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Original Investigation
January 2018

Blood Pressure Trajectories in the 20 Years Before Death

Author Affiliations
  • 1Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, United Kingdom
  • 2Health Statistics Research Group, Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, United Kingdom
  • 3University of Connecticut Center on Aging, University of Connecticut Health, Farmington
  • 4Longitudinal Studies Section, National Institutes of Health, Harbor Hospital, Baltimore, Maryland
JAMA Intern Med. 2018;178(1):93-99. doi:10.1001/jamainternmed.2017.7023
Key Points

Question  Do blood pressures (BPs) decrease in older patients, and if so are decreases related to age, proximity to death, or better survival without hypertension?

Findings  In a 20-year cohort analysis of medical records, systolic and diastolic BPs decreased for 14 to 18 years before death. Decreases were present in patients not treated for hypertension but were steepest in patients with hypertension, dementia, heart failure, and late-life weight loss.

Meaning  Substantial BP decreases toward the end of life may have implications for treatment monitoring, and decreases in BP may also bias risk estimation and complicate trial design.


Importance  There is mixed evidence that blood pressure (BP) stabilizes or decreases in later life. It is also unclear whether BP trajectories reflect advancing age, proximity to end of life, or selective survival of persons free from hypertension.

Objective  To estimate individual patient BP for each of the 20 years before death and identify potential mechanisms that may explain trajectories.

Design, Study, and Participants  We analyzed population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom, using retrospective cohort approaches with generalized linear mixed-effects modeling. Participants were all available individuals with BP measures over 20 years, yielding 46 634 participants dying aged at least 60 years, from 2010 to 2014. We also compared BP slopes from 10 to 3 years before death for 20 207 participants who died, plus 20 207 birth-year and sex-matched participants surviving longer than 9 years.

Main Outcomes and Measures  Clinically recorded individual patient repeated systolic BP (SBP) and diastolic BP (DBP).

Results  In 46 634 participants (51.7% female; mean [SD] age at death, 82.4 [9.0] years), SBPs and DBPs peaked 18 to 14 years before death and then decreased progressively. Mean changes in SBP from peak values ranged from −8.5 mm Hg (95% CI, −9.4 to −7.7) for those dying aged 60 to 69 years to −22.0 mm Hg (95% CI, −22.6 to −21.4) for those dying at 90 years or older; overall, 64.0% of individuals had SBP changes of greater than −10 mm Hg. Decreases in BP appeared linear from 10 to 3 years before death, with steeper decreases in the last 2 years of life. Decreases in SBP from 10 to 3 years before death were present in individuals not treated with antihypertensive medications, but mean yearly changes were steepest in patients with hypertension (−1.58; 95% CI, −1.56 to −1.60 mm Hg vs −0.70; 95% CI, −0.65 to −0.76 mm Hg), dementia (−1.81; 95% CI, −1.77 to −1.87 mm Hg vs −1.41; 95% CI, −1.38 to −1.43 mm Hg), heart failure (−1.66; 95% CI, −1.62 to −1.69 mm Hg vs −1.37; 95% CI, −1.34 to −1.39 mm Hg), and late-life weight loss.

Conclusions and Relevance  Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older. 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.