Individualizing Blood Pressure Goals in Older Adults: Mitra Jamshidian, Simon Ascher and Mark Supiano

Eric 00:11

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, today we’re going to be talking about individualizing blood pressure in older adults. Who do we have on the show with us?

Alex 00:19

We are delighted to welcome Mitra Jamshidian, who is a nephrologist and researcher at UCSF and San Francisco General Hospital. Mitra, welcome to the GeriPal Podcast.

Mitra 00:32

Hi. Thanks for inviting me.

Alex 00:35

We’re delighted to welcome Simon Ascher, who’s a hospitalist researcher at UC Davis. Simon, welcome to the GeriPal Podcast.

Simon 00:42

Thanks for having me.

Alex 00:44

And we’re delighted to welcome back Mark Supiano, who’s a geriatrician researcher at the University of Utah. I looked it up. Mark, has it been this long? Did we last have you on in 2017? It was the episodes titled, “How low should we go with blood pressure?”

Eric 00:57

Holy smokes.

Mark 01:01

Good to be back. Yes. That was right after the sprint study results were published, as I recall.

Alex 01:07

It’s so great to have you back, and it’s been too long. So glad to have you with us, Mark.

Mark 01:11

Happy to be here. Thanks for the invitation.

Eric 01:14

So we’ve got a lot to talk about. We’re going to take a deep dive in blood pressure in older adults. But before we do, Simon, do you have the song request for Alex?

Simon 01:23

Yeah. Yeah. I was thinking about Frank Sinatra’s My Way.

Eric 01:28

Why are you choosing Frank Sinatra My Way?

Simon 01:31

I mean, first, I’m just excited to hear Alex play it, but I don’t.

Eric 01:34

Think he’s ever done a Frank Sinatra song before.

Alex 01:36

This is a first.

Eric 01:37

He’s a crooner at heart, so we’ll see.

Alex 01:40

50 songs, and this is a first.

Simon 01:42

All right, well, now I’m especially looking forward to it, but, yeah, I also think that Sinatra reflecting on how he lived his life, his way, making its own choices, fits with this topic of personalized blood pressure goals and allowing patients to express what matters most to them.

Eric 02:01

Great.

Alex 02:02

Here’s a little bit. I’ll do the intro here, and then at the end, I might go for it.

Alex 02:15

(singing)

Eric 03:05

That was great, Alex.

Alex 03:07

Thank you, Simon. I want to sing for a long time. Thank you so much.

Simon 03:11

Thank you. Now I can avoid my blood pressure medicine. That really got me down 10 points.

Eric 03:19

So I was actually just listening to an AGS talk by Jeff Williamson. And you know, the thing that struck me was he was talking about when he was in training, how they defined blood pressure. It was, I believe it was like 90 or 100 plus your age. I actually forget the first number, but it was like if you were 70 years old, your average, the normal blood pressure was like 170. I wonder. It sounds like we’ve progressed since those times. How are we defining high blood pressure nowadays? I’m going to take a big, big step back. Before we talk about individualizing blood pressure, let’s talk about what is hypertension?

Mitra 04:00

I mean, I think every organization defines it differently. So, like the WHO defines it as 140 over 90. But as a nephrologist, I follow KD GO guidelines which say that a patient who has CKD who’s not on dialysis has high blood pressure. If that blood pressure is above 120.

Eric 04:17

120, they have hypertension at 120. Any other thoughts?

Mark 04:24

So lot. Lots. So back in 2017 when I joined you to talk about the sprint results, the American Heart Associate guidelines had just been published which lowered the threshold. Previously had been 140 down to 130. So the AHA current guideline is at 130. My understanding is that guideline is being revised this year and we expect to see a new guideline published sometime later this year. So it has been a moving target, but it is based on evidence and some of the evidence we’ll dive into today.

Eric 04:56

Well, was that the guideline where there was like pre hypertension, which was like 120 to 129, and then like was the stage one was 130 to 139. Am I remembering that correctly?

Mark 05:08

Anybody remember Slight notification was actually the prior version because the. There was in the 2017 version, there are no stages anymore. It’s simple. Oh, 1:30 or higher, 130 or higher.

Eric 05:21

How do we all feel about that? Right? Because this is a, this is a risk factor, everybody with a blood pressure of 130. What was the. Because we’re going to be talking about Sprint. What was the blood pressure was down to 120.

