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

Not Applicable

Completed

Interventions: Other: Anti-hypertensive therapy to SBP 130 mm Hg
Other: Anti-hypertensive therapy to SBP 145 mm Hg

Brief Summary: 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.

Detailed Description: 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.

Recruitment & Eligibility

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).

Arm && Interventions

Group	Intervention	Description
Intensive	Anti-hypertensive therapy to SBP 130 mm Hg	Intensive anti-hypertensive therapies using standard blood pressure medications to lower blood pressure to a level less than or equal to 130 mmHg
Standard	Anti-hypertensive therapy to SBP 145 mm Hg	Standard anti-hypertensive therapies using standard blood pressure medications to lower blood pressure to a level less than or equal to 145 mmHg

Primary Outcome Measures

Name	Time	Method
Mobility - Measured by Change in Gait Speed	Change from baseline to 36 months	Change in gait speed (walking 8 meters) in seconds mediated by the accrual of white-matter hyperintensity lesions (WMH/intracranial cavity volume) using MRI and including degeneration of axonal and myelin components of white matter using MRI technology known as diffusion tensor imaging (DTI).

Secondary Outcome Measures

Name	Time	Method
Cognitive Function - as Measured by Change in Stroop Test Score	Change from baseline to 36 months	Change in cognitive function as measured by stroop test score: number of correct responses in 45 seconds. The score for the Stroop Test is the number of correct responses provided in 45 seconds on each test condition: word reading, color naming, and inhibition. For the inhibition condition, words are written in an incongruous ink color (e.g., the word red written in blue ink) and participants must provide the ink color. Scores range from 0 to no upper limit, with higher scores indicating better performance.