ESC) Congress 2021 by Jun Cai, MD, from FuWai Hospital, Beijing, China.[3] It was simultaneously published online in the New England Journal of Medicine.[4]
"Several large trials have shown a beneficial effect of intensive blood pressure control on cardiovascular outcomes in older patients, but the appropriate systolic blood pressure target remains unclear," Dr Cai said.
"Our large trial provides important evidence, showing that a reduction in the systolic blood pressure to less than 130 mm Hg resulted in cardiovascular benefits in older patients with hypertension in China," he stated.
"There is no doubt that the intensified treatment dramatically reduced cardiovascular events and was well tolerated, which is an important consideration in older patients. The levels of blood pressure were also achieved with a conventional strategy that we recommend in current guidelines," noted Dr Williams, who was the recent chair of the ESC/European Society of Hypertension guideline task force.
However, he pointed out that the population involved was relatively low risk, robust and healthy, and not all older patients would be able to achieve the blood pressure levels attained in this study.
The STEP trial enrolled 8511 Chinese patients with hypertension, aged 60 to 80 years, who were assigned to a systolic blood-pressure target of from 110 to less than 130 mm Hg (intensive treatment) or a target of from 130 to less than 150 mm Hg (standard treatment).
At 1 year of follow-up, the mean systolic blood pressure was 127.5 mm Hg in the intensive treatment group and 135.3 mm Hg in the standard treatment group.
The primary outcome was a composite of stroke, ACS (acute myocardial infarction and hospitalization for unstable angina), acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes.
During a median follow-up period of 3.34 years, primary outcome events occurred in 3.5% of patients in the intensive treatment group compared with 4.6% of patients in the standard treatment group (hazard ratio, 0.74; 95% confidence interval [CI], 0.60-0.92; P=.007).
The results for safety and renal outcomes did not differ significantly between the 2 groups, except for the incidence of hypotension, which was higher in the intensive treatment group (3.4% vs 2.6%), although there was no difference in dizziness, syncope, or fracture.
"Bespoke Medicine"In his discussion of the trial, Dr Williams noted that the issue of blood pressure targets in older people was challenging because as people age, patient heterogeneity increases dramatically as a consequence of multiple morbidities.
He pointed out that the population in the STEP trial was relatively low risk, with 75% younger than 70 years. Only 2% had a renal impairment, 6% had cardiovascular disease, and patients with prior stroke were excluded. The mean baseline blood pressure was 146/83 mm Hg. "So we're not talking about lowering an elderly person's blood pressure from a very high level down to a low target," he noted.
"This does not diminish the importance of the findings, but it puts them into context on where the patients sit on the scale of heterogeneity."
In a comparison with SPRINT, Dr Williams said the STEP data showed remarkable similarity, with big reductions in major events.
He said there would be suggestions that SPRINT went lower in terms of blood pressure levels, but he noted that SPRINT used a methodology to measure blood pressure which many thought resulted in lower than usual clinic values, and when this is taken into account, "the blood pressure levels achieved in STEP and SPRINT are probably quite similar, as are the outcomes."
What Do Current Guidelines Advise?Dr Williams explained that in terms of current recommendations for older people, US guidelines advise aiming for a blood pressure of below 130/80 mm Hg with no qualifiers. European guidelines recommend getting below 140/90 mm Hg if possible and then aim to go down to 130 mm Hg if tolerated but do not recommend going lower than 130 mm Hg.
"Perhaps as a consequence of this study, you could say that tailored targets in older patients over 65 years of age would be firstly, to try to get blood pressure below 140/90 mm Hg because many patients can't even achieve that level of control. Then we can aim to go lower down below 130 mm Hg if you can, if patients will tolerate it and accepting that this is most likely to be possible in those who are independent and active with fewer comorbidities like the patients in the STEP study."
Also commenting on the STEP results, Diederick Grobbee, MD, University Medical Center, Utrecht, the Netherlands, agreed with Dr Williams.
"This is important information showing that it is possible to lower blood pressure in older patients safely and it works," he said. "It is about generalizability. This population is clearly a healthy one who tolerated this sort of reduction well. We know that many patients can't do this, and these types of patients were not abundant in this study," he said.
European Society of Cardiology (ESC) Congress 2021. Presented August 30, 2021.
N Engl J Med. Published online August 30, 2021.