Mark 05:34

Maybe that guideline wasn’t low enough. I’ll throw that out there.

Eric 05:37

How are you eligible for sprint? Did you have to have a blood pressure Greater than 130 or 140 History.

Mark 05:42

Of hypertension and what, 140 was the average starting for people in sprint?

Simon 05:48

Yes.

Eric 05:49

Go ahead.

Simon 05:49

I would just say I do think this is interesting to think about how a very common chronic condition, how the definition has changed over time and seems to be guided by what the next trial compares standard of care to. And even now with Sprint out and a few more recent trials since then, I think if I’d have to look this up. But if you, you know, say, look at an older adult who’s 70 years old and stand across the guidelines, I imagine we might find three or four different definitions of hypertension and what their blood pressure goal should be.

Alex 06:29

We recently published a podcast that was kind of a hype up for the AGS plenary session that Eric and Ken Kavinsky and I do. We just did last week in Chicago. And one of my favorite songs, we kind of went through like favorite songs from prior years, parody songs. And one of my favorites was Let It Go about treating inpatient blood pressure to outpatient blood pressure guidelines. And the last line of that was hypertension never bothered her anyway. And so my. I guess I don’t know if we want to go down this rabbit hole, but is hypertension a disease or is it a pre disease or just a.

Eric 07:11

Risk factor for a disease?

Alex 07:13

What is it? Any opinions about that? Anyone want. Nobody wants to take this is philosophy class.

Simon 07:19

I was about to say I can.

Eric 07:20

Live grenade, wax poetically.

Simon 07:23

I can get philosophy.

Mark 07:25

I would posit, Alex, that it’s a marker of underlying disease. It’s a manifestation of a vascular aging phenomenon related to arterial stiffness. And I won’t go further down that rabbit hole. But there is a mechanistic explanation for this and why it’s particularly a concern for older adults and why it particularly contributes to problems in the aging brain, heart and kidney, which is what we’ll be talking about. This is why we have nephrologist in this panel today.

Eric 08:01

And it’s super common. Right. Like I think I read in the intro of your article, Mitra, like 75% of people older than the age of 75, I think have hypertension.

Mitra 08:13

Yeah, that comes from names. The names data from 2007 to 2012 showed that nearly one third of U.S. adults aged 75 and above have hypertension and would have been eligible for sprint.

Eric 08:27

And I also read that, you know, I just turned to age 50, I have a 90% chance of developing hypertension over the course of my lifetime.

Alex 08:37

Wow.

Eric 08:38

Yeah. If I don’t have it already.

Mark 08:40

That’s that vascular aging component, Eric.

Eric 08:43

Yeah. So is this just normal aging?

Mark 08:46

Well, Mark, what is normal aging? We can go down that rabbit hole, but it is a common age related physiologic change. Yeah, can’t say it’s normal.

Eric 08:58

And then I guess the question is what do we know about managing this common physiological change that we see with aging, this arterial stiffness with medications? What do we know as far as does it help our patients?

Simon 09:15

I think I can speak a little bit to Sprint but you guys feel free to chime in. But at least with respect to our older adults, you know, there as Sprint showed that treating to a goal of less than 120 versus less than 140 led to clear cardiovascular and mortality benefits. There was a companion study called Sprint Mind that also showed that what’s good for the heart is good for the brain. So it led to more intensive blood pressure lowering, reduced the risk of cognitive impairment and dementia.

Alex 09:50

Wasn’t it cognitive impairment but not dementia?

Simon 09:53

It was the true, I think the composite, you’re right. I think if you separated them it was mostly driven by cognitive impairment. But the, the overall composite, I believe there was a effect there, right?

Alex 10:06

I think it was.

Eric 10:07

So it had an effect on MCI and the combined MCI plus dementia, but not just dementia likely because I think they followed for three and a half to five years. So not a lot of dementia cases in that group.

Simon 10:21

Right.

Alex 10:21

And we had with Jeff Williamson in 2019 about that. Go ahead, Mark.

Mark 10:26

I was just going to add to that end. There are now follow up data, extended or legacy effects from the sprintline study that were published in Neurology earlier this year. Jeff Williamson and I are co authors on that paper and it basically showed the same thing. There were more cases that accrued but still hazard ratio in favor of preventing probable dementia was evident. It did not meet the standard for what we typically accept for statistically significance at 0.08. But again the MCI and the composite MCI and dementia outcomes persisted.

