PRO: Should We Target Hypertension Treatment to <120/80 mm Hg?

Oparil S, Lewis CE.
Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target? A Protagonist View From SPRINT. Circulation 2016;Sep 12:[Epub ahead of print].

Editor’s Note: This is Part I (PRO) of a two-part Journal Scan review. Go to Part II (CON).

The following are key points from a protagonist viewpoint regarding whether patients with cardiovascular (CV) risk factors should receive intensive treatment of hypertension to <120/80 mm Hg target:

  1. This protagonist viewpoint is based on the main results of SPRINT (Systolic Blood Pressure Intervention Trial), and is in contrast to the antagonist viewpoint of Lonn and Yusif, who felt the SPRINT study was not applicable to clinic practice. Oparil and Lewis strongly believe that older hypertensive patients at high CV risk should receive intensive treatment to a target systolic blood pressure (SBP) of <120 mm Hg.
  2. The SPRINT study tested the hypothesis that intensive treatment of SBP to a target of <120 mm Hg would reduce clinical events more than standard treatment to a target of <140 mm Hg. Enrollees were age ≥50 years with SBP 130-180 mm Hg who were treated or untreated including those age >75 years (SPRINT-Senior), blacks, and those with chronic kidney disease (CKD) or CV disease (CVD). The mean 10-year Framingham CVD risk score for all participants was 20%.
  3. SBP fell rapidly in the intensive-treatment group (target SBP <120 mm Hg), reaching a level approximately 15 mm Hg lower than in the standard group at 1 year (121.4 vs. 136.7 mm Hg). SPRINT was stopped early because of a 25% reduction in the primary composite endpoint (myocardial infarction [MI], non-MI acute coronary syndrome, stroke, acute decompensated heart failure, and CV death) and a 27% reduction in all-cause mortality in the intensive-treatment group.
  4. The effects of the intensive intervention on the primary outcome and all-cause mortality were consistent across all prespecified subgroups including presence or absence of previous CVD or CKD, and baseline SBP tertile. The benefits of intensive treatment were greater in the SPRINT-Senior subgroup. The number needed to treat for 3.26 years to prevent one primary outcome was 61 in the study as a whole and 28 in the SPRINT-Senior subgroup; to prevent one death, 90 in the study as a whole and 41 in the SPRINT-Senior subgroup. The pattern of adverse events in those >75 years old was similar to the cohort as a whole. In the CKD subgroup, progression resulting in ≥50% reduction in estimated glomerular filtration rate, long-term dialysis, or renal transplantation was rare and similar in both treatment groups.
  5. Both the protagonists and antagonists emphasized that the method of measuring BP in SPRINT would result in considerably lower BP than is obtained in the busy office. This could lead to overuse of antihypertensive medication with the result being an increase in serious adverse events including worsening of CKD, and an increase in cardiac and neurologic events. Against the generalized application of SPRINT was also that intense BP lowering did not lower the risk of MI or strokes, and that a considerable percent of benefit of the primary composite endpoint was related to reduction in heart failure, which may have been related to an increase in use of diuretics.
  6. Importantly, SPRINT did not include patients with heart failure or severe CKD. Future trials will need to assess the degree to which more intense SBP lowering will benefit lower-risk patients (age <50 or >50 with 10-year Framingham risk score <15%).
  7. Three other well-designed trials offered little help. HOPE-3 evaluated intermediate-risk patients with a “weak” combination treatment that lowered BP by 6/3 mm Hg and had no benefit unless SBP was >143 mm Hg. The ACCORD trial showed no benefit of more intense BP lowering in diabetics. In the SPS3 trial, which assessed persons recovering from a lacunar stroke, there was no reduction in strokes, MI, or vascular deaths targeting to BP <130 mm Hg compared to 131-149 mm Hg. However, the rate of intracranial hemorrhage was reduced (0.37, p = 0.03). Until further large and long-term trial results are available, the clinician is left with many options that require careful assessment. The most important is counterintuitive. That is the benefit of more intense BP lowering appears to be greater in those >75 years who are high risk and may have mild CKD, but without a history of stroke and in the setting in which BP is measured often using American Heart Association standards. The strategy should not be applied to persons in an assisted living facility.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Cardiovascular Diseases, Diabetes Mellitus, Glomerular Filtration Rate, Hypertension, Heart Failure, Intracranial Hemorrhages, Metabolic Syndrome X, Myocardial Infarction, Primary Prevention, Renal Insufficiency, Chronic, Risk Factors, Stroke

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