A New Blood Pressure Target for High-Risk Patients?

Year in Review |
December 30, 2015

A New Blood Pressure Target for High-Risk Patients?

  1. Allan S. Brett, MD

In SPRINT, adverse cardiovascular events occurred less frequently when the systolic BP treatment target was 120 mm Hg.

  1. Allan S. Brett, MD

In the 2010 ACCORD blood pressure trial, treating hypertensive diabetic patients intensively to reach a systolic blood pressure (BP) target of <120 mm Hg did not improve outcomes compared with treatment to a standard target of 140 mm Hg (NEJM JW Gen Med Apr 15 2010 and N Engl J Med 2010; 362:1575). Now, in the randomized Systolic Blood Pressure Intervention Trial (SPRINT), researchers compared the same targets in 9361 high-risk nondiabetic hypertensive patients.

To enroll in SPRINT, patients were required to have known cardiovascular (CV) disease, 10-year Framingham risk score >15%, reduced glomerular filtration rate, or age ≥75. Average systolic BP during the trial was 121.5 mm Hg in the intensive group and 134.6 mm Hg in the standard group. The trial was stopped after average follow-up of 3.3 years, when incidence of the primary outcome (a composite of nonfatal and fatal adverse CV events) was significantly lower with intensive than with standard treatment (5.2% vs. 6.8%). The 1.6 percentage point difference means that 60 patients were treated for 3 years to prevent one event. Several serious adverse effects (e.g., hypotension, acute kidney injury) were slightly more common with intensive treatment (NEJM JW Gen Med Dec 15 2015 and N Engl J Med 2015; 373:2103).

SPRINT's positive results have been greeted with enthusiasm, but the trial should be considered in proper perspective. First, only high-risk patients were enrolled; many of our hypertensive patients would not meet SPRINT eligibility criteria. Second, because the average achieved systolic BP in the intensive group was 121.5 mm Hg, fewer than half the patients met the 120 mm Hg target. Third, BP was measured very carefully at SPRINT study visits: Three readings were averaged over several minutes after patients had been seated comfortably for several minutes. We know that rushed measurements in busy practices can raise BP transiently and lead to overtreatment.

SPRINT will change hypertension guidelines and appropriately so. But I will be interested to see whether guideline writers will generalize from SPRINT and recommend intensive treatment for hypertensive populations not represented in the trial. For patients in whom intensive treatment is advised, guideline authors will have to decide whether to recommend a systolic target of <120 mm Hg or a higher target (e.g., <130 mm Hg), given that the average achieved BP in SPRINT remained higher than 120 mm Hg.

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

Reader Comments (2)

Alejandro Saleh

The physician has to check well which patient's bloodpressue has to go 120/80 especially older patients to prevent adverse reactions.

Prof.Alejandro Saleh

Manuel A Veloso Jr. MD. Physician, Obstetrics/Gynecology, retired

personal experience in trying to comply with SPRINT criteria, it's difficult and time consuming.
I found generic drugs( using losartan/hctz100/25 ) from different manufacturers produces a significant effect in lowering the blood pressure throughout 24 hr period.Sprint Trial drugs , where they generic or brand.

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