So really cool thing is that for an intervention that after all only lasted three years before the trial stopped, had this now long term benefit with almost eight years of follow up on protecting the brain. So that’s a pretty cool finding and I think why we’re going to be talking about the benefits in terms of cognitive outcomes in this net benefit discussion we’ll get into.

Eric 11:26

All right, before we do that, just a big reminder for our listeners. So Sprint, this big study 2016, was it 2016? I think it came out 2015. You know, before that there was always this concern about like A J shaped or U shaped curve where you’ve dropped the blood pressure too low. People had worsening mortality. Sprint came out 150 versus 120 goal. Importantly, right Mark, non institutionalized ambulatory community dwelling adults. So they looked like the patients that we were seeing out there in community, but they were not nursing home patients.

There were some significant exclusions too. And lo and behold, the target of 120 was much better than the target of 140. As far as if you came close to 120, I think the average in the end was like 121. In the 120 goal group, man mortality was improved. They stopped the study early because it was so good. And again we, we saw other potential benefits as far as improvement in rates of mci. But everything has a trade off, right?

Mark 12:39

Was there one before we dive into the trade off just to bring this up to date, since Sprint. So again, that was 2015, there have now been two additional randomized controlled trials, both of which conducted in China. So step and a spree. 9 to 11,000 people enrolled. Very similar, designed to Sprint. Similar targets of 140 to 120 older adults. Older adults average age mid 6 or late 60s, actually.

Eric 13:07

All right, so younger than sprint.

Mark 13:09

A little younger, but very similar positive outcomes for mortality and cardiovascular benefit. Then most recently the China Rural Health Project, Jeff Williamson cited this in his Henderson Award lecture that you mentioned because he was a collaborator with that group in China. Little different design. It wasn’t a randomized controlled trial, but took individuals in rural villages in China. And it was a cluster randomized design trial where the entire village was approached with community health workers to get people uncontrolled blood pressure treated.

The short story is same cardiovascular and mortality benefit and the adjudicated cognitive outcomes and show the very similar hazard rate reductions to what was seen in Sprint mind. There’s now four different studies, three from and Sprint, that show very compelling results getting individuals down to the 120 range.

Eric 14:14

So 120 is good. That is our goal.

Alex 14:17

And I just want to emphasize one more time, these were like clearly not hospitalized patients. So these are outpatient ambulatory patients. Oh, we just lost Mitra Hope she comes back.

Eric 14:30

Non institutionalized, right?

Alex 14:32

Non institutionalized. And I believe Sprint excluded people with diabetes, people who had a history of stroke. So when we did our geriatrics journal club about this, I remember Lauren Hunt commenting that this doesn’t sound like typical geriatrics patients where it’s like the frailest frail, the oldest old, the sickest sick, like maybe it’s a subset. These are primarily patients who might be seen in like family practice, internal medicine clinics, the sort of generally, well, older adults. Is that a fair characterization, Mark?

Mark 15:06

I think that’s fair. You do not want to overgeneralize the results. For sure, yeah.

Eric 15:15

Okay. Trade off, Simon, was there any trade off? Were there any harms from targeting 120 versus 140 in the sprint trial?

Simon 15:25

Yeah. So Sprint pre specified looked at some what are called serious adverse events of interest or potential harms, including ER visits or hospitalizations for aki, syncope, hypotension, serious electrolyte derangements and showed overall, and I think in the subgroup of older adults that there were some potential trade offs in terms of intensive blood pressure lowering leading to a higher risk of some of these harms.

Eric 16:00

I could tell our nephrologist left because she, she was worried we’re going to be talking about aki. That seems like a bad thing, right? People developing aki?

Simon 16:13

Yeah, my sense of the data. Feel free to chime in, Mark. But you know, I think Sprint investigators looked into the AKI events and it turns out that I think the vast majority of them were classified as being mild or stage one. And most patients had returned to pretty close to their baseline creatinine after the index ER visit or hospitalization. So these weren’t, you know, AKI events leading to dialysis or massive CKD progression.

