Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Lower Blood Pressure Target and CV Risk

Intensive vs standard BP control

Publish date:

This trial, known by its acronym as the SPRINT (Systolic Blood Pressure Intervention) trial, showed that treating to a blood pressure of < 120 mmHg rather than to the standard < 140 mmHg yielded a significantly greater benefit in reducing cardiovascular morbidity and mortality among patients without diabetes presenting with a systolic blood pressure of 130 mmHg or higher, according to a study of 9,361 persons. Study participants were randomly assigned to a systolic blood pressure target of < 120 mmHg (intensive treatment) or a target of < 140 mmHg (standard treatment). The mean systolic blood pressure was 121 mm Hg in the intensive-treatment group and 135 mm Hg in the standard-treatment group.

Study results indicated the following:

• There was a significantly lower rate of the primary composite outcome (myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes) in the intensive-treatment group vs the standard-treatment group (1.65% per year vs 2.19% per year; HR with intensive treatment, 0.75).

• All-cause mortality was significantly lower in the intensive-treatment group (HR, 0.73).

• Rates of some serious adverse events were higher in the intensive-treatment group.

Citation: Wright JT, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. [Published online ahead of print November 9, 2015]. N Engl J Med. doi: 10.1056/NEJMoa1511939.

Commentary: This landmark article will radically change the target blood pressure goals for a significant proportion of our patients with hypertension. It is important to note that patients included in this trial were all patients with a high risk of cardiovascular outcomes. Specifically, patients included in the trial had (with percent of patients enrolled in the study in parenthesis): clinical or subclinical cardiovascular disease other than stroke (20%); chronic kidney disease with eGFR of 20 to less than 60 ml per minute per 1.73 m2 of body-surface area (28%); a 10-year risk of cardiovascular disease of 15% or greater on the basis of the Framingham risk score (61%); or an age of 75 years or older (28%).

This study showed that it is not easy to achieve lower systolic blood pressure and on the average required the addition of 1 extra blood pressure medication to achieve the lower level of blood pressure control (1.8 vs 2.8 medications). These results are important, consistent with a wealth of observational data, and differ from the results of the ACCORD trial. It will be important to see what guidelines committees recommend. I suspect they will recommend lower blood pressure targets in patients who meet the high-risk criteria of patients included in this study. It will also be important to use judgment, recognizing that it may be beneficial to achieve these lower targets in patients in whom the goals can be met with the use of 3 medications, but for the many patients for whom lower blood pressure targets may be very difficult to achieve, a combination of judgment and evidence in determining the appropriate goal may be more important than ever. —Neil Skolnik, MD

This Week's Must Reads

Must Reads in Cardiology

Consumption of SSBs & Risk of Mortality, Circulation; ePub 2019 Mar 18; Malik, et al

Dietary Cholesterol or Egg Consumption & CVD, JAMA; 2019 Mar 19; Zhong, Van Horn, et al

Physical Activity & Incidence of CHD & CVD in Women, JAMA Netw Open; ePub 2019 Mar 15; LaCroix, et al

Intensive BP Control in Adults with Hypertension Who Smoke, JAMA Netw Open; ePub 2019 Mar 8; Scarpa, et al