Is It Safe to Lower BP in Older Adults With Lacunar Stroke?
Is It Safe to Lower BP in Older Adults With Lacunar Stroke?
Objectives To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke.
Design Cohort study.
Setting The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130–149 mmHg) for secondary stroke prevention.
Participants Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses.
Measurements Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined.
Results Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59–1.01) but not in older participants (HR = 1.01, 95% CI = 0.59–1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18–0.98), with a significant interaction between age and SBP group (P = .049).
Conclusion Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death.
Hypertension is a powerful independent risk factor for stroke, and reducing blood pressure (BP) is an effective intervention to prevent stroke. Although they are at greatest risk of stroke, data from several studies suggests that BP is less well controlled in older adults. Undertreatment may be related to concerns about side effects or interactions, both of which may be more common in older than younger adults.
Several trials have demonstrated that hypertension treatment in older adults can be undertaken with minimal risk. Furthermore, the Hypertension in the Very Elderly Trial (HYVET) showed a 30% reduction in stroke (P = .06) and 21% reduction in mortality (P = .02) with BP lowering. Given that only 7% of participants in HYVET had a history of stroke, the safety and effectiveness of BP control in older adults with established cerebral small vessel disease could not be studied.
Elderly adults are the fastest-growing segment of the population in developed countries and will contribute significantly to a growing stroke burden. This underscores the need for evidence-based information on targeted risk factor management for this population. The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial was undertaken to define efficacious therapies for prevention of recurrent stroke and cognitive decline in individuals with symptomatic lacunar (subcortical) stroke. There was a nonsignificant reduction in recurrent stroke associated with SBP lowering (hazard ratio (HR) = 0.81, 95% confidence interval (CI) = 0.64–1.03) and a nonsignificant interaction with age (<65 vs ≥65; P = .53). The objectives of the present analyses were to examine the safety and tolerability of lowering BP in the older subgroup of participants in the SPS3 trial.
Abstract and Introduction
Abstract
Objectives To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke.
Design Cohort study.
Setting The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130–149 mmHg) for secondary stroke prevention.
Participants Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses.
Measurements Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined.
Results Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59–1.01) but not in older participants (HR = 1.01, 95% CI = 0.59–1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18–0.98), with a significant interaction between age and SBP group (P = .049).
Conclusion Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death.
Introduction
Hypertension is a powerful independent risk factor for stroke, and reducing blood pressure (BP) is an effective intervention to prevent stroke. Although they are at greatest risk of stroke, data from several studies suggests that BP is less well controlled in older adults. Undertreatment may be related to concerns about side effects or interactions, both of which may be more common in older than younger adults.
Several trials have demonstrated that hypertension treatment in older adults can be undertaken with minimal risk. Furthermore, the Hypertension in the Very Elderly Trial (HYVET) showed a 30% reduction in stroke (P = .06) and 21% reduction in mortality (P = .02) with BP lowering. Given that only 7% of participants in HYVET had a history of stroke, the safety and effectiveness of BP control in older adults with established cerebral small vessel disease could not be studied.
Elderly adults are the fastest-growing segment of the population in developed countries and will contribute significantly to a growing stroke burden. This underscores the need for evidence-based information on targeted risk factor management for this population. The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial was undertaken to define efficacious therapies for prevention of recurrent stroke and cognitive decline in individuals with symptomatic lacunar (subcortical) stroke. There was a nonsignificant reduction in recurrent stroke associated with SBP lowering (hazard ratio (HR) = 0.81, 95% confidence interval (CI) = 0.64–1.03) and a nonsignificant interaction with age (<65 vs ≥65; P = .53). The objectives of the present analyses were to examine the safety and tolerability of lowering BP in the older subgroup of participants in the SPS3 trial.
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