Mark 16:45

That’s right. So the good news is there was no rate of renal failure leading to dialysis. So that was not a concern. There were no permanent injurious kidney outcomes. And like the other adverse events, frankly, these are transient and reversible. The guess is, the best guess is that a lot of the AKI was due to dehydration. One of the common additions to the armamentarium to get blood pressure down to the 120 target was a thiazide class diuretic, which may have contributed to some dehydration and AKIS related to that, which as Simon mentioned, fortunately were reversible and did not lead to these longer term outcomes.

Eric 17:30

All right, so a lot of potential Benefits, target of 120 over 140, some potential harms, but generally they sounded very manageable. As far as like falls, I forget there was greater hypotension and syncope, but no. Was there?

Mark 17:47

No.

Eric 17:47

I think Jeff said, I remember in a podcast, was there no difference in falls?

Mark 17:51

There was no difference in injurious falls. That was the adjudicated outcome for adverse events and that held up across all age groups, including those 85 and older, there was no effect of randomization based on the rate of injurious falls. Older people had more falls, but it was the same rate in both the standard and the intensive group.

Simon 18:14

And this may be parsing a little bit, but I think, correct me if I’m wrong, Mark, but I think some of the. If you syncopize and that resulted in a fall, I think that counted as syncope. So I generally think these injurious falls were not preceded by a sinkable event.

Eric 18:33

So, yeah, we lost Mitra, because now I kind of want to know, like, how do we apply this and individualize it to our patients? Y’ all did a great study. Mitra was the lead author in this study that was published in JAGS about, like, some ways we can think about individualizing this data. Simon, until Mitra comes back, can you tell us kind of why you started this study and maybe just start off with that?

Simon 19:02

For sure. Thinking about this both from a clinical perspective and research perspective, I think clinically, as we’ve talked about, namely with Sprint, we have high quality evidence supporting lower blood pressure goals for older adult patients. But it’s still challenging in clinical practice to apply that evidence to your individual patient. And thinking about how to balance the those potential benefits and harms, especially for our older adult patients who might have more advanced age or frailty or polypharmacies who are taking a lot of medications, it can be challenging to think about how to apply that in the real world setting. I think just from a research perspective, what our group has been thinking about for the last couple years, and really what I think led to this project is how to, you know, potentially move from this, like, one size fits all approach to blood pressure treatment, especially for older adults who are very heterogeneous, that, you know, have a range of comorbidities and cognitive and physical function.

And so that’s sort of what led us to thinking about, can we develop a personalized approach that takes into account each person’s expected benefits and harms, but also, you know, importantly, is patient centered, meaning, you know, related to the geriatric forums that patient centered in terms of being able to elicit and factor in what matters most to the patients?

Eric 20:31

So, Mitra, if you could summarize briefly, what did you actually do in this study?

Mitra 20:37

Yeah, so basically what we did was we incorporated both the treatment benefits, like reduced cardiovascular events, mortality and cognitive decline and harms like the AKI syncope and falls into these different risk preference scenarios that patients Might have to estimate the net benefit of the intensive versus the standard blood pressure lowering. And we did this for each adult in sprint. And then we also stratified the results by age, frailty, and polypharmacy as well.

Eric 21:06

So you looked at each individual enrolled in sprint, looked at the benefits and the harms, and then modeled it out or, like, what it actually.

Mitra 21:18

Yeah, so, like, net benefit would be like the benefits minus the harms equal the overall absolute benefit. And if that’s positive, that means the benefits outweigh the harms. If it’s negative, that means the harms outweigh the benefits.

Simon 21:32

Okay, just to maybe add to that Erica’s great nutrient, it is conceptually challenging to think about. Like, how do you weigh mortality versus these apples?

Eric 21:45

Like, for a nephrologist, AKI is the most important thing. Right.

Mark 21:48

Nitrate.

Eric 21:50

No, go ahead, Simon.

Simon 21:53

NDR visits for hospitalists now. Yeah, so as Alex said, it is kind of an apples to oranges comparison. And so, you know, what Mitra and our team did was model patient preferences as sort of a weight where you can sort of quantify the relative importance of a stroke versus a AKI event. And, you know, if we can say, well, Maybe stroke is 10 times more important to prevent than an AKI event, now we’re, now we’re dealing with a basket of apples, and we can make sort of a clearer trade off.

Eric 22:31

Now you can quantify things. Okay, so I, you know, we probably could spend an hour on the wonkiness, like the, the methods that our listeners.

