Intensive Versus Standard Blood Pressure Lowering to Prevent Functional Decline in Older People

Intensive Versus Standard Blood Pressure Lowering to Prevent Functional Decline in Older People

This randomized clinical trial examines if lowering and maintaining 24-hour ambulatory systolic blood pressure to <130 mmHg (intensive control) versus <145 mmHg (standard control) slows/halts the progression of deterioration of mobility and cognitive function linked to white-matter disease (also known as white-matter hyperintensity or WMH) in patients with normal or mildly impaired mobility and cognition in subjects with detectable cerebrovascular disease (>0.5% WMH fraction of intracranial contents). The study patients will be enrolled and randomized to one of two levels of ambulatory blood pressure control (intensive to achieve a goal 24-hour systolic blood pressure of < 130 mmHg or standard to achieve a goal 24-hour systolic blood pressure of < 145 mmHg) for a total of 36 months.

The study patients will be enrolled and randomized to one of two levels of ambulatory BP control (intensive to achieve a goal 24-hour systolic BP of < 130 mmHg or standard to achieve a goal 24-hour systolic BP of < 145 mmHg) for a total of 36 months. Similar antihypertensive regimens will be used in both of the treatment groups. Titration of antihypertensive therapies will be performed at monthly intervals for the first 3 to 6 months post-randomization to achieve goal systolic BP. The primary and secondary outcomes will be evaluated at baseline, and following 18 months and 36 months of therapy.

Inclusion Criteria:

• 75 years of age or older
• Seated clinic systolic BP >150 mmHg in the untreated state (see criterion D)
• At risk for cerebrovascular disease (history of smoking, dyslipidemia, type 2 diabetes, longstanding hypertension, family history). Patients must have visible (0.5% WMH or more)white-matter hypertensity lesions on screening magnetic resonance imaging
• To achieve success in maintaining a 24-hour systolic BP of <140-145 mmHg in the standard treatment group or a systolic BP <125-130 mmHg in the intensive treatment group, patients will be eligible for inclusion if (1) their clinic systolic BP is 150-170 mmHg, and they are taking 0 to 2 antihypertensives, (2) their systolic BP is >170 mmHg and they are taking 0 to 1 antihypertensives

Exclusion Criteria:

• Uncontrolled diabetes mellitus (HBA1c >10%)
• History of stroke, dementia or clinically impaired gait (Mini-mental status exam score (MMSE) <24, Short Physical Performance Battery for gait (SPPB) < 9,)
• Body Mass Index > 45 kg/m2 and/or arm circumference > 44 cm)
• Poor kidney function (defined as estimated GFR <30 ml/minute)
• Active liver disease or serum transaminases >3 times the upper limit of normal
• Major cardiovascular event (e.g. myocardial infarction) or procedure (e.g. cardiac bypass surgery) in past 3 months; stroke with residual gait abnormality
• Uncompensated congestive heart failure (NYHA class III or IV or documented ejection fraction <30%)
• Chronic atrial fibrillation that disallows ambulatory BP monitoring to be successfully performed
• Medical conditions that limit survival to < 3 years
• Non-dermatologic cancer diagnosed within 2 years
• Organ transplantation requiring anti-rejection drug therapy
• Severe and unexplained weight loss (>15%) in past 6 months
• Medical need to undergo recurrent phlebotomy or blood transfusions
• Current participation in another investigational trial
• Unable to obtain informed consent
• Factors limiting adherence to the interventions
• MRI contraindications (including MRI-incompatible implants, severe claustrophobia).