Hajjar Ihab, Rosenberger Kristine J, Kulshreshtha Ambar, Ayonayon Hilsa N, Yaffe Kristine, Goldstein Felicia C
Department of Medicine, Emory School of Medicine, Atlanta, Georgia.
Department of Neurology, Emory School of Medicine, Atlanta, Georgia.
JAMA Neurol. 2017 Oct 1;74(10):1199-1205. doi: 10.1001/jamaneurol.2017.1863.
The Eighth Joint National Committee (JNC-8) recommended treating systolic blood pressure (SBP) to a target below 150 mm Hg in older adults, whereas data from the Systolic Blood Pressure Intervention Trial (SPRINT) suggested that a SBP level of lower than 120 mm Hg decreases cardiovascular event rates. Target SBP guidelines have not addressed the potential that black patients may have greater morbidity and mortality from hypertension, especially with regard to cognitive outcomes. The association of these discordant SBP targets with cognition and differences by race have not been systematically evaluated in the same population.
To assess the long-term outcomes of the various recommended SBP levels and to determine if racial differences exist based on long-term cognitive trajectories.
DESIGN, SETTING, AND PARTICIPANTS: A total of 1657 cognitively intact older adults receiving treatment for hypertension were studied from 1997 to 2007 in the Health Aging and Body Composition study. Data analysis was conducted from October 1, 2016, to January 1, 2017.
Cognition was assessed using the Modified Mini-Mental State Examination (3MSE) 4 times and the Digit Symbol Substitution Test (DSST) 5 times. At each visit, participants were classified as having an SBP level of 120 mm Hg or lower, 121 to 139 mm Hg, 140 to 149 mm Hg, or 150 mm Hg or higher based on the mean SBP level of 2 seated readings. Mixed models assessed the association of SBP levels with 10-year cognitive trajectories. The impact of race was tested using a race interaction term.
During the 10-year study period, among the 1657 individuals (908 women and 784 black patients; mean [SE] age, 73.7 [0.1] years), there was a differential decrease in 3MSE and DSST scores by the SBP levels, with the greatest decrease in the group with SBP levels of 150 mm Hg or higher (adjusted decrease was 3.7 for 3MSE and 6.2 for DSST) and the lowest decrease in the group with SBP levels of 120 mm Hg or lower (adjusted decrease was 3.0 for 3MSE and 5.0 for DSST) (P < .001 for both). Compared with white patients, black patients had a greater difference between the higher and lower SBP levels in the decrease in cognition; adjusted differences between the group with SBP levels of 150 mm Hg or higher and the group with SBP levels of 120 mm Hg or lower were -0.05 in white patients and -0.08 in black patients for 3MSE (P = .03) and -0.07 in white patients and -0.13 in black patients for DSST (P = .05).
For patients 70 years of age or older receiving treatment for hypertension, a SPRINT SBP level of 120 mm Hg or lower was not associated with worsening cognitive outcome and may be superior to the JNC-8 target for cognition. Lower SBP treatment levels may result in improved cognition in black patients.
美国国家联合委员会第八次报告（JNC - 8）建议将老年人的收缩压（SBP）治疗目标设定为低于150 mmHg，而收缩压干预试验（SPRINT）的数据表明，SBP水平低于120 mmHg可降低心血管事件发生率。目标SBP指南尚未涉及黑人患者可能因高血压而具有更高发病率和死亡率的可能性，尤其是在认知结局方面。这些不一致的SBP目标与认知的关联以及种族差异尚未在同一人群中进行系统评估。
评估各种推荐SBP水平的长期结局，并确定基于长期认知轨迹是否存在种族差异。
设计、背景和参与者：1997年至2007年期间，在健康老龄化与身体成分研究中对1657名接受高血压治疗的认知功能完好的老年人进行了研究。数据分析于2016年10月1日至2017年1月1日进行。
使用改良简易精神状态检查表（3MSE）进行4次认知评估，使用数字符号替换测验（DSST）进行5次认知评估。每次就诊时，根据两次坐位测量的平均SBP水平，将参与者分为SBP水平为120 mmHg或更低、121至139 mmHg、140至149 mmHg或150 mmHg或更高。混合模型评估SBP水平与10年认知轨迹的关联。使用种族交互项测试种族的影响。
在10年研究期间，在1657名个体（908名女性和784名黑人患者；平均[SE]年龄为73.7[0.1]岁）中，3MSE和DSST分数随SBP水平存在差异下降，SBP水平为150 mmHg或更高的组下降最大（3MSE调整后下降3.7，DSST调整后下降6.2），SBP水平为120 mmHg或更低的组下降最小（3MSE调整后下降3.0，DSST调整后下降5.0）（两者P均<0.001）。与白人患者相比，黑人患者在认知下降方面，较高和较低SBP水平之间的差异更大；3MSE方面，SBP水平为150 mmHg或更高的组与SBP水平为120 mmHg或更低的组之间的调整差异在白人患者中为 - 0.05，在黑人患者中为 - 0.08（P = 0.03）；DSST方面，在白人患者中为 - 0.07，在黑人患者中为 - 0.13（P = 0.05）。
对于70岁及以上接受高血压治疗的患者，SPRINT设定的SBP水平为120 mmHg或更低与认知结局恶化无关，可能在认知方面优于JNC - 8目标。较低的SBP治疗水平可能会改善黑人患者的认知。
