Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy

Abstract

Background: Our understanding of the growing population of very old patients (aged >or=80 years) with coronary artery disease and hypertension is limited, particularly the relationship between blood pressure and adverse outcomes.

Methods: This was a secondary analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable hypertensive coronary artery disease patients aged >or=50 years. The patients were grouped by age in 10-year increments (aged >or=80, n=2180; 70-<80, n=6126; 60-<70, n=7602; <60, n=6668). Patients were randomized to either verapamil SR- or atenolol-based treatment strategies, and primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke.

Results: At baseline, increasing age was associated with higher systolic blood pressure, lower diastolic blood pressure, and wider pulse pressure (P <.001). Treatment decreased systolic, diastolic, and pulse pressure for each age group. However, the very old retained the widest pulse pressure and the highest proportion (23.6%) with primary outcome. The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures. The systolic pressure at the hazard ratio nadir increased with increasing age, highest for the very old (140 mm Hg). However, diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old (70 mm Hg). Results were independent of treatment strategy.

Conclusion: Optimal management of hypertension in very old coronary artery disease patients may involve targeting specific systolic and diastolic blood pressures that are higher and somewhat lower, respectively, compared with other age groups.

Figure 1

Systolic blood pressure (A), diastolic blood pressure (B), and pulse pressure (C) as a function of age (in 10-year increments) and time.

Figure 2

Primary and secondary outcomes as a function of age (in 10-year increments).

Figure 3

Fatal myocardial infarction and stroke as a function of age (in 10-year increments).

Figure 4

Primary and secondary outcomes as a function of age (in 10-year increments) based upon treatment strategy.

Figure 5

Adjusted hazard ratio as a function of age (in 10-year increments), systolic and diastolic blood pressure. Reference systolic and diastolic blood pressure for hazard ratio: 140 and 90 mm Hg, respectively. Blood pressures are the on-treatment average of all postbaseline recordings. The quadratic terms for both systolic and diastolic blood pressures were statistically significant in all age groups (all P <.001, except for diastolic blood pressure in 60–70-year-olds for whom P = 0.006). The adjustment was based upon sex, race, history of myocardial infarction, heart failure, peripheral vascular disease, diabetes, stroke/transient ischemic attack, renal insufficiency, and smoking.