Cochrane Clinical Answers - Fulltext - What are the benefits and harms of blood pressure targets in older adults with hypertension?

Question:What are the benefits and harms of blood pressure targets in older adults with hypertension?

THIS CLINICAL ANSWER IS NEW Published Online: 20 DEC 2017

Clinical Answer:

Using a lower blood pressure (BP) target in older adults may decrease the number with systolic or diastolic hypertension and the number dying or experiencing a serious cardiovascular or cerebrovascular event, but the quality of evidence is low, and the numbers of people who would experience these outcomes very low; therefore no firm conclusions can be drawn.

Compared with a lower BP target (systolic < 140 mmHg and diastolic 90 mmHg) in adults with systolic or diastolic hypertension, evidence from randomized controlled trials (RCTs) suggests that a higher BP target (systolic < 150 to 160 mmHg and diastolic 95 to 100 mmHg) results in more deaths, both all-cause (on average, 39 vs 31 per 1000 people; low-quality evidence) and cardiovascular (on average, 6 vs 4 per 1000 people) across a mean follow-up of 2.6 years. Evidence also suggests that more people with a higher BP target experienced a serious cardiovascular event (on average, 50 vs 42 per 1000 people; low-quality evidence), cerebrovascular disease (on average, 29 vs 24 per 1000 people), or stroke (on average, 25 vs 20 per 1000 people; low-quality evidence); researchers reported no clear differences between groups in renal failure, vascular disease, or cardiac disease. Event rates for these outcomes were very low, and analyses of outcomes with the lowest event rates were underpowered to detect differences between groups even if differences were present. Trials reported no clear differences between groups in the overall incidence of serious adverse events or in the numbers of people withdrawing from treatment owing to adverse events (low-quality evidence), but again, event rates were low.

It is worth noting that all three trials were conducted in far Eastern countries, used different medications, and included people with varying risk factors, so it is unclear how these findings will apply to specific scenarios or populations.

Full outcome data is detailed below:

1.Higher versus lower blood pressure (BP) target

  • Population, Intervention, Comparator

    Population:

    Adults (mean age range 74 to 77 years, 38% to 66% men) with systolic hypertension (2 trials) or systolic or diastolic hypertension (1 trial). The proportion of participants with diabetes was 12% to 23%, and 14% to 25% smoked; one trial (4418 participants) reported that 55% had received prior BP treatment. Trials were conducted in Japan (2 trials) or China (1 trial).

    Initial medication was a long-acting dihydropyridine calcium antagonist (efonidipine; 1 trial), angiotensin II type 1 receptor blocker (valsartan; 1 trial), or monotherapy with an angiotensin-converting-enzyme inhibitor (enalapril), beta-blocker (bisoprolol or metoprolol), calcium channel blocker (amlodipine), or diuretic (indapamide) (1 trial). All three trials adjusted drug upwards, and numbers of drugs increased, until BP achieved the required target

    Intervention:

    Higher BP target: Systolic < 150-160 mmHg and diastolic 95-100 mmHg

    Comparator:

    Lower BP target: Systolic < 140 mmHg and diastolic 90 mmHg

  • OUTCOME 1.1: All-cause mortality (mean 2.6 years’ follow-up)

    Quality of the evidence:

    The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

    Narrative result:

    Three RCTs with 8221 participants found that more people died in the higher BP target group than the lower target group, but the difference did not quite reach statistical significance.

    Relative effect or mean difference:

    There was no statistically significant difference between groups (RR 1.24, 95% CI 0.99 to 1.54).

    Forest plot from Cochrane Review

    Absolute effect:

    39 per 1000 people (95% CI 31 to 48) with higher BP target compared with 31 per 1000 people with lower BP target.

    Reference:
    Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
    • OUTCOME 1.2: Cardiovascular mortality (mean 2.6 years’ follow-up)

      Risk of bias of studies:

      The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the three studies, two failed to report adequate allocation concealment, none blinded participants/carers and one had unclear numbers of withdrawals; all used appropriate random sequence generation and blinded outcome assessors.

      Narrative result:

      Three RCTs with 8221 participants found that more people died due to cardiovascular causes with higher BP target than with lower BP target.

