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October 13, 2022
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SPRINT: Benefits of intensive BP lowering may be lost quickly if treatment not sustained

Fact checked byRichard Smith
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The benefits of intensive BP treatment on CV death and all-cause mortality observed in the SPRINT trial did not persist beyond the conclusion of the trial intervention, researchers reported.

Perspective from Randall Zusman, MD

At 10 years, the mean systolic BP among those assigned to the intensive treatment group was not significantly different compared with those assigned to a standard BP target, according to the long-term results of the SPRINT trial published in JAMA Cardiology.

Graphical depiction of data presented in article
Data were derived from Jaeger BC, et al. JAMA Cardiol. 2022;doi:10.1001/jamacardio.2022.3345.

“Findings from our ancillary study of outpatient [systolic] BP measured in routine clinical practice indicated that the difference in [systolic] BP between treatment groups diminished steadily over time, with no detectable difference in [systolic] BP approximately 9 years after randomization,” Byron C. Jaeger, PhD, assistant professor of biostatistics and data science at Wake Forest University School of Medicine, and colleagues wrote. “These results, in combination with the primary findings of the trial, indicate that the beneficial effect of intensive treatment among adults with hypertension appears to diminish quickly if intensive BP control is not sustained.”

As Healio previously reported, an aggressive systolic BP target of less than 120 mm Hg was associated with lower rates of the primary composite outcome of MI, other ACS, stroke, HF and death from CV causes, in addition to lower all-cause mortality, compared with a standard target of systolic BP less than 140 mm Hg.

For the present secondary analysis, researchers evaluated the 4.5 years occurrence of CV death and all-cause mortality among participants in the SPRINT cohort using outpatient electronic health record data (mean age, 67.9 years; 35.6% women; 31.5% Black).

Long-term CV and all-cause death in SPRINT

The intervention phase of SPRINT occurred between Nov. 8, 2010, and Aug. 20, 2015.

The current study includes part of the trial phase and additional follow-up through July 1, 2016, and observational follow-up that continued through December 2020.

Total median follow-up time was 8.8 years for both treatment arms.

During the trial phase of SPRINT, risk for all-cause mortality in the intensive treatment arm was lower compared with the standard treatment arm (HR = 0.83; 95% CI, 0.68-1.01); however, the benefit of intensive treatment did not persist and was attenuated at 2.8 years following trial randomization (HR = 1.08; 95% CI, 0.94-1.23).

Results were similar for the outcome of CV death, where the benefits of intensive treatment compared with standard care during the trial period (HR = 0.66; 95% CI, 0.49-0.89) were attenuated at 5.6 years during the observational phase (HR = 1.02; 95% CI, 0.84-1.24).

After performing a subgroup analysis of 2,944 participants with a median of 20 outpatient BP measurements during the observational phase, researchers observed a mean between-group difference in systolic BP of 0.21 mm Hg at 10 years (95% CI, 3.6 to 3.2). The mean systolic BP in the intensive treatment group rose from 132.8 mm Hg at 5 years to 140.4 mm Hg at 10 years.

“A lingering question from this study is what were the primary drivers of the increase in BP in the intensive treatment group following the trial,” the researchers wrote. “Unfortunately, as part of the [electronic health record] ancillary study, we only have access to medication data in the Veterans Affairs system and do not have information about who participants had encounters with, and so our ability to inform this question is quite limited. We believe this will be an important topic for future research in trials such as the STEP trial and other ongoing trials investigating more intensive BP control.”

Standard approaches ‘fail to achieve ideal BP control’

Daniel W. Jones

In a related editorial, Daniel W. Jones, MD, director of clinical and population sciences at the Mississippi Center for Obesity Research at the University of Mississippi School of Medicine, and colleagues discussed how clinical practice must shift to better improve BP control to a degree seen during the SPRINT trial.

“The SPRINT study participants were older with a history of atherosclerotic disease or at high risk. Once blood vessels and organs are damaged from years of hypertension and other risk factors, BP management and control become more challenging,” the authors wrote. “The vigorous controlled strategies used in the SPRINT study were able to overcome this challenge. However, contemporary clinical practice strategies seem less likely to do so.

“There is good evidence to reform our systems to mimic rigorous management strategies used in clinical trials proven to provide better BP control rates than traditional approaches,” the authors wrote. “Telehealth strategies are another promising area that can improve upon the intermittent, reactive and time-consuming process of in-person clinic visits. It is time to acknowledge that standard approaches to BP management in clinical practice in the United States are failing to achieve ideal BP control rates.”

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