Intense BP control safe in frail elderly

Older, frail people benefit from intensive blood pressure control without increasing the risk of falls, research suggests.

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Intensive blood pressure control in the frail elderly does not increase the risk of serious adverse events such as falls or fainting, research suggests.

The observational study of 9300 people aged over 75 found that frail participants had twice the risk of myocardial infarction, acute coronary syndrome, stroke, heart failure and cardiovascular death compared to patients without frailty over a three-year period. 

But intensive blood pressure control did not increase the risk of a serious adverse event – such as hypotension, syncope, bradycardia, electrolyte imbalance, injurious fall, acute kidney injury, low sodium, low potassium and excessive potassium – in frail participants.

“Patients with frailty benefit similarly to other patients from intensive blood pressure control without an increased risk of serious adverse events,” the researchers wrote in Circulation.

“Frailty should not be a barrier to intensive blood pressure management for people at high cardiovascular risk.

“Although patients with frailty are more likely to develop cardiovascular events, especially acute decompensated heart failure, they still experience benefits from more intensive blood pressure lowering without unnecessarily higher risks of serious adverse events,” the researchers said.  

The findings were a secondary analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial).

The original SPRINT study found that intensive blood pressure management – bringing systolic blood pressure to less than 120mmHg – reduced the risk of major cardiovascular events by 29% in patients with hypertension.

Intensive therapy benefited frail and non-frail patients equally on all cardiovascular outcomes, except for cardiovascular death which was reduced substantially more in patients without frailty.

But researchers found patients with frailty received less intensive blood pressure control, with the intensive treatment group only achieving a 2mmHg lower systolic blood pressure than the standard treatment group.

Intensive intervention led to a 13.2mmHg drop compared to standard treatment in non-frail participants, and an 11.3mmHg drop in frail participants, they found.

“According to a large-scale meta-analysis conducted by the Blood Pressure Control Treatment Trialists Collaboration, a 5mmHg drop in SBP corresponded to a 10% reduction in major cardiovascular events. In patients with frailty, the 2mmHg narrower BP differential may partially mitigate the effect of intensive BP treatment,” the authors wrote.

The researchers said frailty, poor health, and comorbidities frequently coexisted, which made therapeutic decisions challenging.

“Physicians tend to be more conservative in treating those with frailty.”

One observational study found that patients with frailty were less likely to receive optimum guideline-directed medical therapy, they said.

“Polypharmacy is also common in patients with frailty. Severe frailty with excess polypharmacy was associated with higher risks of adverse events, especially unplanned hospitalisation.”

Circulation 2023, online 4 July