Clinical outcomes of modifying hypertension treatment intensity in older adults treated to low blood pressure.
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BORIS DOI
Date of Publication
October 2021
Publication Type
Article
Division/Institute
Author
Ha, Jin-Kyung | |
Kim, Hyungjin Myra | |
Kerr, Eve A | |
Hofer, Timothy P | |
Min, Lillian |
Series
Journal of the American Geriatrics Society
ISSN or ISBN (if monograph)
0002-8614
Publisher
Wiley-Blackwell
Language
English
Publisher DOI
PubMed ID
34097300
Uncontrolled Keywords
Description
BACKGROUND/OBJECTIVES
Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP.
DESIGN
Longitudinal cohort study (2011-2013) with 9-month follow-up.
SETTING
U.S.-nationwide primary care Veterans Health Administration healthcare system.
PARTICIPANTS
Veterans aged 65 and older with baseline SBP <130 mmHg and ≥1 antihypertensive medication during ≥2 consecutive visits (N = 228,753).
EXPOSURE
Deintensification or intensification, compared with stable treatment.
MAIN OUTCOMES AND MEASURES
Cardiovascular events, syncope, or fall injury, as composite and distinct outcomes, within 9 months after exposure. Adjusted logistic regression and inverse probability of treatment weighting (IPTW, sensitivity analysis).
RESULTS
Among 228,753 patients (mean age 75 [SD 7.5] years), the composite outcome occurred in 11,982/93,793 (12.8%) patients with stable treatment, 14,768/72,672 (20.3%) with deintensification, and 11,821/62,288 (19.0%) with intensification. Adjusted absolute outcome risk (95% confidence interval) was higher for deintensification (18.3% [18.1%-18.6%]) and intensification (18.7% [18.4%-19.0%]), compared with stable treatment (14.8% [14.6%-15.0%]), p < 0.001 for both effects in the multivariable model). Deintensification was associated with fewer cardiovascular events than intensification. At baseline SBP <95 mmHg, cardiovascular event risk was similar for deintensification and stable treatment, and fall risk lower for deintensification than intensification. IPTW yielded similar results. Mean follow-up SBP was 124.1 mmHg for stable treatment, 125.1 mmHg after deintensification (p < 0.001), and 124.0 mmHg after intensification (p < 0.001).
CONCLUSION
Antihypertensive treatment deintensification in older patients with tightly controlled SBP was associated with worse outcomes than continuing same treatment intensity. Given higher mortality among patients with treatment modification, confounding by indication may not have been fully corrected by advanced statistical methods for observational data analysis.
Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP.
DESIGN
Longitudinal cohort study (2011-2013) with 9-month follow-up.
SETTING
U.S.-nationwide primary care Veterans Health Administration healthcare system.
PARTICIPANTS
Veterans aged 65 and older with baseline SBP <130 mmHg and ≥1 antihypertensive medication during ≥2 consecutive visits (N = 228,753).
EXPOSURE
Deintensification or intensification, compared with stable treatment.
MAIN OUTCOMES AND MEASURES
Cardiovascular events, syncope, or fall injury, as composite and distinct outcomes, within 9 months after exposure. Adjusted logistic regression and inverse probability of treatment weighting (IPTW, sensitivity analysis).
RESULTS
Among 228,753 patients (mean age 75 [SD 7.5] years), the composite outcome occurred in 11,982/93,793 (12.8%) patients with stable treatment, 14,768/72,672 (20.3%) with deintensification, and 11,821/62,288 (19.0%) with intensification. Adjusted absolute outcome risk (95% confidence interval) was higher for deintensification (18.3% [18.1%-18.6%]) and intensification (18.7% [18.4%-19.0%]), compared with stable treatment (14.8% [14.6%-15.0%]), p < 0.001 for both effects in the multivariable model). Deintensification was associated with fewer cardiovascular events than intensification. At baseline SBP <95 mmHg, cardiovascular event risk was similar for deintensification and stable treatment, and fall risk lower for deintensification than intensification. IPTW yielded similar results. Mean follow-up SBP was 124.1 mmHg for stable treatment, 125.1 mmHg after deintensification (p < 0.001), and 124.0 mmHg after intensification (p < 0.001).
CONCLUSION
Antihypertensive treatment deintensification in older patients with tightly controlled SBP was associated with worse outcomes than continuing same treatment intensity. Given higher mortality among patients with treatment modification, confounding by indication may not have been fully corrected by advanced statistical methods for observational data analysis.
File(s)
File | File Type | Format | Size | License | Publisher/Copright statement | Content | |
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Aubert_JAmGeriatrSoc_2021.pdf | Adobe PDF | 1.09 MB | published |