Alex 22:42

Will thank us.

Eric 22:45

But we may have to dive a little bit into it. But before we do that, what did you actually find in this study?

Mitra 22:51

Yeah, so overall, the benefits outweighed the harms for most older adults. And in fact, when we model the scenario where someone really prioritizes preventing like heart disease, stroke, death, or dementia, every single participant had a net benefit, even those who are older, frailer, or on lots of meds. And interestingly, it was actually these older ones and the frailer ones who stood to gain the most benefit more than these younger and less frail, more fit ones.

Eric 23:25

Why is that? Is that just because the event rates are much higher in those individuals?

Mitra 23:29

Yeah, so that’s a great question. So both the harms go up in these individuals, but also the benefits go up in these individuals too. And overall, the, the benefit outweighs the harm, and the amount that the benefit goes up is higher than the amount that the harms go up. So the balance comes out in favor of intensive treatment for nearly everyone.

Mark 23:50

That’s Great.

Alex 23:50

That was a very clear explanation. And my question is back to that. Like, how frail? Because when you’re saying like, the older, the frailer, I’m thinking again, back to that comment from our Journal Club that there were a lot of exclusions here. Is this like, you know, when you’re talking about like lots of medications, how frail, how multimorbit, how old are we talking here? Are there limits to how far we can generalize this? Go ahead.

Mark 24:19

If you don’t mind me jumping in. Since Nick Priuski and I had something to do with calculating the frailty for sprint participants, so we did use the Rockford approach for deficit accumulation and calculated the frailty and index for every participant in sprint for those 75 and older. That included a gait speed. So we have average usual gait speed for those 75 and older. And that went into the frailty equation, so to speak as well. So with the caveat, Alex, you’re right. These are community dwelling ambulatory adults. They’re able to come into clinic. They’re not nursing home residents.

Eric 24:54

We signed up for a clinical study.

Mark 24:56

But who enrolled in a clinical trial and came into clinics for their blood pressure management and so forth. The frailty indices, and I’m not going to remember this off the top of my head, but a sizable fraction, I’m thinking it was at least a quarter would meet the Rockwood definition for frail. These are not pristine older adults. Their average MOCA scores, for example, were 22. These are not the super healthy marathon runners that we occasionally see in our clinics. These are standard older adults that all of us care for.

There was a range of frailty. One of the cool things about the study we’re talking about, about it is that as you pointed out correctly, you know, the people who had the greatest net benefit were the oldest, the frailest, and those on more drugs. So the greater the risk, the greater the benefit.

Eric 25:48

All right, I’m going to push you on that because I actually pulled up the original frailty article. So original sprint did not include frailty. Like, there was no frailty measure, right?

Mark 25:58

No, it did. It did.

Eric 25:59

I thought there was this. So the Sprint frailty index was developed by, Was it developed post or after the publication? During the public. Okay. During the sprint trial. So it was the sprint frailty index, which I think was 36 different items. Right. One of them included gate speed. And when I looked at the like, it wasn’t like the full range of frailty. Right. I think that’s the key thing. There was a spectrum of Frailty that.

Mark 26:26

Within dwelling older adults.

Alex 26:28

Right, so it’s not dwelling adults, right, who haven’t. Don’t have diabetes and haven’t had a stroke.

Mark 26:33

Correct.

Eric 26:33

Yeah. So in this paper, Mitra. Right. So in that population, of that spectrum of frailty, the worst in that spectrum, they actually did better. Right. As far as if their priority was avoidance of mortality, MI, things like that, those individuals did better with aggressive versus less aggressive blood pressure.

Mitra 26:58

Yes, that’s right. But even when we took the more cautious approach, like saying, okay, what if you cared just as much about avoiding harms like Aki or falls as much as the benefits, like preventing the benefits, like heart disease or stroke or dementia, 85% of them still had a net benefit. And we saw the same pattern that those who are older and more frail had an even greater net benefit.

Eric 27:22

So does any. I guess the question is, this is a, the topic is individualizing blood pressure control, but what I’m hearing is everybody has a net benefit of tighter blood pressure control. Did I title this podcast wrong? Simon.

