March 04, 2015
Prescribing 2 or more antihypertensive medications to frail elderly individuals with low systolic blood pressure (SBP) increased their risk of death, according to a new study.
The researchers monitored for 2 years 1,127 nursing home residents (78.1% of whom were women) older than 80 years. Residents with systolic blood pressure (SBP) less than 130 mm Hg who took 2 or more antihypertensive medications were 81% more likely to die from cardiovascular and non-cardiovascular causes than patients without low blood pressure, according to the study. Notably, the higher all-cause mortality rate was not due to the presence of comorbidities.
Polypharmacy is also a major concern in elderly patients; participants in this study took an average of 7 drug, including 2 blood pressure medications. The researchers noted that residents with SBP less than 130 mm Hg were more often prescribed loop and potassium-sparring diuretics than residents with SBP above 130 mm Hg. However, residents with the lower SBP were less likely to receive calcium channel blockers, thiazide diuretics, and angiotensin receptor blockers.
Recently released European guidelines suggested lowering SBP to between 140 mm Hg and 150 mm Hg in individuals older than 80 years with initial SBP of at least 160 mm Hg. Additionally, in 2011, the American College of Cardiology Foundation and American Heart Association recommended maintaining SBP between 140 mm Hg and 145 mm Hg in patients older than 80 years.
Despite the guidelines, controversy surrounds the treatment of frail elderly patients with low SBP, which could indicate malnutrition, heart failure, or other conditions with a poor prognosis. What should be the course of treatment when SBP drops below 130 mm Hg? Should the amount of antihypertensive medications be reduced in patients who took the drugs to battle high blood pressure?
No clear strategy exists, and clinical evidence does not identify how to best treat hypertension in the elderly, noted the researchers, who cautioned against applying treatment recommendations that are often based on studies involving younger, healthier individuals.
Health status, not age, is a better determining factor for identifying hypertensive patients at greatest risk of illness and death, noted the researchers, who suggested exercising caution when reducing SBP to between 140 mm Hg and 150 mm Hg in weak elderly patients. They said assessing comorbidities, polymedication, and frailty is a prudent approach for delivering safe and effective blood-pressure-lowering medication therapy.
The study was published online in JAMA Internal Medicine.
1. Benetos A, Labat C, Rossingnol P, et al. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents. JAMA Intern Med. 2015 Feb 16.