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Cochrane Database of Systematic Reviews

Objetivos de presión arterial para la hipertensión en adultos mayores

Información

DOI:
https://doi.org/10.1002/14651858.CD011575.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 08 agosto 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Hipertensión

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Cifras del artículo

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Contraer

Autores

  • Scott R Garrison

    Correspondencia a: Department of Family Medicine, University of Alberta, Edmonton, Canada

    [email protected]

  • Michael R Kolber

    Department of Family Medicine, University of Alberta, Edmonton, Canada

  • Christina S Korownyk

    Department of Family Medicine, University of Alberta, Edmonton, Canada

  • Rita K McCracken

    Department of Family Medicine, University of British Columbia, Vancouver, Canada

  • Balraj S Heran

    Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada

  • G Michael Allan

    Department of Family Medicine, University of Alberta, Edmonton, Canada

Contributions of authors

Dr Garrison drafted both the protocol and the full review and is the guarantor of the review. All authors performed critical review and approved the final text. Drs Garrison, McCracken, Korownyk and Allan searched for and identified studies for inclusion. Drs Korownyk and Kolber assessed studies for bias and extracted data. Dr Heran entered data and studies into Review Manager 5 and performed the analyses. Dr Allan verified the data extraction and entry into Review Manager 5.

Sources of support

Internal sources

  • University of Alberta, Canada.

    Academic salary (SRG, MRK, CSK, GMA)

  • Alberta Health Services, Canada.

    Clinical practice income (SRG, MRK, CSK, GMA)

  • British Columbia Medical Services Plan, Canada.

    Clinical practice income (RKM)

External sources

  • Clinical Scholar Award, Canada.

    Competitive research trainee program offered by the University of British Columbia's Dept of Family Practice (RKM)

  • Providence Health Care Research Award, Canada.

    Competitive research award from the author's local health authority (RKM)

  • British Columbia College of Family Physicians Research Award, Canada.

    Competitive research award from professional body (RKM)

Declarations of interest

Scott Garrison: none

Mike Kolber: none

Tina Korownyk: none

Rita McCracken: none

Benji Heran: none

G Michael Allan: none

Acknowledgements

We would like to acknowledge the assistance provided us by Cochrane Hypertension ‐ in particular the assistance of Doug Salzwedel (Information Specialist), who designed and ran most of our electronic searches.

Version history

Published

Title

Stage

Authors

Version

2017 Aug 08

Blood pressure targets for hypertension in older adults

Review

Scott R Garrison, Michael R Kolber, Christina S Korownyk, Rita K McCracken, Balraj S Heran, G Michael Allan

https://doi.org/10.1002/14651858.CD011575.pub2

2015 Mar 10

Blood pressure targets for hypertension in older adults

Protocol

Scott R Garrison, Michael R Kolber, Christina S Korownyk, Rita K McCracken, G Michael Allan

https://doi.org/10.1002/14651858.CD011575

Differences between protocol and review

In the original protocol we stated that we would examine outcomes at two years and, if some studies did not extend that far, at one year. Only one of our studies reported two‐year outcomes. Rather than interpolating results from these other studies to the two‐year time frame, we chose instead to report outcomes using the mean period of observation from each analysis (ranging from 2.4 to 2.6 years). We made this revision upon recognizing it to be the standard approach in other Cochrane Reviews.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Aged; Female; Humans; Male;

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Study flow diagram
Figuras y tablas -
Figure 1

Study flow diagram

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 1. All‐cause mortality.
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Figure 3

Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 1. All‐cause mortality.

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Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 2. Stroke
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Figure 4

Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 2. Stroke

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Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 4. Cardiovascular serious adverse events
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Figure 5

Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome 4. Cardiovascular serious adverse events

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Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome7. Withdrawals due to adverse effects
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Figure 6

Forest plot of comparison higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, outcome7. Withdrawals due to adverse effects

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 1 All‐cause mortality.
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Analysis 1.1

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 1 All‐cause mortality.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 2 Stroke.
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Analysis 1.2

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 2 Stroke.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 3 Cardiovascular serious adverse events.
Figuras y tablas -
Analysis 1.3

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 3 Cardiovascular serious adverse events.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 4 Cardiovascular mortality.
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Analysis 1.4

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 4 Cardiovascular mortality.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 5 Non‐cardiovascular mortality.
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Analysis 1.5

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 5 Non‐cardiovascular mortality.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 6 Unplanned hospitalisation.
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Analysis 1.6

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 6 Unplanned hospitalisation.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 7 Cardiovascular serious adverse events (by component).
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Analysis 1.7

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 7 Cardiovascular serious adverse events (by component).