Simon 27:41

To your point, I think even though most of the older adults in Sprint did have this benefit harm trade off that favored intensive blood pressure lowering, there’s a lot of variation in the magnitude of that net benefit. And there are some people that just have this massive, massive benefits outweighing the harms, irrespective of their preferences. And then there are arguably more patients that were a little bit more closer to the middle. Where it gets into this question of if your net benefit is just above.

Eric 28:15

Zero, who were the people that fell into that group? What do we know about them?

Simon 28:22

That group tended to be the lower risk patients. So, you know, the converse of, you know, Mitra’s point, the younger fit patients with fewer medications, the net benefit was still positive. Favorite intensive blood pressure lowering, but smaller. And yeah, I think that maybe lends itself to more of this kind of like shared decision making discussion of how much do you need? The benefits outweigh the harms too.

Eric 28:52

But is it shared decision? Because I feel like Sprint was called off early. Right. It was stopped early because you were seeing this mortality benefit. How much is it? In that younger patient group, there just wasn’t time to see the benefit. You needed to follow these people 10 years to see a net benefit, and that net benefit may be huge.

Mitra 29:15

Yeah, that’s really true.

Simon 29:18

Yeah, great, great point. Thinking about, you know, lifetime cardiovascular risk and, you know, if you’re 55 year old, patient’s gonna be treated for 20 years, how much of a risk reduction are you gonna get? From there. So that I think that was one of the limitations of, of this study is that this is looking at events during the average three, three and a half year follow up period.

Mark 29:42

With that being said, I think it also is important to emphasize that we’ve commented already about what matters most, this net benefit that should matter most to our patients. But the other point is that the outcomes that we’re talking about, the benefits are just not the traditional cardiovascular, prevent a heart attack outcome. People don’t care about heart attacks anymore, right? You go into the hospital, you just stand to go home the next day, no big deal. But the outcomes that matter most to our patients are developing dementia or cognitive impairment, developing, having a stroke, developing heart failure.

These are all outcomes that impact older adults functional and cognitive status. So what I’m excited about in terms of how we’re looking at this in terms of net benefit, it’s not from some esoteric benefit that no one cares about. Older people care about preventing these outcomes. And I think as we’re having patient centered discussions with our patients about the potential benefits we can share with them, these are things that are going to matter to you for which your risk will be lower if you’re able to get to this lower blood pressure.

Eric 30:56

So I guess hearing that Mark, when you saw this study, did it change anything that you do or is it just how you communicate that with patients? Are you saying maybe for this group, maybe I should individualize my approach more?

Mark 31:13

Well, good question. And prior to this paper’s publication, when I give this grand rounds presentation, I group it into the four M’s and under the what matters most category, I would do a little hand waving about this patient centered approach. Now we have this study with some real compelling evidence from the modeling that they have done to show that most everyone does have a net benefit and again that it’s older individuals who may benefit the most. Back to Jeff Williamson and his really fantastic Henderson Award presentation.

He spoke about the compression of morbidity. James Free’s article from the 1980, I think it was, I pulled it out again. It had been so long since I read it. But this is the compression of morbidity. This is a benefit that’s going to prevent those devastating events that are going to impact the quality of life for older adults as they age in terms of their health span improving. This is health span reduction or health span extension rather in play, as Jeff pointed out during his presentation.

Eric 32:23

Mitra, does that sound kind of how you want people to use it for kind of. I mean, it sounds like, what I’m hearing from the study is most people benefit from a. Who would have been included in the sprint trial and these other trials benefit from intensive blood pressure control.

Mitra 32:40

Yeah. So most people benefit why this is important and how you can use it. I mean, you, like, for the sheds decision making component, you want to, like, ask what are you hoping to get out of treatment? Like, what worries you? For some patients, like, maybe their family member had a stroke, a really bad stroke, and so preventing a stroke to them is something that’s most paramount. Whereas, like, for someone else, they may not want to fall, they may not want to break a bone.

So you could kind of understand their priorities and then explain the risks and benefits. And then if, like the next step is really what Simon’s working on next is building like some sort of calculator that’s like what we wish, that you could input these numbers so you give that values a weight and then that calculator could compute a net benefit and you could tell your patient. So, you know, I like it. The overarching, like intensive blood pressure control would align with your values and lead to a benefit in your life. But for me, the next person, it wouldn’t. Maybe the harms would outweigh the benefits.

Alex 33:48

Oh, I love that idea. The prognosis in us likes that idea. This is great.

Simon 33:54

Inspired by you guys.

