A strategy of progressively reducing antihypertensive medication for frail, older nursing home residents with well-controlled blood pressure does not lower all-cause mortality compared to usual care, according to findings from the RETREAT-FRAIL trial.¹ The study addresses a significant evidence gap regarding the benefits and risks of deprescribing in this vulnerable population.
The RETREAT-FRAIL trial (NCT03453268) was a multicentre, randomised, controlled trial conducted across France. The study enrolled 1,048 nursing home residents aged 80 years or older who were receiving more than one antihypertensive drug and had a systolic blood pressure (SBP) below 130 mm Hg.
Participants were assigned in a 1:1 ratio to either a protocol-driven strategy of progressive reduction of antihypertensive treatment (step-down group; n=528) or to receive usual care (usual-care group; n=520). Patients were followed for up to 4 years, with an estimated median potential follow-up of 38.4 months.
The primary endpoint was death from any cause. Secondary endpoints included the change in the number of antihypertensive drugs used from baseline to the final visit and the change in SBP over the follow-up period.
The primary endpoint of all-cause mortality was not met. Death occurred in 326 patients (61.7%) in the step-down group and 313 patients (60.2%) in the usual-care group, with no significant difference between the two (adjusted hazard ratio, 1.02; 95% CI, 0.86 to 1.21; P=0.78).
Regarding secondary endpoints, the mean number of antihypertensive drugs being used decreased from 2.6 at baseline to 1.5 at the last visit in the step-down group. In the usual-care group, the mean number decreased from 2.5 to 2.0. The adjusted mean between-group difference in the change in SBP during follow-up was 4.1 mm Hg (95% CI, 1.9 to 5.7) higher in the step-down group. There were no apparent differences in adverse events between the trial groups.
These findings suggest that for frail nursing home residents aged 80 and over with an SBP below 130 mm Hg, a strategy of reducing antihypertensive therapy is not superior to usual care in terms of survival, though it does successfully reduce medication burden. As the RETREAT-FRAIL Study Group concluded, “Among older nursing home residents with frailty who were receiving treatment with antihypertensive agents and had a systolic blood pressure below 130 mm Hg, an antihypertensive treatment step-down strategy did not lead to lower all-cause mortality than usual care.”¹ The management of hypertension in the oldest old remains a complex clinical challenge.²
References
1. Benetos A, Gautier S, Freminet A, et al. Reduction of Antihypertensive Treatment in Nursing Home Residents. N Engl J Med 2025;393:1990-2000. https://doi.org/10.1056/NEJMoa2508157
2. Supiano MA, Ascher SB, Rich MW. Hypertension in the Oldest Old. JACC: Advances 2025. https://doi.org/10.1016/j.jacadv.2025.102306
This study was funded by the French Ministry of Health, the French National Research Agency, and the Health Regional Agency of Eastern France.
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