Dialogue
Inside all over the country cohort out of 374,250 very old Koreans treated to possess blood circulation pressure, our very own research revealed that there was a love anywhere between standard blood tension and you will ischemic stroke, MI, and all sorts of-produce dying, immediately after adjusting having ages, gender, Bmi, smoking, ingesting, do it, income reputation, diabetic issues mellitus, dyslipidemia, and you may persistent renal state.
SBP used a beneficial J-bend getting ischemic heart attack and you will good U contour for everybody-end up in dying, which have nadir range regarding 120 so you’re able to 129 mmHg and you will 140 to 149 mmHg, respectively. not, the absolute boost in stroke or dying from the all the way down blood pressure level is actually seemingly brief, based on the yearly frequency of secret endpoint.
The HR for MI was similar to the reference group when SBP was < 160 mmHg, but was significantly increased when SBP was ? 160 mmHg. While a high DBP yielded a higher risk for MI and death, DBPs below 80 mmHg and 90 mmHg, respectively, had similar risks compared to the reference groups. The SBP/DBP combination analysis revealed that even with treatment SBP < 130 mmHg, higher DBP ? 90 mmHg had a higher HR compared to the reference group, for all three outcome measures. Within the same DBP level, the death hazard was higher for SBP < 130 mmHg than when SBP was 130 to 149 mmHg.
Translation and you can research together with other knowledge
The most important issues regarding BP control in the very elderly are: (1) is the lower the better, or is there a cutoff point below https://datingranking.net/ilove-review/ which there is no benefit or even harm? and (2) if there is a cutoff point, can it be defined? Our findings imply that very low SBP may not further reduce the risk of ischemic stroke, MI, and all-cause death in the very elderly. SBP below nadirs for ischemic stroke and death showed higher risk, and for MI, SBP < 160 mmHg represented a homogenous group with no significant difference from the reference group. Similarly, for DBP in MI and all-cause death, a DBP < 80 mmHg and < 90 mmHg had a relatively similar risk as the reference group with DBP < 70 mmHg, suggesting there may be no further benefits below a certain DBP level. These results are in agreement with findings from previous randomized controlled trials in the very elderly, indicating that lowering BP has cardiovascular and survival benefits , but below certain levels may not be beneficial [6, 21]. The HYVET trial showed that targeting BP levels below mmHg reduced stroke mortality and total mortality , but the JATOS and VALISH trials found there were no further benefits below SBP < 140 mmHg.
In the INVEST sub-study of elderly patients aged ? 80 years, the primary outcome of total mortality, nonfatal stroke, or nonfatal MI followed J-curves for both SBP and DBP, with nadirs at 140 mmHg and 70 mmHg, respectively . Moreover, the CLARIFY cohort showed that for elderly aged > 75 years, the HR of primary composite outcome of cardiovascular death, MI, and stroke was significantly higher with an SBP < 120 mmHg or DBP < 70 mmHg, than for the reference SBP 120 to 129 mmHg or DBP 70 to 79 mmHg .
On the contrary, results of the most recent SPRINT trial and the ACC/AHA guideline revisions seem to support “the lower the better” hypothesis. In the SPRINT trial, even in elderly patients aged ? 75 years, there were significant mortality benefits and coronary, cerebrovascular event reductions with a target SBP of 120 mmHg . However, it should be taken into consideration that this trial excluded patients with diabetes, low eGFR, or low (< 110 mmHg) standing BP, which might not adequately represent the real-world general population. Moreover, side effects such as orthostatic hypotension were strictly controlled, which also may not represent the real-world conditions. When comparing and interpreting the results of the SPRINT study emphasizing strict blood pressure control with the results in this study, we also would like to mention that the difference in blood pressure measurement environment needs to be considered. In the SPRINT study, researchers adapted Automated Office Blood Pressure (AOBP) method to measure blood pressure. On the other hand, in the past, the method of measuring blood pressure in Korea was a manual measurement method using a mercury sphygmomanometer. In general, manual blood pressure measurements taken directly by medical staff are higher than AOBP blood pressure measurements.