Alex 33:55

This is great. So one question. On e prognosis, we have a cancer screening module and in the end of that module we say for persons with life expectancies like yours, and then we have red light, green light where they’re. Cancer screening would be more beneficial than harmful. And then below that we show here are the number of people who would be harmed, and those harms are typically immediate. And it’s a fair number of people usually. And then here are the number of people who would benefit. And it’s usually very few number of people.

But those benefits, as we’ve discussed, are much greater in terms of preventing cancer that would kill you. And then we also show the number of people who would die, whether or not they got screened for this cancer. And so I wonder how prognosis plays into this, if at all, if you’ve considered that in your approach. And my guess is because these were ambulatory fairly well, older adults with some spectrum of frailty, there weren’t many deaths. So you probably didn’t model that much in your.

Mitra 35:05

Yeah, that’s a really good question and a really important point. So Sprint excluded patients who had a limited life expectancy and excluded patients who were institutionalized in a nursing facility. So that’s a really important point and we definitely need more trials that focus on these sorts of people.

Mark 35:27

So, Alex, what that does bring to my mind is work from one of your E prognosis colleagues. I think, you know someone named, say, Lee.

Alex 35:35

Oh, yeah, heard of him.

Mark 35:39

They had a paper published. I think it was in jags. I better double check. But looking at the time to benefit, this was for stroke. So not all of the outcomes, but the time to benefit from intensive therapy to prevent stroke is on average 1.7 years.

Simon 36:00

Pretty short.

Mark 36:01

Pretty short. The other paper, again JAGS paper, Nick Paiuski modeled out benefits of the very old included in sprints. Even above the age of 85, there was a benefit in terms of cognitive impairment. My take on that is that it’s not too late to start and that there’s still time to benefit from intensive therapy.

Alex 36:27

I want to ask when residency. Wait, one more thing, Eric. We tell people, jump in and talk over each other. Eric. When I was in residency, we looked at the guidelines in the UK around management of high blood pressure and they had looser and looser criteria for treating high blood pressure as people got older. I don’t know if that’s still the case. Maybe somebody on this call who might be from the UK or have an accent that resembles one. I might be able to comment because your data suggests the opposite, that maybe we should have tighter guidelines as people get older.

Mark 37:05

So times have changed, I would submit. And the other factor is, and we have some evidence of this actually, from Sprint, there’s therapeutic nihilism and ageism in older adults. Our bias is there’s an age bias that older adults aren’t going to benefit the same way that younger adults will from intensive blood pressure therapy. It’s ageism. We have a paper published, Alex Arudolin is the first author, that basically, even in sprint, there was therapeutic inertia evident in the oldest sprint participants, the therapeutic inertia meaning that they showed up to a clinic visit, they weren’t quite at target. Was an action taken?

It was less likely to result in an action if you were over the age of 75. So even in sprint, there’s therapeutic inertia and ageism. So that’s a big factor still today. And I’m delighted that this paper is calling attention to the fact that when we look at these relevant outcomes to older adults and what matters most, there is net benefit. And as geriatricians, I think it’s incumbent on us to get this word out so thank you for giving us this platform to get the word out.

Mitra 38:25

Yeah, I agree with that. I think clinicians shouldn’t just automatically shy away from a systolic blood pressure target of 120 just because the patient is older and frail. And this study kind of shows that most of them may actually have a net benefit.

Eric 38:41

Okay, go ahead, Simon.

Simon 38:44

Oh, I was just gonna add, you know, I think we aired into some, like, philosophical discussion earlier just to kind of bring us back into that. You know, I think what’s been really enjoyable about working with Mitra on this and, you know, frankly, reading a lot of Mark’s papers in this space is, you know, he brought up, like, clinical inertia when it comes to treating blood pressure. And, you know, I think clinically, as a provider, when someone does get a harm, so if they do go to the ER or get hospitalized for an AKI or sinkable event or have a major fall, you know, we see that and we might, you know, we might get reminded of that or, you know, we’ll follow that patient up.

And I think, in contrast, one of the challenges with preventive medicine and, you know, in the case of hypertension is we don’t see the stroke that we prevented or the heart failure that was avoided. And if it is prevented, that’s a good thing, but that’s sort of invisible to us. And hopefully with these kinds of tools where the benefits and harms are laid out more explicitly, those unseen benefits become more readily visible.