      Relative effect or mean difference:

      There was a statistically significant difference between groups, in favor of lower BP target (RR 1.52, 95% CI 1.06 to 2.19).

      Forest plot from Cochrane Review

      Absolute effect:

      6 per 1000 people (95% CI 4 to 9) with higher BP target compared with 4 per 1000 people with lower BP target.

      Reference:
      Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
      • OUTCOME 1.3: Serious cardiovascular events (mean 2.6 to 3 years’ follow-up)

        Quality of the evidence:

        The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

        Narrative result:

        Three RCTs with 8221 participants found that more people experienced a serious cardiovascular event with the higher BP target, but the analysis did not quite reach statistical significance. Serious cardiovascular events included cerebrovascular disease, cardiac disease, vascular disease, and renal failure.

        Each component of the composite of serious cardiovascular disease was analyzed separately. More people experienced a cerebrovascular disease with the higher BP target, but the analysis did not reach statistical significance; there were no statistically significant differences between groups for the other outcomes. Click below for full details.

        Relative effect or mean difference:

        There was no statistically significant difference between groups (RR 1.19, 95% CI 0.98 to 1.45).

        Forest plot from Cochrane Review

        Absolute effect:

        50 per 1000 people (95% CI 41 to 61) with higher BP target compared with 42 per 1000 people with lower BP target.

        Reference:
        Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
        • Subgroup analysis 1.3.1: Serious cardiovascular events – [subgroup: Cerebrovascular disease]
          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the three studies, two failed to report adequate allocation concealment, none blinded participants/carers and one had unclear numbers of withdrawals; all used appropriate random sequence generation and blinded outcome assessors.

          Narrative result:

          Three RCTs with 8221 participants found that more people experienced a cerebrovascular disease with the higher BP target, but the analysis did not reach statistical significance.

          Relative effect or mean difference:

          There was no statistically significant difference between groups (RR 1.22, 95% CI 0.93 to 1.61).

          Forest plot from Cochrane Review

          Absolute effect:

          29 per 1000 people (95% CI 22 to 38) with higher BP target compared with 24 per 1000 people with lower BP target.

          Reference:
          Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
        • Subgroup analysis 1.3.2: Serious cardiovascular events – [subgroup: Cardiac disease]
          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the three studies, two failed to report adequate allocation concealment, none blinded participants/carers and one had unclear numbers of withdrawals; all used appropriate random sequence generation and blinded outcome assessors.

          Narrative result:

          Three RCTs with 8221 participants found no statistically significant difference between groups.

          Relative effect or mean difference:

          There was no statistically significant difference between groups (RR 1.21, 95% CI 0.82 to 1.79).

          Forest plot from Cochrane Review

          Absolute effect:

          13 per 1000 people (95% CI 9 to 19) with higher BP target compared with 11 per 1000 people with lower BP target.

          Reference:
          Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
        • Subgroup analysis 1.3.3: Serious cardiovascular events – [subgroup: Vascular disease]
          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study used adequate allocation concealment, random sequence generation and blinding of outcome assessors, and had low numbers of withdrawals, but did not blind participants/carers.

          Narrative result:

          One RCT with 4418 participants found no statistically significant difference between groups.

          Relative effect or mean difference:

          There was no statistically significant difference between groups (RR 2.01, 95% CI 0.37 to 10.94).

          Forest plot from Cochrane Review

          Absolute effect:

          2 per 1000 people (95% CI 0 to 10) with higher BP target compared with 1 per 1000 people with lower BP target.

          Reference:
          Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
        • Subgroup analysis 1.3.4: Serious cardiovascular events – [subgroup: Renal failure]
          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the two studies, one failed to report adequate allocation concealment, neither blinded participants/carers and one had unclear numbers of withdrawals; both used appropriate random sequence generation and blinded outcome assessors.

          Narrative result:

          Two RCTs with 7497 participants found no statistically significant difference between groups.

          Relative effect or mean difference:

          There was no statistically significant difference between groups (RR 0.85, 95% CI 0.38 to 1.89).

          Forest plot from Cochrane Review

          Absolute effect:

          3 per 1000 people (95% CI 1 to 7) with higher BP target compared with 4 per 1000 people with lower BP target.

