Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality

Abstract

Background Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target <120 mmHg. However, all-cause mortality by attained BP in routine care in frail adults aged above 75 is unclear. Objectives To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty. Methods Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory. Results Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail <85 and frail 75–84-year-olds and all above 85 years. SBPs above the 130–139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75–84 years: 150–159 mmHg Hazard Ratio (HR) mortality compared to 130–139: non-frail HR = 0.94, 0.92–0.97; moderate/severe frailty HR = 0.84, 0.77–0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life. Conclusions In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75–84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.

Diretrizes Brasileiras de Hipertensão Arterial – 2020

“…Isso se deve, principalmente, ao fato de os idosos frágeis e multimórbidos estarem pouco representados nos ECR e pelo alto risco de vieses nos estudos observacionais e não randomizados, nos quais a melhor sobrevida naqueles com PA elevada pode ser explicada porque estes apresentam melhor reserva orgânica. [818][819][820][821][822]…”

“…827,828,831,832 A fragilidade está associada a maior risco de HA, doença subclínica, eventos CV e mortalidade. 821,[833][834][835] O controle adequado da HA pode influenciar a trajetória da fragilidade. Por outro lado, graus avançados de fragilidade estão associados a menores valores de PA, menor índice de massa corporal (IMC), menor massa muscular, pior cognição e maior mortalidade.…”

“…Os idosos mais frágeis foram sistematicamente excluídos dos diversos estudos clínicos, sendo, portanto, fundamentais estudos clínicos específicos para tal população. 307,821 Entre esses extremos, estão os idosos em situação funcional intermediária, com múltiplas comorbidades não CV, que podem gerar grandes desafios para a decisão terapêutica. Neles, uma avaliação mais aprofundada pode ser fundamental para definir o real risco/benefício e a individualização das várias estratégias terapêuticas.…”

Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke

“…We demonstrated poorer blood pressure control in the elderly compared with younger patients. However, hypertension is more prevalent in the elderly [35] and several studies document that this patient population frequently have insufficient BP control [10,13,35]. International guidelines are inconsistent regarding treatment thresholds for BP in older adults [6,7,35], but acknowledge the importance of BP lowering in older age.…”

“…However, hypertension is more prevalent in the elderly [35] and several studies document that this patient population frequently have insufficient BP control [10,13,35]. International guidelines are inconsistent regarding treatment thresholds for BP in older adults [6,7,35], but acknowledge the importance of BP lowering in older age. However, all guidelines recommend thorough monitoring of side effects and clinical judgement to determine BP targets for frail elderly with short life expectancy, when a treatment to target approach might not be beneficial.…”