SR: Lower BP Targets Reduce Stroke Risk and Cardiovascular Events in Older Adults

Background: Hypertension is a prevalent condition in older adults and a major risk factor for cardiovascular morbidity and mortality. Despite widely accepted benefits of treating blood pressure (BP) above 160 mmHg in this population, the optimal BP target remains uncertain. Many guidelines recommend a systolic BP (SBP) goal of < 140 mmHg in all adults, including those aged ≥ 65 years. However, evidence suggests older, possibly frail individuals might experience different benefit–risk ratios with more relaxed BP targets. This Cochrane review updates the previous 2017 analysis to determine whether aiming for higher BP targets in older adults (e.g., < 150–160 mmHg systolic) confers comparable or better outcomes than standard or more aggressive targets (< 140 mmHg).

Objective: To assess the effects of a higher BP target (SBP < 150–160 mmHg or diastolic BP < 95–105 mmHg) versus a lower (conventional or more aggressive) BP target (< 140/90 mmHg or lower) on mortality, stroke, and serious cardiovascular events in hypertensive adults aged ≥ 65 years.

Methods:

• Design and Searches: This is an updated Cochrane systematic review of randomized controlled trials (RCTs) comparing higher vs lower BP targets in older adults with hypertension. Databases searched through June 2024 included MEDLINE, Embase, CENTRAL, the Cochrane Hypertension Specialised Register, and ClinicalTrials.gov.
• Inclusion Criteria: RCTs of ≥ 1 year’s duration enrolling participants aged ≥ 65 years with baseline systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. Trials had to compare a higher BP target range (SBP < 150–160/DBP < 95–105 mmHg) to a lower BP target (< 140/90 mmHg).
• Outcomes: Primary outcomes were all-cause mortality, stroke, institutionalization, and serious cardiovascular adverse events (including myocardial infarction, heart failure, and renal failure). Secondary outcomes included cardiovascular mortality, non-cardiovascular mortality, total serious adverse events, and withdrawals due to adverse effects.

Results:

• Included Studies: Four open-label RCTs (N = 16,732) from Japan and China, with mean ages around 70 years (range 65–77). Mean follow-up ranged from 2 to 4 years.
• Mortality: Lower BP targets may result in little to no difference in all-cause mortality (RR 1.14, 95% CI 0.95–1.37; low-certainty).
• Stroke Prevention: A lower BP target clearly reduced the risk of stroke (RR 1.33, 95% CI 1.06–1.67; high-certainty), with an absolute reduction of approximately 6 stroke events per 1000 individuals treated over ~3 years.
• Serious Cardiovascular Events: A lower BP target likely reduced total serious cardiovascular adverse events (RR 1.25, 95% CI 1.09–1.45; moderate-certainty), equating to roughly 10 fewer cardiovascular events per 1000 people treated.
• Adverse Effects: Lower BP targets likely did not increase withdrawals due to adverse effects (RR 0.99, 95% CI 0.74–1.33; moderate-certainty). Data on other adverse events (e.g., hypotension) were limited but showed small absolute differences.

Conclusions: Treating older adults’ systolic BP to < 140 mmHg (vs < 150–160 mmHg) reduces stroke and likely reduces overall serious cardiovascular events without clearly affecting all-cause mortality or increasing dropouts due to adverse effects. While these findings support standard BP targets (< 140 mmHg) for many older patients, the absolute reduction in events is modest. Caution may be warranted in individuals aged ≥ 80 years or those who are frail, as the included studies had fewer such participants.

Implications for Practice: For most older adults, targeting SBP < 140 mmHg can prevent a modest but meaningful number of cardiovascular events, particularly stroke. Clinicians should balance these benefits against patient-specific concerns, such as frailty, multiple comorbidities, and polypharmacy. Monitoring for hypotension, renal function changes, and other adverse effects remains important.

Study Strengths and Limitations:

• Strengths: Inclusion of four RCTs with low attrition rates; assessment of major vascular endpoints relevant to older adults.
• Limitations: All trials were open-label, increasing risk of bias in subjective outcomes. Adverse event reporting was incomplete, and very elderly or frail individuals were often underrepresented. Most data originated from Asian populations, limiting generalizability to other regions.

Future Research: Further RCTs in populations aged ≥ 80 years, those with significant frailty, or living in nursing homes are essential to clarify optimal BP targets. Studies should capture quality-of-life measures and long-term safety outcomes, especially regarding adverse drug–drug interactions in complex older patients.

Reference: Falk JM, Froentjes L, Kirkwood JE, Heran BS, Kolber MR, Allan GM, Korownyk CS, Garrison SR. Higher blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews. 2024; Issue 12. DOI: http://doi.org/10.1002/14651858.CD011575.pub3