Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Oct;69(10):2831-2841.
doi: 10.1111/jgs.17295. Epub 2021 Jun 7.

Clinical outcomes of modifying hypertension treatment intensity in older adults treated to low blood pressure

Affiliations

Clinical outcomes of modifying hypertension treatment intensity in older adults treated to low blood pressure

Carole E Aubert et al. J Am Geriatr Soc. 2021 Oct.

Abstract

Background/objectives: Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP.

Design: Longitudinal cohort study (2011-2013) with 9-month follow-up.

Setting: U.S.-nationwide primary care Veterans Health Administration healthcare system.

Participants: Veterans aged 65 and older with baseline SBP <130 mmHg and ≥1 antihypertensive medication during ≥2 consecutive visits (N = 228,753).

Exposure: Deintensification or intensification, compared with stable treatment.

Main outcomes and measures: Cardiovascular events, syncope, or fall injury, as composite and distinct outcomes, within 9 months after exposure. Adjusted logistic regression and inverse probability of treatment weighting (IPTW, sensitivity analysis).

Results: Among 228,753 patients (mean age 75 [SD 7.5] years), the composite outcome occurred in 11,982/93,793 (12.8%) patients with stable treatment, 14,768/72,672 (20.3%) with deintensification, and 11,821/62,288 (19.0%) with intensification. Adjusted absolute outcome risk (95% confidence interval) was higher for deintensification (18.3% [18.1%-18.6%]) and intensification (18.7% [18.4%-19.0%]), compared with stable treatment (14.8% [14.6%-15.0%]), p < 0.001 for both effects in the multivariable model). Deintensification was associated with fewer cardiovascular events than intensification. At baseline SBP <95 mmHg, cardiovascular event risk was similar for deintensification and stable treatment, and fall risk lower for deintensification than intensification. IPTW yielded similar results. Mean follow-up SBP was 124.1 mmHg for stable treatment, 125.1 mmHg after deintensification (p < 0.001), and 124.0 mmHg after intensification (p < 0.001).

Conclusion: Antihypertensive treatment deintensification in older patients with tightly controlled SBP was associated with worse outcomes than continuing same treatment intensity. Given higher mortality among patients with treatment modification, confounding by indication may not have been fully corrected by advanced statistical methods for observational data analysis.

Keywords: Veterans; cardiovascular event; deintensification; elderly; fall injury; hypertension; intensification; syncope; treatment.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

FIGURE 1
FIGURE 1
Study design. Eligibility was defined as two consecutive visits with systolic blood pressure <130 mmHg and ≥1 antihypertensive medication within a 2‐year period. Treatment assignment was defined by calculating the difference (Δ) in dose and medication count between day 0 (baseline) and day 90. The follow‐up was between 90 days and 1 year after baseline
FIGURE 2
FIGURE 2
Adjusted absolute risk for (A) composite outcome, (B) cardiovascular event, (C) syncope, and (D) fall injury, according to dose change and baseline systolic blood pressure. Based on logistic regression models weighted to account for missing outcome. The models included interaction terms between age and systolic blood pressure and between systolic blood pressure and treatment strategy, and were also adjusted for baseline antihypertensive medication dose and for chronic conditions (Table S1)

Similar articles

Cited by

References

    1. Dorans KS, Mills KT, Liu Y, He J. Trends in prevalence and control of hypertension according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline. J Am Heart Assoc. 2018;7:e008888. - PMC - PubMed
    1. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887‐1898. - PubMed
    1. Sprint Research Group , Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood‐pressure control. N Engl J Med. 2015;373:2103‐2116. - PMC - PubMed
    1. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673‐2682. - PMC - PubMed
    1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127‐e248. - PubMed

Publication types

Substances