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Treatment to intensive systolic BP target could save 100,000 US lives annually
Aggressively lowering BP could save more than 100,000 lives in the United States each year, according to predictions based on data from SPRINT.
“Currently about 80 million Americans have higher [BP]: one out of three. And the treatment cost of hypertension is about $80 billion a year,” Adam Bress, MD, assistant professor of population health sciences at the University of Utah School of Medicine, said in a press release. “The public health impact of adopting intensive treatment in the right patients is enormous.”
Using data from the National Health and Nutrition Examination Survey cohort from 1999 to 2006 and results from SPRINT, which found treating high-risk patients without diabetes to a systolic BP target of < 120 mm Hg resulted in fewer CV events than treatment to < 140 mm Hg, the researchers identified 2,185 individuals from NHANES who met the trial eligibility criteria (older than 50 years, at high risk for CVD and no history of diabetes or stroke).
Based on those data, Bress and colleagues estimated the number of deaths or cases of HF prevented and serious adverse events incurred with intensive BP therapy as used in SPRINT.
Between 1999 and 2006, about 18.1 million U.S. adults met the SPRINT eligibility criteria. The overall observed mortality rate was 2.2% (95% CI, 1.91-2.48) per year.
Based on the SPRINT HRs, intensive systolic BP treatment was projected by Bress and colleagues to prevent about 107,500 deaths (95% CI, 93,300-121,200; analysis of extremes, 34,600-179,600) and 46,100 cases of HF (95% CI, 41,800-50,400) per year. Benefits of intensive treatment were more pronounced in those aged 75 years or older, according to the researchers.
Intensive systolic BP control of < 120 mm Hg would increase episodes of hypotension by 56,100 (95% CI, 50,800-61,400), episodes of syncope by 34,400 (95% CI, 31,200-37,600), serious electrolyte disorders by 43,400 (95% CI, 39,400-47,500) and cases of acute kidney injury by 88,700 (95% CI, 80,400-97,000) per year, Bress and colleagues found.
“Implementation of the SPRINT intensive regimen will require overcoming a number of obstacles,” the researchers wrote. “Because SPRINT was a practice-based trial and recruited patients from clinics, it is unclear how likely intensive [systolic] BP goals will be achieved among population-based free-dwelling adults. It is likely that an additional investment will be required from providers and patients (eg, more frequent clinic visits, lab testing and additional medications) to produce the mean [systolic] BP change achieved in SPRINT (14.8 mm Hg after 1 year of treatment).” – by Cassie Homer
Disclosure: The researchers report no relevant financial disclosures.
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The authors applied SPRINT eligibility criteria to the 1999-2006 NHANES cohort and linked them with the National Death Index. There is little doubt that the resulting calculations are correct. Deceptive, however, is that the SPRINT BP measurements were uncritically extrapolated to NHANES. In SPRINT, BPs were measured unwitnessed with an automated device after 5 minutes of rest. In doing so, BP results are at least 10 mm Hg lower than those measured routinely in a physician’s office. Thus, although the authors’ calculations may be correct, the results are not, since they are based on inaccurate premises. The statement that intensive systolic BP treatment in the office to SPRINT targets could prevent about 107,500 deaths per year therefore becomes mostly wishful thinking.
Practicing physicians have neither time nor office space to implement SPRINT BP measurements in clinical practice. There is little question that better BP control in general would be desirable and remains to be achieved. However, when targeting a systolic BP of ≤ 120 mm Hg in a SPRINT-like patient, festina lente (make haste slowly) seems to be the best advice for the time being. This approach is supported by the HOPE-3 data showing that antihypertensive therapy with candesartan and hydrochlorothiazide did not lower the rate of major CV events among normotensive patients at intermediate risk who did not have CVD.
The office BP target is rarely an issue for practicing physicians. What has become more pertinent recently is BP variability, white coat hypertension and masked hypertension. BP may be at target and well controlled in the office between 9 am and 4 pm, but completely uncontrolled during the night and early morning hours, because many drugs have a too short duration of action.
A simple but inescapable truth in medicine is that patients are genetically, physiologically, psychologically, pathologically and culturally different. Accordingly, there never will be only one way only to diagnose and treat all medical disorders, including hypertension. To lower systolic BP of all hypertensive patients uniformly to 120 mm Hg or below clearly has to be considered absurd, regardless of the SPRINT results. We can only hope that despite — or even because of — SPRINT, physicians will continue to treat patients and not mm Hg only.