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Blood Pressure Targets in Older Patients: Many Guidelines, Much Confusion An Interview With Franz Messerli, MD

In 2014, the Joint National Committee (JNC) 8 relaxed the systolic blood pressure (SBP) goal for people ≥ 60 years from < 140 mm Hg to < 150 mm Hg.[1] The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) joint practice guideline reaffirmed this target and suggested a lower goal (< 140 mm Hg) in those with a history of stroke/transient ischemic attack or at high cardiovascular risk.[2] Meanwhile, a prespecified subgroup analysis of the SPRINT trial (SPRINT-SENIOR) in patients ≥ 75 years showed a significant reduction in fatal and nonfatal major cardiovascular events and all-cause mortality among those treated to an SBP target of < 120 mm Hg vs < 140 mm Hg, with no increase in serious adverse events.[3] And a recent viewpoint by a JNC 7 author proposed a long-term SBP goal < 130 mm Hg for patients aged 50-74 years and < 140 mm Hg for those ≥ 75 years.[4]

We interviewed hypertension expert Franz H. Messerli, MD, to help make sense of the different recommendations.
How would you define "older," and should the goals of therapy be different according to patient age?
Dr Messerli
: I can remember when we used the term "senile" to describe old patients; then, it became "elderly." Presently, even that is no longer politically correct, so we say "older."

The patient's age is less important than their blood pressure reading for initiating therapy. An 80-year-old marathon runner may physiologically be "younger" than a 50-year-old obese smoker with diabetes. However, an SBP > 170 mm Hg clearly will mandate treatment in both of these patients.

theheart.org | Medscape: In your opinion, what are appropriate blood pressure targets for older patients?

Dr Messerli: Targets are much more for the guidelines than the practicing physician. You have to address the patient in front of you and aim to lower the blood pressure as much as you can without interfering with quality of life (QoL) and without exposing them to risk factors caused by too low a blood pressure, such as dizziness, syncope, or hip fractures.

A reasonable target in most patients is SBP of 130 mm Hg provided it doesn't cause harm or impair QoL. For patients older than 75 years, a general goal of 140 mm Hg is acceptable.

theheart.org | Medscape: Would you alter targets for primary vs secondary prevention?

Dr Messerli: It shouldn't make much of a difference. Most patients > 60 or 70 years will have some degree of coronary artery disease, but they may not have had a myocardial infarction (MI) yet. Similarly, they will have cerebrovascular disease but not yet had a stroke or transient ischemic attack.

You want an optimal blood pressure to prevent the event in primary prevention or a recurrence in secondary prevention. You should also use a statin; HOPE-3 showed us that this is a superb complementary treatment in most hypertensive patients regardless of their low-density lipoprotein cholesterol levels.[5]

theheart.org | Medscape: What factors would lean you toward initiating medical therapy in someone > 75 years?

Dr Messerli: The healthier they are, the more I would be inclined to initiate therapy, because they usually have a superb QoL. Stroke, whether hemorrhagic or ischemic, is the most devastating complication of hypertension—you could be paralyzed for months or years.

If someone is a healthy 80- to 85-year-old with an SBP of 170 mm Hg, they should be put on antihypertensives right away. Obviously, in this age group, blood pressure lowering should be gradual. However, I've successfully used triple antihypertensive therapy in patients who are > 90 years, and they do well.

theheart.org | Medscape: Is extreme fear of stroke still valid, given the improvements in stroke management?

Dr Messerli: The event by itself is absolutely devastating to a patient. It's true that if they are near a top medical center and can get there quickly, we have good results in terms of reversing neurologic symptoms. But often, it takes a long time for the patient to recognize the symptoms, and modern treatments (eg thrombectomy) are not available everywhere.

When I lecture physicians, I sometimes ask the audience: If you had to wake up tomorrow with either MI or a stroke, which would you pick? No one picks stroke.

theheart.org | Medscape: Should goals be more aggressive in patients with diabetes?

Dr Messerli: Yes and no.

Yes, for the simple reason that patients with diabetes are at higher risk, so you need to be more aggressive to reduce this risk. And no, because people with diabetes also have an impaired autonomic nervous system and stiff arteries—they very often don't tolerate low blood pressure as well.

I think 140/90 mm Hg remains a reasonable goal for patients with diabetes. If the patient can tolerate 130/80 mm Hg, then more power to them, but we need to individualize.

In addition, there is the issue of target-organ heterogeneity. By that, I mean that one organ (eg, the brain) may require a blood pressure that is too low for another organ (eg, the heart). So in optimizing blood pressure for stroke prevention, you may end up with more cardiac, renal, or retinal events. [6] Lowering SBP to < 120 mm Hg may reduce stroke, but that may not be the optimal level for the heart because the coronary arteries are no longer well perfused.

The game is always a J-shaped curve (a blood pressure of 0 equals 100% mortality). There is a blood pressure point where the risk goes up as the blood pressure falls, and that may be a different data point for the brain, the heart, and the kidney.

theheart.org | Medscape: How should clinicians weigh the risk for side effects and impact on QoL in older patients?

