Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target?
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.116.023263
ISSN1524-4539
AutoresSuzanne Oparil, Cora E. Lewis,
Tópico(s)Sodium Intake and Health
ResumoHomeCirculationVol. 134, No. 18Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target? Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBShould Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target?A Protagonist View From the SPRINT Trial (Systolic Blood Pressure Intervention Trial) Suzanne Oparil, MD and Cora E. Lewis, MD, MSPH Suzanne OparilSuzanne Oparil From Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, The University of Alabama at Birmingham (S.O.); and Department of Medicine, Division of Preventive Medicine, The University of Alabama at Birmingham (C.E.L.). and Cora E. LewisCora E. Lewis From Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, The University of Alabama at Birmingham (S.O.); and Department of Medicine, Division of Preventive Medicine, The University of Alabama at Birmingham (C.E.L.). Originally published12 Sep 2016https://doi.org/10.1161/CIRCULATIONAHA.116.023263Circulation. 2016;134:1308–1310Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 1, 2016: Previous Version 1 IntroductionOpposing Viewpoint, see p 1311On the basis of the main results of the SPRINT (Systolic Blood Pressure Intervention Trial), we strongly believe that older hypertensive patients at high cardiovascular risk should receive intensive treatment to a target systolic blood pressure (SBP) of <120 mm Hg.1,2 SPRINT 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. SPRINT enrolled persons ≥50 years of age with an SBP from 130 to 180 mm Hg (treated or untreated) and at high cardiovascular risk. In particular, SPRINT overenrolled high-risk subgroups, including those ≥75 years of age (SPRINT-Senior), blacks, and those with chronic kidney disease or cardiovascular disease. The mean 10-year Framingham cardiovascular disease risk score for all participants was 20%.SBP fell rapidly in the intensive-treatment group (target SBP <120 mm Hg), reaching a level ≈15 mm Hg lower than in the standard group at 1 year (121.4 vs 136.7 mm Hg) with administration of an average of 1 more antihypertensive medication. The SPRINT intervention was stopped early (median 3.26 years of follow-up) because of a 25% reduction in the primary composite end point (myocardial infarction, non–myocardial infarction acute coronary syndrome, stroke, acute decompensated heart failure, and cardiovascular death) and a 27% reduction in all-cause mortality in the intensive-treatment group. The effects of the intensive intervention on the primary outcome and all-cause mortality were consistent across all prespecified subgroups (presence or absence of previous cardiovascular disease or chronic kidney disease, male or female sex, black or nonblack race, ≥75 or <75 years of age, and baseline SBP tertile). The benefits of intensive treatment were numerically greater (34% reduction in the primary outcome and 33% reduction in all-cause mortality) in the SPRINT-Senior subgroup.2 There were no significant differences in cardiovascular or mortality benefits of intensive BP treatment by baseline frailty or functional status. The number needed to treat for 3.26 years to prevent 1 primary outcome was 61 in the study as a whole and 28 in the SPRINT-Senior subgroup; to prevent 1 death, 90 in the study as a whole and 41 in the SPRINT-Senior subgroup. The pattern of adverse events in those ≥75 years of age was similar to that in the cohort as a whole.The large benefits of intensive treatment came at some cost. Although serious adverse events overall were not different between randomized groups, serious adverse events that resulted from hypotension, syncope, electrolyte abnormalities, and acute kidney injury or acute renal failure were more frequent in the intensive- versus standard-treatment groups (4.7% vs 2.5% of patients, respectively). However, in the chronic kidney disease 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. Although hypotension and syncope were more common in the intensive-treatment group, measured orthostatic hypotension was more common in the standard-treatment group, and there was no significant difference in injurious falls.The impressive reductions in cardiovascular outcomes and all-cause mortality in SPRINT have significant public health implications. A recent analysis of National Health and Nutrition Examination Survey 2007 to 2012 data estimated the prevalence, number, and characteristics of US adults meeting SPRINT eligibility criteria and used these to determine the broader population to whom SPRINT could be generalized.3 The report concluded that 16.8 million US adults (7.6% of the total population) and 8.2 million with treated hypertension (16.7% of the treated hypertensive population) would meet eligibility requirements for SPRINT. Thus, at a minimum, this number would likely benefit from adoption of the intensive SPRINT treatment goal.SPRINT excluded patients with diabetes or prior stroke because ongoing National Institutes of Health-sponsored trials, ACCORD (Action to Control Cardiovascular Risk in Diabetes) and SPS3 (Secondary Prevention of Small Subcortical Strokes), were examining similar BP targets in these populations. ACCORD found a statistically nonsignificant 12% reduction in risk of the primary outcome in the intensive-treatment group; a 95% confidence interval included the possibility of a 27% lower risk, consistent with the cardiovascular benefit seen in SPRINT. ACCORD also found a significant 41% reduction in stroke in the intensive-treatment group. The nonsignificant 11% reduction in