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Fewer patients with hypertension meet SPRINT BP goals
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Fewer adults with hypertension meet the BP goals from the SPRINT study than the 2014 hypertension recommendations by the panel convened for the Eighth Joint National Committee, according to a new analysis.
Min Jung Ko, PhD, of the division for health care technology assessment research, National Evidence-based Healthcare Collaborating Agency in Seoul, Korea, and colleagues analyzed data from 81,311 patients with hypertension using the Korean National Health and Nutrition Examination Survey of 2008 to 2013 and the Korean National Health Insurance Service 2007 health examinee cohort to estimate the proportion of patients meeting the SPRINT BP goals and the 2014 hypertension recommendations of the panel convened for the Eighth Joint National Committee (JNC 8).
The data from the health examinee cohort also were used to compare risks for major CV events.
According to the results, 11.9% of adults with hypertension would meet the SPRINT BP goals (intensive treatment group: systolic BP < 120 mm Hg) compared with the 70.8% of adults who would meet the 2014 recommendations (systolic BP < 140 mm Hg, except < 150 mm Hg in adults aged 60 years without diabetes or chronic kidney disease).
Generalizability a concern
Patients who met the stricter BP goals were more likely to be older women with diabetes, chronic kidney disease and prevalent CVD. The 10-year risk for CVD events was lowest in the group meeting the intensive-control goals from SPRINT (6.15%) compared with the group that met the 2014 recommendations but not the SPRINT BP goals (7.65%) and the group that met neither target (9.39%; P < .001).
After multivariable adjustment, those who met neither target (HR = 1.62) and those who met only the 2014 target (HR = 1.17) had higher risk for major CV events compared with those who met the SPRINT BP goals (P for trend < .001), according to the researchers.
In the health examinee cohort, specifically, the researchers observed a “significant linear trend, suggesting an increased risk of major [CV] events in patients with less stringent BP control.”
Ko and colleagues wrote, “Despite greater [CV] protection with intensive BP lowering, achieving SPRINT-defined BP goals might not be easy or practical” and would require “a more aggressive and time-consuming approach. ... Further investigations are required to determine the applicability and the potential impact of the results of SPRINT to a less restrictive, general population.”
Caution needed
In an accompanying editorial, Paul K. Whelton, MD, MD, MSc, of the department of epidemiology at the Tulane University School of Public Health and Tropical Medicine in New Orleans, and Paul Muntner, PhD, of the department of epidemiology at the University of Alabama at Birmingham, wrote: “The findings of Ko et al must be interpreted with caution. The survey data estimates of BP levels during [hypertension] treatment were collected before publication of both the SPRINT main results paper and the 2014 BP recommendations paper, at a time when Korean guidelines for [hypertension] management recommended much less intensive reduction in BP than would meet SPRINT goals.”
Paul K. Whelton
According to Whelton, chair of the SPRINT steering committee, and Muntner, also of importance were the differences in the basis for the CVD event rate and in the definition of CVD. The authors also emphasized the need for more “SPRINT-like trials” in different populations, including patients with diabetes and those living in countries where stroke plays a larger role in CVD mortality.
“Until these and other SPRINT-like trials have been completed, guideline committees and the practice community must use caution when generalizing SPRINT results to adults with a profile that differs from the participants in the parent study,” Whelton and Muntner wrote. – by Tracey Romero
Disclosure: The researchers report no relevant financial disclosures. Whelton reports serving as chair of the SPRINT steering committee. Muntner reports receiving funding from Amgen unrelated to the present topic.
Perspective
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Franz H. Messerli, MD, FACC, FACP
The statement of Ko and colleagues, “Despite greater [CV] protection with intensive BP lowering, achieving SPRINT-defined BP goals might not be easy or practical” makes perfect sense when one considers how BP measurements were performed in SPRINT. SPRINT is unique in that all BP measurements were unattended. This most likely was done to avoid the alert or white-coat effect without having to resort to ambulatory BP measurements. As Sverre E. Kjeldsen, MD, PhD, and colleagues pointed out, the implications thereof are that, No. 1, BPs taken in SPRINT cannot be directly compared with BPs in other trials and, No. 2, the treatment arm goal of less than 120 mm Hg in SPRINT compares with considerably higher systolic BP values in the other trials (Kjeldsen SE, et al. Hypertension. 2016;doi:10.1161/HYPERTENSIONAHA.116.07257). For generalization of SPRINT results, the number of mm Hg that should be added to make outcomes comparable to other trials can only be estimated. Suggestions vary from 5 to 10 mm Hg up to 10 to 20 mm Hg and a recent study indicates 16 mm Hg. Little surprise that, in the study by Ko and colleagues, the conclusion was that “achieving SPRINT-defined BP goals might not be easy or practical.”
We have to remember that our patients are genetically, socially, physiologically, metabolically, pathologically, psychologically and culturally different. Accordingly, there never will be only one way to diagnose and treat many medical disorders, including hypertension. To lower BP of all hypertensive patients uniformly to less than or equal to 120 mm Hg clearly has to be considered absurd, regardless of the SPRINT results.
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