Systolic Blood Pressure Intervention Trial (SPRINT) and Target Systolic Blood Pressure in Future Hypertension Guidelines

Abstract

The Systolic Blood Pressure (SBP) Intervention Trial (SPRINT) Research Group concluded that among patients at high risk for cardiovascular events but without diabetes mellitus, an SBP (mm Hg) target <120 rather than <140 reduced major cardiovascular events 25% and cardiovascular mortality 43%. 1 The investigators stated that "SPRINT now provides evidence of benefits for an even lower SBP target than that currently recommended in most patients with hypertension." This statement suggests that future guidelines should consider lowering the SBP goal to a value below <140 currently recommended for most hypertensives, for example, <130 or <120.SPRINT's impact on future hypertension guidelines reflects 2 implicit assumptions. The first assumption is that SPRINT standard treatment produced SBP values as low or lower than the SBP of US adults with treated hypertension. If SPRINT standard treatment did not attain SBP values as low as in US adults with treated hypertension, then the benefit of intensive treatment in the population could be overestimated. The second assumption is that SPRINT intensive treatment produced a lower mean SBP than in US adults with treated hypertension and SBP <140. If this is not the case, then the rationale for lowering the SBP target would be less compelling, whereas the basis for raising the percentage of treated adults with SBP <140 mm Hg would be enhanced. 2Our study addressed these 2 implicit assumptions using National Health and Nutrition Examination Survey (NHANES) data. First, mean SBP in 3 groups of NHANES adults with treated hypertension was compared to mean SBP achieved with SPRINT standard treatment. The 3 groups with treated hypertension included (1) a SPRINT-like group, (2) all adults ≥18 years, and (3) adults ≥18 years excluding the SPRINT-like group and others with SPRINT-like exclusions. Second, mean SBP in the same 3 groups of NHANES adults with treated hypertension and SBP <140 was compared to mean SBP with SPRINT intensive treatment. MethodsThe NHANES are repeated cross-sectional assessments over time of the health and nutritional status in a representative sample of the US civilian population. All adults provided written consent approved by the National Center for Health Statistics. Since 1960, National Health Examination Surveys have been used to assess hypertension prevalence, awareness, treatment, and control in the United States 3,4 Participants for this analysis included adults meeting SPRINT-like inclusion-exclusion criteria in NHANES 1999 to 2012. Inclusion Abstract-The Systolic Blood Pressure (SBP, mm Hg) Intervention Trial (SPRINT) showed that targeting SBP <120 mm Hg (intensive treatment, mean SBP: 121.5 mm Hg) versus <140 (standard treatment, mean SBP: 134.6 mm Hg) reduced cardiovascular events 25%. SPRINT has 2 implicit assumptions that could impact future US hypertension guidelines: (1) standard therapy controlled SBP similarly to that in adults with treated hypertension and (2) intensive therapy produced a lower mean SBP than in adults with treated hypertensio...

Defining Hypertension by Blood Pressure 130/80 mm Hg Leads to an Impressive Burden of Hypertension in Young and Middle‐Aged Black Adults: Follow‐Up in the CARDIA Study

“…This author has expressed concern about the class I recommendation for antihypertensive pharmacotherapy as primary prevention in adults with stage 1 hypertension (BP, 130–139/80–89 mm Hg) given the paucity of data on the benefit of antihypertensive medications for primary prevention in this group 14. Yet, in 2010, we stated that concerned clinicians may elect to begin antihypertensive pharmacotherapy for primary prevention when systolic BP is 130 to 139 mm Hg and absolute 10‐year CVD risk is ≥10% 15.…”

Controlling Systolic Blood Pressure below 140 mm Hg in Most Hypertensive Patients matches Systolic Blood Pressure Intervention Trial Intensive Treatment: Practical Implications for Patient Care

“…If this assumption is not correct, then the rationale for lowering the SBP target to <120 or <130 for treated adults with hypertension is weakened. As reported, 72.2% of all US adults with treated hypertension were controlled to a SBP <140 in 2009-2012, 2 and their mean SBP was 120.9, which is comparable to 121.4 after 1 year of SPRINT intensive treatment. 1 Furthermore, the current report indicates that mean SBP of treated hypertensive patients controlled to <140 is also declining over time (Table 2 and Graphs 1A to F) and could fall further as control to SBP <140 improves.…”

“…We previously examined the first two implicit assumptions in SPRINT. 2 In fact, a representative sample of treated adults with hypertension had lower mean SBP than participants in SPRINT standard treatment. Moreover, SPRINT intensive treatment did not lead to lower SBP than adults in usual care who were treated for hypertension and controlled to SBP <140 mm Hg.…”

“A Cross Sectional, Observational Study of the Antihypertensive Pharmacotherapeutic Profile in an Urban Indian Adult Population”

“…While the JNC 8 guidelines merit due consideration for its quality of evidence from numerous randomised controlled trials, it is not without critique. For starters, results from the Systolic Blood Pressure intervention trial was in contradiction to JNC 8 recommendations and showed an increased benefit from stringent blood pressure control (120/80 mmHg) 19 . However, the strength of evidence in the JNC 8 guidelines come from more than 30 RCTs and should be enough for the time being to hold its own.…”