INVEST: Older patients with CAD had better outcomes with systolic BP target <140 mm Hg

Patients aged 60 years and older with CAD and hypertension who achieved a systolic BP target <140 mm Hg had better CV outcomes compared with those who achieved the Eighth Joint National Committee-recommended target of 140 mm Hg to <150 mm Hg, according to new data from the INVEST trial.

These results call into question the JNC 8 panel recommendation to relaxsystolic BP targets to <150 mm Hg for patients aged 60 and older, according to the researchers.

“This study supports the concerns raised by many stakeholders, including the American College of Cardiology, the American Heart Association and a number of individual members of the JNC 8 panel, about the panel’s 2013 recommendations to raise [BP] targets in older patients,” Patrick O’Gara, MD,president of the ACC, and Elliott Antman, MD, president of the AHA, said in a press release. “This new research suggests that raising the threshold for treatment of hypertension in patients 60 years of age or older with [CAD] may be detrimental to the best interest of patients and the public. It underscores ongoing concerns about adopting the unofficial 2013 targets as proposed by the panel originally appointed to write JNC 8. The ACC and AHA, working with the NHLBI, are in the process of assembling the writing panel that will evaluate evidence from a variety of sources and provide a comprehensive update of the hypertension guideline.”

Evaluation of optimal BP

Sripal Bangalore, MD, MHA, and colleagues conducted a non-prespecified post-hoc analysis of 8,354 participants in the INVEST study to evaluate the optimal BP in patients aged 60 years or older with hypertensive CAD. All patients analyzed had systolic BP >150 mm Hg at baseline and were randomly assigned to receive verapamil-SR or an atenolol-based multidrug strategy.

“We had previously published that lower is not better, that it is a J-shaped curve, but we felt that 150 [mm Hg] was too high” as a target for systolic BP, Bangalore, who is associate professor of medicine, director of research at the Cardiac Catheterization Laboratory and director of the Cardiovascular Outcomes Group at the Cardiovascular Clinical Research Center at New York University School of Medicine, told Cardiology Today. “We wanted to take a look because there was not much evidence to support or refute what the panel members recommended.”

For the present analysis, the researchers stratified patients into three groups: those who achieved systolic BP <140 mm Hg (57%), those who achieved systolic BP 140 mm Hg to <150 mm Hg (21%) and those who achieved systolic BP ≥150 mm Hg (24%). In total, they analyzed 22,308 patient-years of follow-up.

The primary outcome was first occurrence of all-cause death, nonfatal MI or nonfatal stroke. Secondary outcomes included all-cause death, CV death, total MI, nonfatal MI, total stroke, nonfatal stroke, HF and revascularization.

Compared with patients who achieved systolic BP 140 mm Hg to <150 mm Hg and≥150 mm Hg, those who achieved systolic BP <140 mm Hg had lower rates of the primary outcome (9.36% vs. 12.71% vs. 21.32%; P<.0001), all-cause death (7.92% vs. 10.07% vs. 16.81%), CV mortality (3.26% vs. 4.58% vs. 7.8%), MI (1.07% vs. 1.03% vs. 2.91%), total stroke (1.19% vs. 2.63% vs. 3.85%) and nonfatal stroke (0.86% vs. 1.89% vs. 2.86%; P<.0001 for all).

CV mortality, stroke risk

The researchers also performed multiple propensity score-adjusted models to adjust for differences in baseline characteristics. Compared with patients who achieved systolic BP <140 mm Hg, those who achieved systolic BP 140 mm Hg to <150 mm Hg had a higher risk for CV mortality (adjusted HR=1.34; 95% CI, 1.01-1.77), total stroke (adjusted HR=1.89; 95% CI, 1.26-2.82) and nonfatal stroke (adjusted HR=1.7; 95% CI, 1.06-2.72).

After propensity score adjustment, compared with patients who achieved systolic BP <140 mm Hg, those who achieved systolic BP ≥150 mm Hg had a higher risk for the primary outcome (adjusted HR=1.85; 95% CI, 1.59-2.14), all-cause death (adjusted HR=1.64; 95% CI, 1.4-1.93), CV mortality (adjusted HR=2.29; 95% CI, 1.79-2.93), total MI (adjusted HR=2.39; 95% CI, 1.87-3.05), nonfatal MI (adjusted HR=2.45; 95% CI, 1.62-3.71), total stroke (adjusted HR=2.93; 95% CI, 2.01-4.27), nonfatal stroke (adjusted HR=2.78; 95% CI, 1.8-4.3).

“We are looking for a sweet spot where benefit is maximized and risk is minimized, and that 150 mm Hg is too high,” Bangalore said in an interview. “So, 140 mm Hg might be the most reasonable target, especially for patients with CAD. We are not saying lower is better; we only looked at 150 and 140 mm Hg. I think too low is bad, but I also think relaxing the target is bad.”

There were no differences between the groups in risk for HF or revascularization, and there were no significant increases in adverse experiences in those who achieved systolic BP <140 mm Hg compared with the other groups, the researchers found.

The analysis does not address the optimal BP target for patients aged 60 or older without CAD, “but age goes hand-in-hand with CAD, so the data are probably applicable to a lot of patients without CAD,” Bangalore said. “I think it becomes a judgment call of risks and benefits in those patients.” – by Erik Swain

For more information:

Bangalore S. J Am Coll Cardiol. 2014;64:784-793.

Sripal Bangalore, MD, MHA, can be reached at: New York University Langone Medical Center, 530 First Ave., SK-9R, Department of Cardiology, New York, NY 10016; email: sripalbangalore@gmail.com.

Disclosure: The study was supported in part by the NIH. Bangalore reports no relevant financial disclosures.

Source: www.cardiosource.org