Blood pressure control in older adults with hypertension: A systematic review with meta-analysis and meta-regression

Abstract

Background: Managing blood pressure reduces CVD risk, but optimal treatment thresholds remain unclear as it is a balancing act to avoid hypotension-related adverse events.

Objectives: This systematic review, meta-analysis and meta-regression evaluated the benefits of intensive BP treatment in hypertensive older adults.

Methods: We systematically searched PubMed, MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials until January 31, 2020. Studies comparing different BP treatments/targets and/or active BP against placebo treatment, with a minimum 12 months follow-up, were included. Risk ratios (RR) and 95% CIs were calculated using a random effects model. The primary outcome was RR of major cardiovascular events (MCEs); secondary outcomes included myocardial infarction (MI), stroke, heart failure (HF), cardiovascular (CV) mortality, and all-cause mortality.

Results: We included 16 studies totaling 65,890 hypertensive participants (average age 69.4 years) with a follow-up period from 1.8 to 4.9 years. Intensive BP treatment significantly reduced the relative risk of MCEs by 26% (RR:0.74, 95%CI 0.64-0.86, p = 0.000; I ² = 79.71%). RR of MI significantly reduced by 13% (RR:0.87, 95%CI 0.76-1.00, p = 0.052; I ² = 0.00%), stroke by 28% (RR:0.72, 95%CI 0.64-0.82, p = 0.000; I ² = 32.45%), HF by 47% (RR:0.53, 95% CI 0.43-0.66, p = 0.000; I ² = 1.23%), and CV mortality by 24% (RR:0.76, 95%CI 0.66-0.89, p = 0.000; I ² = 39.74%). All-cause mortality reduced by 17% (RR:0.83, 95%CI 0.73-0.93, p = 0.001; I ² = 53.09%). Of the participants - 61% reached BP targets and 5% withdrew; with 1 hypotension-related event per 780 people treated.

Conclusions: Lower BP treatment targets are optimal for CV protection, effective, well-tolerated and safe, and support the latest hypertension guidelines.

Keywords: BP, blood pressure; Blood pressure treatment targets; CI, confidence interval; CV, cardiovascular; CVD, cardiovascular disease; Cardiovascular events; HF, heart failure; Hypertension; MCE, major cardiovascular event; Mortality; RR, relative risk or risk ratio.

Fig. 1

PRISMA flow diagram.

Fig. 2

Effect of intensive BP treatment on relative risk of major cardiovascular event and all-cause mortality. A p-value <0.05 represents a significant pooled point of estimate of risk ratio. Short vertical lines across each horizontal lines and horizontal lines represents risk ratio and 95% confidence interval (CI) for each study. The vertical line on the scale 1 interval across all horizontal lines represents the estimate of overall risk ratio. The diamond represents the 95% CI for pooled estimates of effect of risk ratio. Tx represent treatment.

Fig. 3

Effect of intensive BP treatment on relative risk of cardiovascular outcome events. A p-value <0.05 represents a significant pooled point of estimate of risk ratio. Short vertical lines across each horizontal lines and horizontal lines represents risk ratio and 95% confidence interval (CI) for each study. The vertical line on the scale 1 interval across all horizontal lines represents the estimate of overall risk ratio. The diamond represents the 95% CI for pooled estimates of effect of risk ratio. Tx represent treatment.