Impact of Elevated Blood Pressure on Cardiovascular and Cerebrovascular Outcomes in Older Adults: A Propensity-Matched Analysis.

Introduction

Hypertension (HTN) management is essential to improving cardiovascular and cerebrovascular morbidity and mortality in the older adult, yet optimal blood pressure (BP) targets remain uncertain. We aim to compare the incidence of major adverse cardiovascular events (MACE) among older adults presenting to the emergency department (ED) with systolic blood pressure (SBP) 140-159 mmHg and diastolic blood pressure (DBP) 90-99 mmHg versus those with SBP ≥ 160 mmHg and DBP ≥ 100 mmHg.

Methods

Retrospective analysis was conducted using the Global Collaborative Network including adults aged ≥ 65 years presenting to the ED with essential HTN without end-stage renal disease. Cohort 1 (SBP ≥ 160 mmHg and DBP ≥ 100 mmHg) included older adults with more severely elevated BP, while Cohort 2 (SBP 140-159 mmHg and DBP 90-99 mmHg) included those with moderately elevated BP. The primary outcome was all-cause mortality over 5 years. Secondary outcomes included AKI, CHF, AMI, ischemic stroke, and hemorrhagic stroke. Propensity score matching was used to balance baseline characteristics.

Results

After propensity score matching, 191,829 patients remained in each cohort. The mean age was 72.6 (±5.9) years; 51.8% were female, 10.5% had diabetes mellitus, and 5.65% were obese. Cohort 2 (SBP 140-159 mmHg) had lower risks across all primary and secondary outcomes compared with Cohort 1 (SBP ≥ 160 mmHg). The largest risk difference (RD) was observed for AKI (RD = 1.28%; 95% CI, 1.09-1.46%; p < 0.0001), followed by ischemic stroke (RD = 1.25%; 95% CI, 1.11-1.39%; p < 0.0001), CHF (RD = 1.11%; 95% CI, 0.93-1.29%; p < 0.0001), AMI (RD = 0.70%; 95% CI, 0.58-0.83%; p < 0.0001), all-cause mortality (RD = 0.33%; 95% CI, 0.15-0.51%; p < 0.0001), and hemorrhagic stroke (RD = 0.29%; 95% CI, 0.22-0.36%; p < 0.0001). All outcomes demonstrated consistently higher absolute risk in Cohort 1 compared with Cohort 2.

Conclusion

Cohort 2 (SBP 140-159 mmHg) was associated with a statistically significant but small decrease in cardiovascular, cerebrovascular, and mortality outcomes, with all absolute RDs uniformly small (<1%) and minimal survival benefit over time. These small gains must be weighed against overtreatment risks, such as medication costs, hypotension, and falls, underscoring the need for individualized, risk-based HTN management in older adults.