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CME / ABIM MOC / CE

Does Intensive Blood Pressure Lowering Show Benefit?

  • Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/29/2021
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 10/29/2022, 11:59 PM EST
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Target Audience and Goal Statement

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:

  • Assess final results of the Systolic Blood Pressure Intervention Trial (SPRINT) comparing different strategies for blood pressure control
  • Compare outcomes of intensive vs standard blood pressure control targets among older adults
  • Outline implications for the healthcare team


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News Author

  • Sue Hughes

    Journalist
    Medscape Medical News

    Disclosures

    Disclosure: Sue Hughes has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

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    Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

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    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.


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CME / ABIM MOC / CE

Does Intensive Blood Pressure Lowering Show Benefit?

Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 10/29/2021

Valid for credit through: 10/29/2022, 11:59 PM EST

processing....

Clinical Context

"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.

Study Synopsis and Perspective

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.

Study Highlights

  • Adults between 60 and 80 years of age were eligible for study participation if they had a blood pressure of at least 140/90 mm Hg on 3 screening visits or were receiving antihypertensive treatment.
  • Adults with any history of stroke were excluded from study participation.
  • Participants were randomly assigned to treatment with systolic blood pressure targets of from 110 to 129 mm Hg or from 130 to 149 mm Hg. Participants were provided with olmesartan, amlodipine, and hydrochlorothiazide to treat hypertension.
  • Participants were followed with clinic visits at least every 3 months. They were also instructed to measure their blood pressure at home at least weekly and transmit their results to the research team via an app on their mobile phone.
  • The main study outcome was a composite of stroke, acute coronary syndrome, acute decompensated heart failure, atrial fibrillation, and cardiovascular death. Researchers also analyzed individual elements of the composite outcome, as well as overall mortality and adverse events.
  • 8511 adults participated in the trial. The rate of study attrition was only 2.7%.
  • The mean age of participants was 66.2 years, and 53.5% were women; 6.3% of participants had a prior history of cardiovascular disease.
  • 95.8% of participants entered home blood pressure values via the app.
  • The trial was stopped early after 2 consecutive interim analyses found superior outcomes in the intensive blood pressure control group.
  • During a median follow-up period of 3.34 years, the mean decrease in systolic blood pressure from baseline was 19.4 mm Hg in the intensive treatment group and 10.1 mm Hg in the standard-treatment group. The respective mean blood pressure values on treatment were 126.7 and 135.9 mm Hg.
  • The rates of the primary outcome was 3.5% and 4.6% in the intensive treatment and standard groups, respectively. The hazard ratio for the main study outcome was 0.74 (95% CI, 0.60-0.92) in comparing the intensive treatment and standard treatment groups.
  • Individual components of the main study outcome improved with intensive vs standard treatment were stroke, acute coronary syndrome, and acute decompensated heart failure. The hazard ratio for mortality in the intensive treatment vs standard treatment group was 1.11 (95% CI, 0.78-1.56), and there was a nonsignificant difference for cardiovascular death as well. The overall respective HR for major adverse cardiac events (MACE) was 0.72 (95% CI, 0.56-0.93).
  • Hypotension was slightly more common in the intensive treatment group, but dizziness was not. There was no difference between groups in terms of syncope or fracture.
  • Renal outcomes were also similar in comparing the intensive treatment and standard treatment groups.

Clinical Implications

  • SPRINT found that more strict blood pressure targets were associated with lower risks for cardiovascular disease and overall mortality. This result remained valid in a subgroup analysis of participants who were aged 75 years or more. A more aggressive systolic blood pressure target was also associated with higher rates of hypotension, electrolyte abnormalities, syncope, and acute kidney injury.
  • In the current study of older adults with hypertension, a strategy of intensive control was associated with a lower risk for MACE vs standard control, although mortality outcomes were similar between groups. There no was difference between groups in terms of syncope or fracture.
  • Implications for the healthcare team: The healthcare team should consider more intensive blood pressure targets among older adults at lower risk for hypotension and falls.

 

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