Elderly CAD patients benefit from a systolic value below 140 mm Hg

The findings reported by Dr. Bangalore and his coauthors support a lower blood pressure target, specifically in patients with hypertension and coronary artery disease. The implication is that the appropriate systolic blood pressure target should be less than 140 mm Hg for patients aged 60 or older with coronary artery disease.

However, the evidence they present does not firmly refute a systolic pressure goal of less than 150 mm Hg for patients aged 60 or older, as recommended by the panel originally constituted as the Eighth Joint National Committee (JNC 8) (JAMA 2014;311:507-20). That’s because all patients included in the analysis – those patients who entered the INVEST trial with a systolic pressure greater than 150 mm Hg – would qualify for treatment based on the recommendations of the former JNC 8 panel. But little, if any, evidence from randomized clinical trials supports the idea that antihypertensive treatment reduces cardiovascular events in older adults who start treatment with a systolic blood pressure of 140-160 mm Hg.

Another limitation of the new analysis is that the INVEST design called on physicians to treat all patients to a goal pressure of less than 140/90 mm Hg or less than 130/85 mm Hg for patients with diabetes or renal impairment using either of two prespecified treatment regimens (JAMA 2003;290:2805-16). Although patients received either one or the other regimen based on the treatment arm to which they were randomized, the intensity of treatment that all patients in INVEST received was roughly the same. After 2 years, 57% of all patients in the subgroup studied in the post-hoc analysis responded with a systolic pressure that achieved the target. Although the 43% who did not meet the target had worse outcomes than the 57% who achieved a lower systolic pressure, it is not clear that the less responsive patients in the 43% group would have done better with intensified treatment that might have driven their systolic pressure down further, below 140 mm Hg.

In other words, the new analysis compared the outcomes of responders with nonresponders. To compare a target of less than 140 mm Hg with a target in the 140-150 mm Hg range among the nonresponder patients in INVEST would require a prospective trial in which the nonresponder patients are randomized to additional antihypertensive treatment or to placebo to test the benefit of intensified treatment to reach the sub–140 mm Hg goal. More aggressive treatment of these elderly nonresponders could increase the number of treatment-related adverse events. Without data like these, there is no right answer to the question of which systolic target to use.

I believe that the blood pressure target recommendations of the former JNC 8 panel are reasonable for patients with hypertension and coronary artery disease. Their recommendations continue to use a diastolic target pressure of less than 90 mm Hg, which helps insure that most patients with significant hypertension will receive appropriate treatment regardless of their systolic pressure. Clinicians need to use their clinical judgment about treatment for patients with isolated systolic hypertension in the 140-149 mm Hg range. Patients at increased risk for stroke should probably receive more intensive treatment. An important corollary recommendation from the former JNC-8 panel was that when treatment drops a patient’s systolic pressure below 140 mm Hg without causing adverse effects, the treatment can be maintained and the patient’s pressure kept at this lower level.

Dr. Alan H. Gradman is a cardiologist who practices in Pittsburgh. He had no relevant disclosures. He made these comments in an editorial that accompanied the report by Dr. Bangalore and coauthors (J. Amer. Coll. Cardiol. 2014;64:794-6).