Exeter, UK—It’s not always a good sign when patients have to discontinue antihypertensive medications because of dropping blood pressure. 

That trend could be predicting something else in older patients, suggests a new study published in JAMA Internal Medicine. Researchers from Great Britain and the United States set out to examine the evidence that blood pressure (BP) stabilizes or decreases in later life. 

The study team sought to clarify whether those downward trends were because of advancing age, proximity to end of life, or selective survival of persons free from hypertension. To do that, they created a trial to estimate individual patient BP for each of the 20 years before death, while also teasing out the reasons for the changes.

The population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom were analyzed, including BP measures over 20 years. The focus was on 46,634 patients who were at least 60 when they died, from 2010 to 2014. Participants, with slightly more women than men, had a mean age of death of 82.4.

At the same time, the investigators tracked BP trajectories from 10 to 3 years before death for 20,207 participants who died, comparing them to an equal number of birth-year and sex-matched participants who survived longer than 9 years.

Results indicate that systolic blood pressure (SDP) and diastolic blood pressure (DSP) reached high points between 18 and 14 years prior to death before decreasing progressively. Declines in SBP from peak values ranged from a drop of 8.5 mm HG for those dying between ages 60 to 69 years, to a drop of 22.0 mm HG for those dying at age 90 years or older.

“Overall, 64.0% of individuals had SBP changes of greater than ?10 mm Hg,” study authors report.

The study found that decreases in BP appeared linear from 10 to 3 years before death, with steeper declines in the last 2 years of life. 

While decreases in SBP from 10 to 3 years before death were detected in older people not treated with blood pressure medications, the average yearly changes were sharpest in patients with hypertension, with an average decline of 1.58; dementia, with an average decline of 1.81; and heart failure, with an average decline of 1.66, as well as in those with late-life weight loss. 

“Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older,” the researchers write. “These BP decreases are not simply attributable to age, treatment of hypertension, or better survival without hypertension. Late-life BP decreases may have implications for risk estimation, treatment monitoring, and trial design.”

In an accompanying commentary, James S. Goodwin, MD, of the University of Texas Medical Branch in Galveston said the value of this study and others using similar databases is that they “should help us dissect out many different trajectories that end in death, to better inform physicians and their patients about what they might expect.”
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