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 8 Total serious adverse events.
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Analysis 1.8

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 8 Total serious adverse events.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 9 Total minor adverse events.
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Analysis 1.9

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 9 Total minor adverse events.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 10 Withdrawals due to adverse effects.
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Analysis 1.10

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 10 Withdrawals due to adverse effects.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 11 Mean systolic BP achieved.
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Analysis 1.11

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 11 Mean systolic BP achieved.

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Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 12 Mean diastolic BP achieved.
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Analysis 1.12

Comparison 1 Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target, Outcome 12 Mean diastolic BP achieved.

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Summary of findings for the main comparison. Higher BP target (< 150‐160/95‐105 mmHg) compared with lower BP target (< 140/90 mmHg) for cardiovascular risk reduction

Higher BP target (< 150‐160/95‐105 mmHg) compared with lower BP target (< 140/90 mmHg) for cardiovascular risk reduction

Patient or population: older adults with primary hypertension

Settings: outpatient

Intervention: higher BP target < 150‐160)/95‐105 mmHg

Comparison: lower BP target < 140/90 mmHg

Outcomes

Illustrative comparative risks1
(95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed
risk

Corresponding
risk

Lower
BP target

Higher
BP target

All‐cause mortality

Mean follow‐up: 2.6 years

31 per 1000

39 per 1000
(31 to 48)

RR 1.24

(0.99 to 1.54)

8221
(3)

⊕⊕⊝⊝
Low2,3

Stroke

Mean follow‐up: 2.6 years

20 per 1000

25 per 1000
(19 to 33)

RR 1.25

(0.94 to 1.67)

8221
(3)

⊕⊕⊝⊝
Low2,3

Cardiovascular serious adverse events

Mean follow‐up: 2.6 years

42 per 1000

50 per 1000
(41 to 61)

RR 1.19

(0.98 to 1.45)

8221
(3)

⊕⊕⊝⊝
Low2,3

Withdrawals due to adverse effects

Mean follow‐up: 2.4 years

17 per 1000

14 per 1000
(10 to 20)

RR 0.83

(0.58 to 1.19)

7497
(2)

⊕⊕⊝⊝
Low2,3

The basis for the assumed risk is provided in footnote below. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
BP: blood pressure; CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different
Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect
Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect

1Rationale for our choice of assumed risk: the risk of cardiovascular events in a hypertensive general population varies considerably across countries (Finegold 2013). With no reason to favour one country over another we have opted to use (now and for future updates) an assumed risk, which is the average across studies included in this review.
2Downgraded due to high risk of bias.
3Downgraded due to heterogeneity and imprecision.

Figuras y tablas -
Summary of findings for the main comparison. Higher BP target (< 150‐160/95‐105 mmHg) compared with lower BP target (< 140/90 mmHg) for cardiovascular risk reduction
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Comparison 1. Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All‐cause mortality Show forest plot

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.24 [0.99, 1.54]

2 Stroke Show forest plot

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.94, 1.67]

3 Cardiovascular serious adverse events Show forest plot

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.98, 1.45]

4 Cardiovascular mortality Show forest plot

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.52 [1.06, 2.19]

5 Non‐cardiovascular mortality Show forest plot

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.81, 1.46]

6 Unplanned hospitalisation Show forest plot

1

3079

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [0.55, 2.53]

7 Cardiovascular serious adverse events (by component) Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1 Cerebrovascular disease

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.22 [0.93, 1.61]

7.2 Cardiac disease

3

8221

Risk Ratio (M‐H, Fixed, 95% CI)

1.21 [0.82, 1.79]

7.3 Vascular disease

1

4418

Risk Ratio (M‐H, Fixed, 95% CI)

2.01 [0.37, 10.94]

7.4 Renal failure

2

7497

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.38, 1.89]

8 Total serious adverse events Show forest plot

1

3079

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.69, 1.24]

9 Total minor adverse events Show forest plot

2

7497

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.91, 1.08]

10 Withdrawals due to adverse effects Show forest plot

2

7497

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.58, 1.19]

11 Mean systolic BP achieved Show forest plot

3

8221

Mean Difference (IV, Fixed, 95% CI)

8.88 [8.38, 9.39]

12 Mean diastolic BP achieved Show forest plot

3

8221

Mean Difference (IV, Fixed, 95% CI)

3.09 [2.72, 3.47]
Figuras y tablas -
Comparison 1. Higher (< 150‐160/95‐100 mmHg) versus lower (< 140/90 mmHg) BP target
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