Epidemiologic studies have demonstrated increasing cardiovascular risk at a systolic blood pressure above 115 mmHg. However, blood pressure treatment targets are less clear with clinical trials limited to evidence of benefit below 150mmHg. The Systolic Blood Pressure Intervention Trial (SPRINT) sought to determine outcomes following treatment to a target of less than 120mmHg (intensive treatment) compared with a target of less than 140mmHg (standard treatment). The study randomized 9361 non-diabetic patients with systolic hypertension (>130mmHg) and at least one other cardiac risk factor. The primary outcome was a composite of major adverse cardiovascular events or cardiovascular death. The choice of pharmacological agents was not mandated, but the use of a thiazide based regimen was encouraged. At 1-year, the mean systolic blood pressures were 121.4mmHg in the intensive treatment group and 136.2mmHg in the standard treatment group. The mean number of blood pressure medications required in the intensive treatment group was 2.8 compared with 1.8 in the standard treatment group. The trial was stopped early in response to a strong signal of benefit with treatment to less than 120mmHg for the primary outcome (1.65% per year vs. 2.19% per year; hazard ratio 0.75; 95% confidence interval, 0.64 to 0.89; P<0.001). This benefit was observed at a median follow-up of 3.26 years. In addition, all-cause mortality was lower in the intensive treatment group (hazard ratio, 0.73; 95% confidence interval 0.60 to 0.90; P = 0.003). Rates of hypotension, syncope, electrolyte disturbance, and acute renal failure were higher in the intensive treatment group.
In this large randomized study of non-diabetic patients with systolic hypertension, treating blood pressure to a target of 120mmHg led to significant cardiovascular and mortality benefits. Translating these results into real-world practice without the intensive monitoring associated with a clinical trial is likely to be challenging, but holds the potential to significantly improve health outcomes in the general population.
Summarized by Hussain Contractor and Steven M. Bradley
Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26;373(22):2103-16.