Eric 39:53

Any thoughts on what we should do for people who are living in nursing homes? How would you think about them, given what you know from this study, from Sprint, from all these other studies? Is this ageism not treating them there? It’s like, should we be targeting lower blood pressure or we just don’t know.

Simon 40:13

We still have the data.

Eric 40:14

Is it ageism just because they’re not included in these studies?

Mark 40:17

It’s a data desert, in my opinion, Eric. I know that we’ve had some submissions to JAGS trying to address this. Like many things, it’s a challenge to study blood pressure regulation in nursing home settings. Measurements are concerned, lots of other contributors. So we need data to really guide that decision. We shouldn’t be excluding nursing home residents from potential benefits, but I think we’re also very concerned, appropriately so, about potential harms. And until the data, I think it’s going to be a real challenge.

Eric 40:50

So trying our best. Go ahead, Simon.

Simon 40:53

Oh, just. Sorry. I was totally agree with Mark. If I could just add one point to the data piece. I think it’s also been humbling. Learning from sprint and thinking about how it fits in the context of the literature is the challenges of studying hypertension control in the observational retrospective setting and all the potential confounders that might drive people with lower blood pressure to different outcomes. In the case of, I think, Eric, you had mentioned the J curve relationship of there was a concern of a lower diastolic blood pressure. If you treat them intensively, there’s observationally that strong association with adverse cardiovascular outcomes. But in sprint, when you eliminate the confounding with randomization, you actually see that those with a low diastolic blood pressure have the same thing. I think hopefully there are trials in the future in the nursing home setting to really sort that out.

Eric 41:52

My last question to all three of you. I’m going to go back to the title of this talk, Individualizing Blood Pressure Management in Older Adults. I’m going to question my title again to each one of you. Should we be individualizing blood pressure control? What our target is for older adults? Or do we have enough data to say that, you know what, if you’re younger, we’re not seeing a huge net benefit because sprint ended early. You need more time to accumulate those events. We should be aiming for less than 120. If you’re older, the net benefit in the course of three and a half years is even better for you. So you should be less than 120. Should we be individualizing or should we all. Everybody should be targeted to less than 120? Simon, what are your thoughts?

Simon 42:39

Yeah, I’ll throw my hat in favor of individualizing, mainly from the perspective of thinking about how much benefit there is and how much is the trade off in the gap between the two. And you may have one patient who you may want to more aggressively treat based on sort of the magnitude of the trade offs as opposed to another patient. So even though most people may be on the side of treating, it’s kind of a question of how aggressively do you go about it, Mitra?

Mitra 43:07

Yeah, I mean, I agree. I think that we could still individualize. I think this study shows us that those who really prioritize, like when we looked at everyone above age 65, those who really prioritize preventing heart disease, stroke or dementia, death over aki and falls, those people all benefited. But then those who were more interested cared about avoiding them all equally, 85% of them benefited. So, like 15% did not have a net benefit. So, I mean, I think that using that, you should still individualize. But most people would benefit if they prioritize preventing heart disease, stroke and dementia.

Eric 43:53

Mark, final words.

Mark 43:55

My pragmatic approach from a geriatrician’s perspective is that the majority of older adults are going to benefit from a target of 130 those at greater risk. So yes, we should individualize based on risk factors so those are greater risk for cardiovascular disease and or cognitive impairment are the ones who are likely to benefit from that individualized approach to getting down to 120 if they can manage that. So that’s where I would see the individualization happening is weighing that those at greater risk are going to derive greater benefit from the lower target.

Eric 44:29

Wonderful. I love all of it. I want to thank you all. It sounds like we’re all going to do it my way, which is the title Individualizing Blood Pressure Control. Alex, do you want to take us away with little Frank Sinatra?

Alex 44:43

Yes.

Speaker 6 44:43

There were times I’m sure you knew When I bit on more than I could chew but through it all when there was doubt I ate it all and spit it out How I faced it all and I stood tall I did it my way.

Eric 45:24

Mitra, Simon, Mark, thanks for joining us on this GeriPal podcast.

Simon 45:28

Thanks so much for having us.

Mitra 45:29

Thank you both for having me. Bye.

Eric 45:31

And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Mitra Jamshidian, Simon Ascher and Mark Supiano have no relationships to disclose.

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