Should patients age 50-plus aim for a systolic level (the higher number in the reading) of 140 to 150, as a panel of experts recommended in 2013? Or should they use extra medication to aggressively lower it to 120, as a major federal study of adults urged in September?
That September announcement included the startling news that the benefits of a 120 reading were so substantial, the National Institutes of Health had halted the study early. Unfortunately, researchers didn’t supply the data detailing those benefits — until this week.
The findings were presented Nov. 9 at an annual scientific meeting of the American Heart Association in Orlando and published in the New England Journal of Medicine.
The results of the study, called Sprint, were dramatic. Of the two groups of subjects — one with a blood pressure target of 120 or lower, the other with a target of 140 or lower — the 120-target group had a 43 percent lower risk of death from heart disease, a 38 percent lower risk of heart failure and a 27 percent lower risk of death from any cause compared to the 140-target group. In addition, these benefits were seen across all age groups, including those 75 and older.
Does this mean older adults with hypertension should lower their blood pressure goal? Experts warn that there are some caveats to keep in mind. Here are three things to know about the new blood pressure trial results:
Not everyone age 50 and up with high blood pressure needs to lower it to 120. Subjects in the study were high-risk. They had high blood pressure (systolic readings between 130 and 180) plus evidence of heart disease or chronic kidney disease or were age 75 or older. The study also excluded those with diabetes or a prior stroke.
That means only about 1 in 6 people already being treated for high blood pressure would have been eligible for the study, making it less relevant to 5 out of 6 patients, wrote cardiologist and Yale professor of medicine Harlan Krumholz in the New York Times.
In addition, although about 70 percent of adults with type 2 diabetes also have high blood pressure, there is little evidence that intensely lowering systolic blood pressure to 120 yields more benefits than maintaining a more moderate 140 reading. A 2010 federal study found little difference in the rate of fatal or nonfatal heart attacks among those who lowered their blood pressure to 120 compared to those whose target was 140. However, lowering it to 120 did reduce the risk of stroke.
The potential benefits must be weighed against the risks. The 120-target group did have fewer deaths — 155 compared with 210 in the 140 group — but it also had more serious side effects, the Sprint researchers reported. Too-low blood pressure, fainting and kidney disease occurred more frequently in the lower blood pressure group, although the 140-target group had more falls from light-headedness.
But Jackson T. Wright Jr., M.D., a blood pressure expert at Case Western Reserve University and a Sprint study researcher, pointed out that there was only a 1 to 2 percent higher rate of serious side effects in the 120 group. For high-risk patients, “a 27 percent lower risk of death will likely trump side effects,” he said in an interview.
More importantly, those age 75 and older tolerated the lower blood pressure level just as well as those under 75. “Clearly, there was no suggestion that those over 75 were more likely to suffer adverse [side] effects compared to those under 75,” Wright said.
Missing from this discussion, however, is whether aggressively lowering blood pressure with additional medication affects dementia. That data, said Wright, won’t be available for another six months or so.
It all comes down to what’s best for you. When it comes to deciding whether to aim for 140 or 120, “a one-size-fits-all approach is not practical,” warns George Thomas, M.D., director of the Center for Blood Pressure Disorders at the Cleveland Clinic.
He favors patients’ discussing with their doctor the benefits and risks of an aggressive versus a not-so-aggressive approach to lowering blood pressure, “and to individualize care based on this.” Both doctors and patients need to keep in mind not only the adverse side effects reported in the study, but also “quality of life and tolerability of medications” when making decisions about intensifying treatment, he said.
Cardiologist and former dean of Boston University School of Medicine Aram Chobanian also noted in a commentary on the Sprint study that a goal of 120 may be impractical for many people. An average of three different medications was required to reach that level in the study, “and still the 120 goal was not reached in some,” he wrote.
Instead, Chobanian favored a compromise between the two groups’ target levels: “In my opinion, the results from Sprint warrant reducing the treatment goal for systolic blood pressure to less than 130 in most people with hypertension who are over 50 years of age and do not have diabetes or a history of stroke.”
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