Episode Transcript
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Interviewer: The current medical guidelines for systolic blood pressure are between 140 to 150 but new research indicates that reducing that to 120 can drastically reduce the chance of heart disease and death for adults 75 or older even if they are considered frail elderly. Dr. Mark Supiano is a geriatrician and the executive director of the University of Utah Center on Aging. This study, is this a new revelation that lower could be better with systolic blood pressure especially for elderly adults?
Dr. Supiano: Yes, Scott. This is exciting new information that came out of the systolic blood pressure intervention trial otherwise known as SPRINT. The trial ended late in 2015, earlier than anticipated because of these very dramatic benefits.
Interviewer: When it initially ended early, a lot of people speculated that that meant bad news but it actually meant quite the opposite.
Dr. Supiano: Yes and particularly for the 28% of the SPRINT subjects who are over the age of 75 there were some concerns, myself and other geriatricians, that the very intensive systolic blood pressure target of 120 might not be safe for older people. When we first got news of the trial ending early I first thought that it was possible that older people had more side effects or more injurious falls or other complications of the very low blood pressure and that was why the data safety monitoring board might have ended the study early. In fact, the results were just the opposite.
Interviewer: Like a revelation almost it seems like.
Dr. Supiano: It really was a surprise to be honest. Not so much as a surprise that the benefit but the surprise that the benefit was of this magnitude and that this occurred this early on on the trial.
Interviewer: So the current guidelines are between 140-150. This study points out that 120 can drastically reduce the chance of heart disease and death. How drastic are we talking?
Dr. Supiano: I'll focus on the population 75 and older as I said, this is 28% of the SPRINT cohort and in that group there was a 33% reduction in the cardiovascular outcomes. This is primarily a myocardial infarction or heart attack or congestive heart failure and stroke and then in addition overall reduction of 32% in mortality.
Interviewer: That's pretty substantial.
Dr. Supiano: It is. To be honest there are very few treatments I can recommend for people over the age 75 that can have this dramatic impact on those outcomes.
Interviewer: So if you're going to do one thing, according to the study so far, it would be try to get that blood pressure down to 120. Now, does that mean taking medication? Does that mean lifestyle changes?
Dr. Supiano: All of the above. On average, the people in the intensive group who are managed to a blood pressure of 120 or taking one additional anti-hyperintensive medication relative to people on the standard arm.
Interviewer: Of course your eyes looking at the risk benefits and something like this. So the benefits are tremendous. Are there risks?
Dr. Supiano: Absolutely. The good news was, and again focusing on those 75 and older population, our major concern would have been there were higher rates of injurious falls or what's called orthostatic blood pressure - a reduction of blood pressure when the people first stand up and get light headed or dizzy. First, there was no increase in serious adverse events between the intensive and the standard arm. Second, and again very reassuring, there was no high rate injurious falls in the intensive group, nor were there serious rates in the intensive group. The intensive group did have higher rates of low blood pressure, of electrolyte abnormalities, largely low sodium levels which was to be expected because of the medications that were used and some other adverse events. But when we weigh though over the benefit of preventing heart attack, stroke, heart failure and death, most believe that those benefits outweigh those risks.
Interviewer: That number of 120, can you go lower than that and get more benefits or is there a point where no?
Dr. Supiano: That would be another study. And it's important to point out the one on average for 75 and older group achieve of systolic blood pressure of just under 122. That meant that half the people had a systolic blood pressure above 122. So 120 maybe recommended as a target blood pressure. That doesn't mean everyone is going to get there. Nor does it mean that the benefit won't accrue if you don't get exactly to that target. I think the take home message is, it seems to be that the lower, the better.
Interviewer: So is this something that if somebody does fall under this group or somebody has a grandparent or parent that's in this group that you would recommend that they go to their doctor and say, "I would like to try for a blood pressure of 120"? Because this isn't the guideline yet.
Dr. Supiano: So important point, the guidelines are being written down or likely incorporate this new information but those guidelines won't be out until later this summer. Even with that guideline, like everything we do in medicine and particularly in geriatric medicine we have to be patient-centric. So we need to weigh someone's benefits and risk of their elevated blood pressure and incorporate that those at greater risk are likely to have greater benefit. So it needs to be an informed decision with patient who discussed the pros and cons and determine their level of interest in trying to achieve this lower target and recognize those benefits.
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