stroke with intensive BP treatment in SPRINT may be related to the exclusion of persons with prevalent stroke or transient ischemic attack or to low stroke rates or merely be a result of chance: 95% confidence interval was wide and included the possibility of a 37% reduction in stroke. ACCORD had a smaller sample size than SPRINT (4733 vs 9361), enrolled a younger cohort (62 vs 68 years of age), excluded persons with chronic kidney disease, and did not include heart failure or non–myocardial infarction acute coronary syndrome in the primary composite end point. ACCORD had a factorial design that compared intensive versus standard glycemic and lipid treatment targets and BP targets. There was 26% reduction in the primary outcome with intensive compared with standard BP treatment in the standard glycemic treatment group.4 Thus, outcome differences between ACCORD and SPRINT could be related to study design, treatment interactions, or chance.An important caveat when adopting the SPRINT intensive BP treatment strategy is to consider the BP measurement technique in SPRINT. SPRINT used a validated automated device for office BP measurements and a standard protocol: participants were seated with their back and arms supported, feet on the floor, and appropriate cuff size, and they underwent 5 min of unobserved rest before measurement. The final clinic BP was based on an average of 3 consecutive BPs taken 1 min apart. In busy outpatient clinic settings, BP measurements are frequently taken manually by a provider with a sphygmomanometer with incorrect patient position, little or no rest period, and improper cuff size and placement, generally leading to overestimation of BP. Such overestimation may result in overtreatment with antihypertensive medications, potentially increasing the risk of serious adverse events if treating to the intensive SPRINT BP target.Largely on the basis of the results of SPRINT, the 2016 CHEP (Canadian Hypertension Education Program) guidelines recommend intensive BP treatment to target SBP ≤120 mm Hg in high-risk patients (Grade B).5 The CHEP report commented that "the risks of intensive BP control would undoubtedly be greater in conventional clinical practice" than in SPRINT and concluded that a shared decision-making process involving both patient and healthcare provider is necessary for the safe implementation of intensive BP control.SPRINT provides important data on the efficacy and safety of intensive SBP control in older, high-risk patients. Questions have been raised about the generalizability of SPRINT results to high-risk populations excluded from the trial (ie, those with heart failure, secondary hypertension, and severe chronic kidney disease) and institutionalized elderly, or to lower cardiovascular risk populations ( 50 years of age with Framingham 10-year risk score <15%). Given the absence of clinical trial data about the benefits and harms of targeting SBP <120 mm Hg in these groups, extrapolation of the SPRINT findings to larger populations of hypertensive and prehypertensive persons is left to the clinical judgment of healthcare providers and future guideline development committees.Sources of FundingThe Systolic Blood Pressure Intervention Trial was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke) under contracts HSN268200900040C, HHSN268200900046C, HHSN268200900047C, HHSN268200900048C, and HHSN268200900049C, and interagency agreement A-HL-13-002-001.DisclosuresDr Oparil reports grant/personal fees/nonfinancial support from the National Heart, Lung, and Blood Institute (NHLBI), Forest Laboratories, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, GlaxoSmithKline, Merck and Co., Novartis, and Arbor Pharmaceuticals LLC. She served as co-chair of the Joint National Committee (JNC) 8 and participated in the previous JNC guidelines writing committees. She is a writing group member of the World Heart Federation, European Society of Hypertension, and European Public Health Association Global Working Group on Optimal Salt Consumption and Cardiovascular Health. She also serves as director/principal investigator (PI) of the University of Alabama at Birmingham (UAB) Clinical Center Network (CCN) for the National Institutes of Health (NIH)/NHLBI-funded SPRINT (Systolic Blood Pressure Intervention Trial) and subinvestigator for a UAB CCN clinical site UAB Hypertension Clinic (site PI: Calhoun, DA). Dr Lewis reports grant funding from NIH and Novo Nordisk (unrelated to this topic). She serves as co-PI of the UAB CCN for the NIH/NHLBI-funded SPRINT. The views expressed in this Circulation point-of-view article are those of the authors and do not necessarily represent the official position of the National Institutes of Health, the U.S. Department of Veterans Affairs, the U.S. government, or the SPRINT Research Group.FootnotesThis is part I of a 2-part article. Part II appears on p 1311.Circulation is available at http://circ.ahajournals.org.Correspondence to: Suzanne Oparil, MD, Vascular Biology and Hypertension Program, 1720 2nd Avenue S, ZRB 1034, Birmingham, AL 35294. E-mail [email protected]References1. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373:2103–2116. doi: 10.1056/NEJMoa1511939.CrossrefMedlineGoogle Scholar2. 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November 1, 2016Vol 134, Issue 18 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.023263PMID: 27619922 Originally publishedSeptember 12, 2016 Keywordshypertensionblood pressureclinical trialhigh blood pressureblood pressure measurement/monitoringPDF download Advertisement SubjectsClinical StudiesHigh Blood PressureHypertensionQuality and Outcomes
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