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Effect of Frailty on Intensive BP Control: SPRINT Post Hoc Analysis
Quick Takes
- Participants in the SPRINT trial with frailty were more likely than others to experience cardiovascular events and can benefit from more intensive BP control to prevent these events.
- Patients with frailty do not experience increased risk of adverse events with an attempt at intensive BP control when compared to patients without frailty.
- Clinicians should offer patients with frailty intensive BP control but naturally remain watchful for signs of intolerance of a lower BP, as was done in the SPRINT trial.
Study Questions:
Do patients in the SPRINT trial with frailty benefit from intensive blood pressure (BP) control without increased risk of harm?
Methods:
The SPRINT (Systolic Blood Pressure Intervention Trial) study, published in 2015 in the New England Journal of Medicine, enrolled 9,361 patients with hypertension and high cardiovascular (CV) risk who were nondiabetic and >50 years of age. The patients were randomized to a systolic BP (SBP) goal of <120 mm Hg versus <140 mm Hg. A benefit was seen in the <120 mm Hg arm of the study. This paper analyzed 9,306 of those patients, of which 26.7% had frailty, as defined by the SPRINT Frailty Index, which assessed 36-37 items in a survey. Participants were defined as frail or nonfrail and analyzed based on their BP treatment arms (<120 mm Hg vs. <140 mm Hg).
Results:
SPRINT trial patients with frailty had a higher risk of CV disease than those without frailty. Absolute risk reduction for the primary outcome (myocardial infarction [MI], acute coronary syndrome without MI, stroke, acute heart failure, and CV death) when BP was treated intensively was comparable between frail and nonfrail groups. Importantly, there was no increase in serious adverse events in the frail or nonfrail groups when they were treated intensively to a goal of SBP <120 compared to SBP <140 mm Hg. There was a different incidence of secondary outcomes (hypotension, acute kidney injury, electrolyte disturbances) in the overall intensively controlled group (<120 mm Hg compared to <140 mm Hg), but no significant difference in this observation was detected in frail versus nonfrail subgroups.
Conclusions:
Patients with frailty have a higher incidence of CV events than those without frailty. They can realize a benefit from a more intensive SBP goal of <120 mm Hg versus <140 mm Hg and this can be achieved without higher risks of serious adverse events.
Perspective:
Clinicians are appropriately concerned about attempting intensive BP treatment for certain subgroups of patients including the frail and the elderly. But is this attempt to “first do no harm” resulting in unnecessarily withholding a potentially life-saving intervention that could introduce great benefit to these populations of patients who are at very high overall CV risk? This analysis of outcomes in frail versus nonfrail participants in the SPRINT trial shows that frail patients have high overall CV risk and can reap considerable benefit from intensive BP lowering, like that of nonfrail patients. The risk of harm is similar, and notably the frail patients were only able to achieve a BP drop of 11.3 mm Hg compared to 13.2 mm Hg in the nonfrail group.
This tells us that we should give frail patients with SPRINT characteristics (nondiabetics >50 years of age with high CV risk) the chance to improve their CV risk by attempting intensive BP control to SBP <120 mm Hg. In the overall SPRINT trial, the average BP reached in the intensive arm was about 121 mm Hg, suggesting that about one-half of the patients were able to achieve the <120 mm Hg goal. So, a careful clinician would be right in attempting to get a frail patient’s SBP down to <120 mm Hg but should remain a bit more vigilant for intolerable side effects while doing this medicine titration, just as the SPRINT investigators were. The <120 mm Hg goal might not be achievable in everybody, but it should be attempted in frail patients, as the potential for benefit is clearly there.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension
Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Blood Pressure, Electrolytes, Frail Elderly, Frailty, Geriatrics, Heart Failure, Hypertension, Hypotension, Myocardial Infarction, Primary Prevention, Risk Factors, Stroke, Vascular Diseases
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