Intensive blood pressure lowering in different age categories: insights from the Systolic Blood Pressure Intervention Trial

Abstract

Aims: The 2018 ESC/ESH guidelines for hypertension recommend differential management of patients who are <65, 65-79, and ≥80 years of age. However, it is unclear whether intensive blood pressure lowering is well-tolerated and modifies risk uniformly across the age spectrum.

Methods and results: SPRINT randomized 9361 high-risk adults without diabetes and age ≥50 years with systolic blood pressure 130-180 mmHg to either intensive or standard antihypertensive treatment. The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The primary safety endpoint was composite serious adverse events. We assessed whether age modified the efficacy and safety of intensive vs. standard blood pressure lowering using Cox proportional-hazards regression and restricted cubic splines. In all, 3805 (41%), 4390 (47%), and 1166 (12%) were <65, 65-79, and ≥80 years. Mean age was similar between the two study groups (intensive group 67.9 ± 9.4 years vs. standard group 67.9 ± 9.5 years; P = 0.94). Median follow-up was 3.3 years. In multivariable models, age was linearly associated with the risk of stroke (P < 0.001) and non-linearly associated with the risk of primary efficacy events, death from cardiovascular causes, death from any cause, heart failure, and serious adverse events (P < 0.001). The safety and efficacy of intensive blood pressure lowering were not modified by age, whether tested continuously or categorically (P > 0.05).

Conclusion: In SPRINT, the benefits and risks of intensive blood pressure lowering did not differ according to the age categories proposed by the ESC/ESH guidelines for hypertension.

Trial registration: SPRINT (Systolic Blood Pressure Intervention Trial); ClinicalTrials.gov Identifier: NCT01206062, https://ichgcp.net/clinical-trials-registry/NCT01206062.

Keywords: Age; Blood pressure; Hypertension; Safety.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.

Figures

Figure 1

Age distribution in the Systolic Blood Pressure Intervention Trial (SPRINT).

Figure 2

The association between age and efficacy and safety endpoints. The solid lines represent the incidence rate (per 100 person-years) at each age interval. The dashed lines represent the upper and lower bounds of the 95% confidence interval. P-values are for adjusted trends (adjusted for treatment group, sex, number of antihypertensive drug classes, smoking status, clinical cardiovascular disease, urine albumin-to-creatinine ratio, total cholesterol, high-density lipoprotein cholesterol, and creatinine).

Figure 3

The effect of intensive vs. standard blood pressure lowering across the age spectrum. The solid lines represent unity (hazard ratio = 1) and the hazard ratio for intensive vs. standard blood pressure lowering at each age interval, respectively. The dotted lines represent the upper and lower bounds of the 95% confidence interval. P-values are for the continuous interaction between age and treatment effect for each endpoint.