          Reference:
          Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
      • OUTCOME 1.4: Stroke (mean 2.6 years’ follow-up)

        Quality of the evidence:

        The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

        Narrative result:

        Three RCTs with 8221 participants found that more people experienced a stroke with the higher BP target, but the analysis did not reach statistical significance.

        Relative effect or mean difference:

        There was no statistically significant difference between groups (RR 1.25, 95% CI 0.94 to 1.67).

        Forest plot from Cochrane Review

        Absolute effect:

        25 per 1000 people (95% CI 19 to 33) with higher BP target compared with 20 per 1000 people with lower BP target.

        Reference:
        Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
        • OUTCOME 1.5: Mean systolic BP achieved (mean 2.6 years’ follow-up)

          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the three studies, two failed to report adequate allocation concealment, none blinded participants/carers and one had unclear numbers of withdrawals; all used appropriate random sequence generation and blinded outcome assessors.

          Narrative result:

          Three RCTs with 8221 participants found that mean systolic BP achieved was higher with the higher BP target compared with lower BP target.

          Relative effect or mean difference:

          There was a statistically significant difference between groups, in favor of the lower BP target (mean difference 8.88 mmHg, 95% CI 8.38 to 9.39).

          Forest plot from Cochrane Review

          Reference:
          Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
          • OUTCOME 1.6: Mean diastolic BP achieved (mean 2.6 years’ follow-up)

            Risk of bias of studies:

            The reviewers did not perform a GRADE assessment of the quality of the evidence. Of the three studies, two failed to report adequate allocation concealment, none blinded participants/carers and one had unclear numbers of withdrawals; all used appropriate random sequence generation and blinded outcome assessors.

            Narrative result:

            Three RCTs with 8221 participants found that the mean diastolic BP achieved was higher with the higher BP target compared with lower BP target.

            Relative effect or mean difference:

            There was a statistically significant difference between groups, in favor of the lower BP target (mean difference 3.09 mmHg, 95% CI 2.72 to 3.47).

            Forest plot from Cochrane Review

            Reference:
            Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
            • OUTCOME 1.7: Total serious adverse events (median 3 years’ follow-up)

              Risk of bias of studies:

              The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, or blinding of participants/carers and had unclear numbers of withdrawals, but used appropriate random sequence generation and blinded outcome assessors.

              Narrative result:

              One RCT with 3079 participants found no statistically significant difference between groups. Serious adverse events included death, hospitalization and/or events requiring medical treatment.

              Relative effect or mean difference:

              There was no statistically significant difference between groups (RR 0.93, 95% CI 0.69 to 1.24).

              Forest plot from Cochrane Review

              Absolute effect:

              52 per 1000 people (95% CI 39 to 70) with higher BP target compared with 56 per 1000 people with lower BP target.

              Reference:
              Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]
              • OUTCOME 1.8: Withdrawals due to adverse events (mean 2.4 years’ follow-up)

                Quality of the evidence:

                The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                Narrative result:

                Two RCTs with 7497 participants found no statistically significant difference between groups.

                Relative effect or mean difference:

                There was no statistically significant difference between groups (RR 0.83, 95% CI 0.58 to 1.19).

                Forest plot from Cochrane Review

                Absolute effect:

                14 per 1000 people (95% CI 10 to 20) with higher BP target compared with 17 per 1000 people with lower BP target.

                Reference:
                Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]

                Additional Information:

                DOI

                10.1002/cca.1896

                Publication Dates

                1. Published Online: 20 DEC 2017

                CCA derived from

                Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011575. DOI: 10.1002/14651858.CD011575.pub2. [Review search date: February 2017]

                How to Cite

                What are the benefits and harms of blood pressure targets in older adults with hypertension? Jane Burch (PhD) and Juliana Ester Martin-Lopez (PhD) (on behalf of Cochrane Clinical Answers Editors). Cochrane Clinical Answers 2017. DOI: 10.1002/cca.1896.

                Further Information

                • CCA Associate editor: Jane Burch (PhD), Editor, CEU, London, UK.
                • CCA Associate editor: Juliana Ester Martin-Lopez (PhD), Family physician and researcher, Andalusian Agency for Health Technology Assessment (AETSA), Seville, Spain.
                • CCA Editor: Karen Pettersen. Correspondence to kpettersen@wiley.com.