Lowering BP May Do Most to Halt Cognitive Decline Among Those Treated Longest

The results point to the need for more study on the effects of long-duration blood pressure treatment to prevent cognitive decline, especially in the highest risk patients.

Can treating high blood pressure (BP) prevent cognitive or functional decline as we age? That was the question researchers sought to answer with a segment of the patients who took part in HOPE-3, the huge trial on the effects of statins that first reported results this spring.

Officials with CMS are anxious to find ways to prevent dementia as swarms of baby boomers enroll in Medicare; there are already 5 million people with Alzheimer’s disease who cost $236 billion to treat, almost as much as it costs the United States in medical and disability costs for 29 million people with diabetes.

The connections between cardiovascular risk factors and cognitive decline are well-established—the question is what to do about it, and whether aggressive BP treatment makes a difference.

On Sunday, researchers reported on findings from 1626 of the original 12,705 participants in HOPE-3. This smaller group, all at least 70 years old, completed a cognitive and functional questionnaire at the start of the trial and again at least 5 years later. The participants were 74 years old on average, and the average follow-up time was 5.7 years.

At first, it did not appear that long-term treatment for BP or cholesterol made much difference. Overall, the results found that the HOPE-3 participants experience cognitive decline over 5.6 years; patients treated in the BP treatment arm, the cholesterol treatment arm, and patients treated for both showed no real difference in cognitive decline compared with patients taking placebo.

But in a press briefing ahead of the session, both the study’s presenter, Jackie Bosch, MD, an associate professor in the Population Health Research Institute of McMaster University, Hamilton, Ontario, and discussant Ralph L. Sacco, MD, MS, chair of neurology at the University of Miami, said subgroup analyses suggest there might be more benefits for those at risk if they are treated early and treatment endures. There are also indications that those who begin treatment at the highest baseline BP do achieve cognitive benefits. Both these findings, however, require more study.

Sacco said the results are important for several reasons: first the assessments were in-depth measures of executive function; and, second, the field needs more work to find every day treatments to prevent this type of impairment.

"This is one of the biggest concerns of our aging population," he said. "We know that vascular disease leads to small vessel disease, small strokes."

In presenting the results, Bosch noted that while there was no apparent benefit for treatment at 5.5 years, a benefit did seem to emerge after that. "The longer duration seemed to have an effect," he said.

Sacco said this is the "silver lining" of HOPE-3. "We need to be treating younger people with uncontrolled blood pressure, and we need to be treating them for longer periods of time."

Reference

Bosch J, for the HOPE-3 investigators. The Heart Outcomes Prevention Evaluation (HOPE-3) Trial: cognitive and functional outcomes. Presented at the 2016 American Heart Association Scientific Sessions, November 13, 2016.