Benefit‐Based Approach to Blood Pressure Control in Older Adults

Supiano, Mark A.

doi:10.1111/jgs.13341

J American Geriatrics Society

2015

DOI: 10.1111/jgs.13341

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Benefit‐Based Approach to Blood Pressure Control in Older Adults

Mark A. Supiano

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Cited by 2 publications

(3 citation statements)

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“…11 We fully recognize that, because of the exclusion criteria required for RCTs, the benefits observed in HYVET and SPRINT cannot be generalized to all older adults with hypertension.…”

mentioning

confidence: 99%

“…11 We fully recognize that, because of the exclusion criteria required for RCTs, the benefits observed in HYVET and SPRINT cannot be generalized to all older adults with hypertension. 12 That said, there are an estimated 5.8 million individuals in the United States aged 75 and older with hypertension who meet SPRINT entry criteria (64% of the 9.1 million with hypertension).…”

mentioning

confidence: 99%

“…We applaud Wu and colleagues' call to "further advance precision medicine," but we contend that a person-centric, benefit-based approach to determining a SBP treatment goal that is founded on rigorous evidence derived from the available RCTs should inform this decision. 11 We fully recognize that, because of the exclusion criteria required for RCTs, the benefits observed in HYVET and SPRINT cannot be generalized to all older adults with hypertension. 12 That said, there are an estimated 5.8 million individuals in the United States aged 75 and older with hypertension who meet SPRINT entry criteria (64% of the 9.1 million with hypertension).…”

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confidence: 99%

See 2 more Smart Citations

Systolic Blood Pressure and Mortality: Role of Reverse Causation

Supiano

Pajewski

Williamson

2017

J American Geriatrics Society

Self Cite

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1 joins a host of other observational studies reporting an inverse relationship between high systolic blood pressure (SBP) and mortality. [2][3][4] The inclusion of measures of grip strength and gait speed in this study provides further evidence that functional status may modify this relationship, but the fundamental limitations inherent in all observational studies that have addressed this relationship compel us to comment. Furthermore, the conclusions derived from two large randomized clinical trials (RCT) of hypertensive treatment in older adults, both including frail adults, conflict with this observational study's findings and conclusions.The Hypertension in the Very Elderly Trial (HYVET) 5 and Systolic Blood Pressure Intervention Trial (SPRINT) 6 reached similar conclusions regarding the mortality benefits identified in older adults with hypertension-aged 80 and older for HYVET and 75 and older for SPRINTactively treated to a target SBP of less than 150 mmHg in HYVET (relative to placebo treatment) and less than 120 mmHg in SPRINT (relative to a standard treatment target of <140 mmHg). The significant 21% decrease in overall mortality in HYVET and 33% decrease in SPRINT participants led to recommendations to end both studies earlier than planned. Both trials included sizable proportions of frail participants; 23.1% of HYVET participants and 16.3% of SPRINT participants had a frailty index score of 0.25 or greater, and 29.4% of SPRINT participants had slow gait speed (<0.8 m/s). The treatment benefits for both trials' primary outcomes and overall mortality were evident even in frail participants. 7,8 What then accounts for the stark contrast between the mortality benefit identified in older, frail adults with hypertension in RCTs and the inverse relationship found in observational studies? Among several differences in study design, the most important concern is the inherent limitation of reverse causation in observational studies. A recent observational cohort study that tracked SBP trajectories for the 5 years before death in 144,403 individuals aged 80 older provides a compelling example of this limitation.9 Consistent with Wu and colleagues and other observational studies, mortality was greatest in those with SBP less than 110 mmHg, although there was a decline in the SBP trajectory noted in the last 3 months of life in individuals undergoing treatment for hypertension and those not undergoing treatment. This terminal decline in SBP provided the best explanation for the observed association between low SBP and mortality in this and probably other observational studies. Although Wu and colleagues attempted to minimize reverse causation by excluding HRS participants who died in the first 2 years of follow-up, this approach fails to fully reduce residual confounding.10 Moreover, the HRS population is heterogeneous and includes persons with and without hypertension.Individuals with low SBP as a consequence of actively and appropriately managed antihypertensive therapy titrated to a specific SBP target are no...

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“…11 We fully recognize that, because of the exclusion criteria required for RCTs, the benefits observed in HYVET and SPRINT cannot be generalized to all older adults with hypertension.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 1 more Smart Citation

Systolic Blood Pressure and Mortality: Role of Reverse Causation

Supiano

Pajewski

Williamson

2017

J American Geriatrics Society

Self Cite

View full text Add to dashboard Cite

show abstract

Effects of intensive blood pressure control on cognitive function in patients with cerebral small vessel disease

Zhao,

Jia,

Yuan

et al. 2023

Journal of Stroke and Cerebrovascular Diseases

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Benefit‐Based Approach to Blood Pressure Control in Older Adults

Cited by 2 publications

References 14 publications

Systolic Blood Pressure and Mortality: Role of Reverse Causation

Systolic Blood Pressure and Mortality: Role of Reverse Causation

Effects of intensive blood pressure control on cognitive function in patients with cerebral small vessel disease

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