Dr Messerli: QoL is very important in the older patient. We don't want to just add years of life, but rather quality years of life. Sexual dysfunction and depression are not uncommon side effects and can severally reduce QoL. Ernest Hemingway comes to mind; he committed suicide in Sun Valley, Idaho, after having become severely depressed on high doses of reserpine.[7,8]

We published an article in the BMJ in which we estimated that for every stroke or MI prevented by beta-blockers, three patients are made impotent, and eight become so fatigued that they stop treatment.[9] That's not acceptable for a completely asymptomatic condition, such as hypertension. And it's not as if the benefits and risks are occurring in the same patient—you may make many others impotent to hopefully prevent a single stroke in a different patient.

We need to talk to our patients and ask whether the treatment is interfering with their lifestyle, their QoL, their sex life, and so on. This is especially important when initiating treatment or up-titrating.

theheart.org | Medscape: Do research studies do a good job of getting at these QoL measures?

Dr Messerli: No, they're not measured enough in the studies. The research trials are much more concerned about efficacy and outcome data. They're less concerned with what it takes to get there, which is unfortunate. I wish we paid more attention to it, but it's most often left to the practicing physician to figure out the risk/benefit ratio.

The SPRINT trial may well tell us that the goal SBP should be < 120 mm Hg, but the physician will know that the patient in front of them only very rarely will be able to tolerate that.

theheart.org | Medscape: In light of SPRINT, should we change how blood pressure is routinely measured?

Dr Messerli: Clearly, SPRINT is unique in that the blood pressure readings were obtained unwitnessed after the patient sat quietly for 5 minutes. I don't think it is feasible to translate the results of SPRINT directly into clinical practice. Physicians are too busy and have neither time nor office space to measure blood pressure as was done in SPRINT.

Can you extrapolate from these readings? There is evidence that you should add about 10-12 mm Hg to the SBP readings in SPRINT to get an equivalent, more typical office blood pressure reading. [10] The SPRINT target of SBP < 120 mm Hg is more like 130-135 mm Hg for a typical measurement.

theheart.org | Medscape: Can you comment on the viewpoint in JAMA by Dr Aram Chobanian,[4] a JNC 7 author, that included SBP goals for older patients?

Dr Messerli: He makes a few excellent points. One is that basing antihypertensive therapy on total cardiovascular risk rather than on specific blood pressure values is a hypothesis that has not been validated.

He also wrote that "for persons aged 75 years or older...reduction of SBP is clearly beneficial, but the exact SBP goal is still unclear. At present, a goal of <140 mm Hg appears reasonable but should be achieved by careful titration of medications and monitoring for orthostatic hypotension and changes in renal function and cognition." Cognition is exceedingly important in the older patient; we shouldn't forget about that.

Dr Chobanian concluded that "for individuals who tolerate treatment well, further efforts might be made to reach a target of < 130 mm Hg, but this may occur in a minority of patients [emphasis mine]." I dare to slightly disagree with that. If you take the time to lower blood pressure carefully over a period of months, we can get to < 130 mm Hg in most of our patients.

theheart.org | Medscape: You are critical of the recent ACP/AAFP guidelines. What do you dislike about them?

Dr Messerli: The authors of these guidelines have no track record in hypertensive cardiovascular disease whatsoever.Their lack of expertise is documented by several deficiencies.

For example, they recommend beta-blockers on an equal basis with other antihypertensive drugs, such as thiazide-type diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium-channel blockers in hypertensive patients aged 60 years or older. Beta-blockers are known to have a pseudoantihypertensive effect: Despite lowering blood pressure, there is no— and I repeat, no—evidence that beta-blockers reduce heart attack, stroke, or death in hypertensive patients ≥ 60 years. Ironclad evidence has been put forward that beta-blockers are not acceptable antihypertensive drugs in this age group. Clearly, this ACP/AAFP recommendation must be considered hogwash.

I can only hope that clinicians will ignore most of these ACP/AAFP recommendations, get their education elsewhere, and continue to treat patients ≥ 60 years on the basis of periodic discussion with the patient regarding the benefits and harms of specific blood pressure targets, and the benefits and risks of the various blood pressure drugs .

theheart.org | Medscape: What should clinicians make of the different guidelines? (The American College of Cardiology/American Heart Association updated guidelines are scheduled for release in the first quarter of 2017.)

Dr Messerli: After JNC 7, it took 11 years to get one more set of guidelines. Now we have six or seven, and they all tell a different story. It has become very confusing to the practicing clinician.

The patient in front of you never quite conforms to the patient in the trial or to the patients from whom the evidence was derived for the latest guidelines. Despite all the guidelines, you still have to be a doctor, and you have to individualize therapy and continue to learn.

Most physicians know that guidelines are more for lawyers than for doctors.





 

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