Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years

Williamson, Jeff D.; Supiano, Mark A.; Applegate, William B.; Berlowitz, Dan R.; Campbell, Ruth; Chertow, Glenn M.; Fine, Larry; Haley, William E.; Hawfield, Amret; Ix, Joachim H.; Kitzman, Dalane W.; Kostis, John B.; Krousel‐Wood, Marie; Launer, Lenore J.; Oparil, Suzanne; Rodríguez, Carlos J.; Roumie, Christianne L.; Shorr, Ronald I.; Sink, Kaycee M.; Wadley, Virginia G.; Whelton, Paul K.; Whittle, Jeff; Woolard, Nancy; Wright, Jackson T.; Pajewski, Nicholas M.

doi:10.1001/jama.2016.7050

Cited by 1,008 publications

(851 citation statements)

References 34 publications

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“…We observed lower prevalence and odds of treatment intensification in older adults; this may result from a relative lack of evidence supporting a goal SBP less than 150 mm Hg in the elderly28, 29 until the recent SPRINT results 15, 16. In contrast, for people with diabetes mellitus, a goal SBP/DBP of 130/80 mm Hg was recommended in 2003,12 and yet treatment intensification from 2005 to 2012 among diabetic adults remained low even compared to those without diabetes mellitus.…”

Section: Discussionmentioning

confidence: 83%

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Lin

Mukamal

2016

JAHA

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BackgroundHypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all‐cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.Methods and ResultsUsing the nationally representative National Ambulatory Medical Care Survey (2005–2012) and National Hospital Ambulatory Medical Care Survey (2005–2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005–2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2–7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.ConclusionsUS hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension‐related morbidity and mortality nationwide.

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Section: Discussionmentioning

confidence: 83%

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Lin

Mukamal

2016

JAHA

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“…These trials consistently show that reducing BP from high to moderate levels reduces ASCVD risks. Some trials have demonstrated that more aggressive BP reductions achieve proportionally greater benefits but at the expense of greater iatrogenic risks, particularly in those with poor health or frailty (13,57 Significant RRR demonstrated with tight control for diabetes-related death, microvascular disease, and stroke at 10 years were not sustained at the posttrial follow-up (56,59). No age-based subgroup analysis was performed; however, the average age of subjects at the posttrial evaluation was 63 6 8 years, suggesting relevance to older adult populations.…”

Section: Bpmentioning

confidence: 99%

“…For example, benefits of cholesterol-or BP-lowering therapies are counterbalanced by higher risk for myalgias and/or hypotension and falls (13,14). Strict glycemic control is counterbalanced by risk for hypoglycemia (15,16).…”

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confidence: 99%

Management of Atherosclerotic Cardiovascular Disease Risk Factors in the Older Adult Patient With Diabetes

Korytkowski

Forman

2017

Diabetes Care

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Older adults with diabetes are at higher risk for atherosclerotic cardiovascular disease (ASCVD) than younger adults with diabetes and older adults without diabetes. The rationale to implement ASCVD risk-lowering therapies in older adults with diabetes is compelling. Recommendations for lifestyle modification, lipidlowering therapy, blood pressure management, blood glucose control, and aspirin therapy are often based on studies that show their efficacy in younger populations. However, the risks associated with each of these interventions increase with age, and favorable risk-to-benefit ratios demonstrated in younger adults with diabetes are less certain in older populations. The variability in health status among older adults is pertinent. Those with robust health are more likely to tolerate and derive benefit from many therapies when compared with those who have more complex health including frailty. Age-and/or frailty-stratified data to help clarify these relationships are sparse. In this Perspective, current recommendations for modifying ASCVD risk are described with a review of the pertinent literature that guides their application in older adults. A pragmatic approach to the treatment of ASCVD risk factors in older adults with diabetes is presented.Diabetes is highly prevalent in the aging population, affecting .25% of individuals aged .65 years and 19% of those aged .75 years (1,2). Physiological changes associated with aging increase susceptibility to coronary heart disease and other atherosclerotic cardiovascular disease (ASCVD) processes (3). The incidence and prevalence of ASCVD-related macrovascular events essentially doubles in older adults with diabetes (4-6). The overlap of older age, diabetes, and other ASCVD risk factors enhances risk for microvascular and macrovascular complications, functional disability, and geriatric syndromes (including frailty, multimorbidity, polypharmacy, cognitive impairment, depression, urinary incontinence, and falls) (1,7-10). As the population of older adults grows, the implications of diabetes on ASCVD risk escalate, and insights regarding optimal care become increasingly important (2).Therapies directed at ASCVD risk factor reduction are important therapeutic priorities for older adults with diabetes as a way of modifying risk for vascular events and improving health-related quality of life (HRQL) (11,12). Therapeutic targets include control of lipids, blood pressure (BP), and blood glucose in combination with antiplatelet agents. The expectation is that these therapies will increase longevity, reduce ASCVD events and need for hospitalizations, and improve HRQL. However, iatrogenic risks and limited life expectancy confound these objectives

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“…What has received scarce attention is that the method of measuring BP in SPRINT was, as expected, research grade. Measurement was performed after a mandatory seated rest in a quiet room for 5 minutes, after which 3 recordings were made at 1‐minute intervals 3. No observer was present in the room during the measurement.…”

Section: Introductionmentioning

confidence: 99%

Implications of Blood Pressure Measurement Technique for Implementation of Systolic Blood Pressure Intervention Trial (SPRINT)

Agarwal

2017

JAHA

107

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BackgroundCardiovascular morbidity and mortality was reduced by 25% when blood pressure (BP) was targeted to 120 mm Hg systolic compared with 140 mm Hg systolic in Systolic Blood Pressure Intervention Trial (SPRINT); however, BP was measured using a research technique. SPRINT specified 5 minutes of seated rest in a quiet room followed by 3 oscillometric measurements without an observer in the room. The relationship of this research‐grade methodology to routine BP measurements is not known.Methods and ResultsAmong 275 people with chronic kidney disease who had BP <140/90 mm Hg when they came to the clinic, we measured BP as in SPRINT and recorded BP on the same day without specification of seated rest. Compared with routine measurement, the research‐grade systolic BP was 12.7 mm Hg lower with wide limits of agreement (−46.1 to 20.7 mm Hg). Research grade systolic BP was 7.9 mm Hg lower than daytime ambulatory systolic BP and had wide agreement limits (−33.2 to 17.4 mm Hg). Whereas the routine, research‐grade, and daytime ambulatory systolic BP were all related to echocardiographic left ventricular hypertrophy, the strength of the relationship between research‐grade and daytime ambulatory systolic BP to left ventricular hypertrophy was similar and stronger than the strength of the relationship between routine systolic BP and left ventricular hypertrophy.ConclusionsTaken together, these results suggest that translation of the SPRINT results will require measurement of BP as performed in that trial. Instead of an algebraic manipulation of routine clinic measurements, the SPRINT methodology of BP measurement would be needed at minimum if implementation of the SPRINT results were to be deployed in the population at large.

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Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years

Cited by 1,008 publications

References 34 publications

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Management of Atherosclerotic Cardiovascular Disease Risk Factors in the Older Adult Patient With Diabetes

Implications of Blood Pressure Measurement Technique for Implementation of Systolic Blood Pressure Intervention Trial (SPRINT)

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