S-10-3: can achieved average systolic blood pressure below 130 mmhg cause harm in elderly hypertensive patients with left ventricular hypertrophy?

Objectives: We previously reported increased mortality in hypertensive patients > 55 yrs. (average 67 yrs., n = 9,193) with left ventricular hypertrophy (LVH) who achieved in-treatment systolic blood pressure (SBP) < 130 mmHg during an average of 5 yrs. of treatment. Possibly hypertrophic myocardium with degenerated microcirculation becomes ischemic causing fatal complications. The present study aimed to investigate similar elderly patients with LVH in a parallel outcome trial and test the hypothesis that achieved average SBP < 130 mmHg may cause harm in the elderly. Design and Methods: Of 15,245 participating hypertensive patients we identified a population without cardiovascular events during the first 18 months (n = 13,808) after enrollment with discontinuation of previous antihypertensive medications and subsequent up-titration of randomized study drugs and stabilization of SBP. Of these 2,458 patients had electrocardiographic LVH with or without strain. Patients who achieved average SBP > = 140 mmHg during the coming 30 months of follow-up (main population n = 5,505, LVH n = 1,200) served as reference groups. Cox-analyses adjusted for age, gender, and a number of baseline variables were used to compare the primary cardiac composite endpoint including fatal events, stroke and congestive heart failure for patients who achieved average SBP 130–139 mmHg (main population n = 5,833, LVH n = 939) and patients who achieved average SBP < 130 mmHg (main population n = 2,465, LVH n = 319). Results: The TABLE shows hazard ratios and 95% confidence intervals for groups with achieved average SBP 130–139 mmHg and < 130 mmHg for the primary cardiac endpoint, stroke and heart failure in the main population and in LVH patients. For the main population achieved average SBP < 130 mmHg prevented primary cardiac events and stroke but not heart failure. For the LVH patients achieved average SBP < 140 mmHg prevented the primary event but < 130 mmHg did not. However, the risks for stroke and heart failure were not significantly reduced with SBP < 140 mmHg in the LVH patients and the risk of heart failure was non-significantly increased < 130 mmHg. Conclusions: Achieved average SBP < 130 mmHg prevents the primary cardiac endpoint and stroke but not heart failure in elderly hypertensive patients. The risk of primary cardiac events was not significantly reduced < 130 mmHg in the LVH patients, and the risks for stroke and heart failure were not significantly reduced < 140 mmHg. On the contrary, < 130 mmHg the risk for heart failure was increased though not significantly. Target SBP thus remains highly uncertain in elderly LVH patients and needs further investigation.