Masoli Jane A H, Delgado Joao, Pilling Luke, Strain David, Melzer David
Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, UK.
Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Exeter, UK.
Age Ageing. 2020 Aug 24;49(5):807-813. doi: 10.1093/ageing/afaa028.
Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target <120 mmHg. However, all-cause mortality by attained BP in routine care in frail adults aged above 75 is unclear.
To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty.
Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory.
Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail <85 and frail 75-84-year-olds and all above 85 years. SBPs above the 130-139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75-84 years: 150-159 mmHg Hazard Ratio (HR) mortality compared to 130-139: non-frail HR = 0.94, 0.92-0.97; moderate/severe frailty HR = 0.84, 0.77-0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life.
In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75-84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.
体弱老年人的血压管理具有挑战性。一项针对大体上非体弱老年人的随机对照试验发现，收缩压（SBP）目标<120 mmHg可带来心血管益处并降低死亡率。然而，75岁以上体弱成年人在常规护理中根据达到的血压水平得出的全因死亡率尚不清楚。
评估75岁以上初级保健人群中，按虚弱程度分层的基线血压与死亡率/心血管结局之间的观察性关联。
使用电子健康记录进行前瞻性观察分析（临床实践研究数据链，n = 415,980）。我们分别使用竞争风险模型和Cox比例风险模型测试血压与心血管事件和死亡率的关联（随访≤10年），按基线电子虚弱指数（eFI：健康（非体弱）、轻度、中度、重度虚弱）分层，并对合并症、心血管风险和血压轨迹进行敏感性分析。
收缩压>150 mmHg时，心血管结局风险增加。非体弱<85岁、体弱75 - 84岁以及所有85岁以上人群中，血压与死亡率的关联各不相同。高于130 - 139 mmHg参考值的收缩压与较低的死亡风险相关，尤其是在中度至重度虚弱或85岁以上人群中（例如，75 - 84岁：150 - 159 mmHg与130 - 139 mmHg相比的死亡风险比（HR）：非体弱HR = 0.94，0.92 - 0.97；中度/重度虚弱HR = 0.84，0.77 - 0.92）。收缩压<130 mmHg和舒张压（DBP）<80 mmHg始终与额外死亡率相关，与生命末期的血压轨迹无关。
在具有代表性的75岁及以上初级保健患者中，血压<130/80与额外死亡率相关。在85岁以上或75 - 84岁且中度/重度虚弱的人群中，高血压与死亡率增加无关，这可能是由于并存合并症的复杂性所致。对体弱老年人积极降低血压的优先性需要进一步评估。
