Objective

In the growing population of older patients with hypertension, limited evidence supports an association between lowering systolic blood pressure (SBP) and decreased adverse events. We aimed to investigate cardiovascular outcomes according to on-treatment SBP in older hypertensive patients.

Methods

This multicenter, retrospective study used data from the Korea University Medical Center database built on electronic health records from 2017 to 2022. Patients initiated on at least two antihypertensive drugs in combination were followed for three years. The patients were grouped by average on-treatment SBP in 10-mmHg increments from <110 to 160 mmHg or more. The primary outcome was a composite of all-cause death, myocardial infarction, stroke, and hospitalization due to heart failure.

Results

A total of 6427 patients aged ≥75 years (mean age, 80 years) were identified. The incidence of the primary outcome was lowest in individuals with an SBP of 120-129 mmHg (14.0%, P  < 0.001), and the adjusted hazard ratio for the primary outcome showed a J-shaped relationship with on-treatment SBP. Achieving an SBP of 120-129 mmHg showed acceptable safety profiles, including electrolyte imbalance, acute kidney injury, new-onset atrial fibrillation, and new-onset dementia or Alzheimer's disease when compared to the group with SBP of 130-139 mmHg.

Conclusions

An average on-treatment SBP of less than 130 mmHg was associated with improved outcomes in older hypertensive patients without raising safety concerns. These findings support the target SBP of 130 mmHg in older patients, if tolerated.