Effect of intensive blood pressure lowering on cardiovascular outcomes based on cardiovascular risk: A secondary analysis of the SPRINT trial

Abstract

Background

It is not clear whether risk stratification can help choose the most favourable systolic blood pressure target for primary prevention of cardiovascular events.

Design

A secondary analysis of Systolic Blood Pressure Intervention Trial (SPRINT).

Methods

To perform a secondary analysis, we obtained the data from SPRINT from the National Heart, Lung, and Blood Institute data repository centre. In SPRINT, an open-label trial, participants without diabetes with systolic blood pressure of ≥130 mmHg were randomly assigned to intensive and standard treatment groups with systolic blood pressure targets of <120 and <140 mmHg, respectively. The primary composite outcome was myocardial infarction and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Here, we have analysed data from participants without cardiovascular disease and chronic kidney disease aged under 75 years categorised based on the baseline 10-year Framingham risk score (<10% (low risk); ≥10% and <15% (intermediate risk); ≥15% (high risk)).

Results

A total of 4298 patients were included in the analysis. With intensive treatment, there was a significant reduction in the primary outcome events in patients at high risk (0.86% per year vs. 1.81% per year; hazard ratio (HR) 0.51; 95% confidence interval (CI) 0.31 to 0.85; P = 0.010), and at intermediate risk (0.60% per year vs. 1.46% per year; HR 0.37; 95% CI 0.17 to 0.82; P = 0.014) but not for those at low risk (0.75% per year vs. 0.57% per year; HR 1.14; 95% CI 0.55 to 2.38; P = 0.714).

Conclusions

Intensive systolic blood pressure reduction is beneficial for primary prevention of cardiovascular morbidity and mortality in patients without diabetes with more than low cardiac risk (above 10%).

Keywords

Blood pressure cardiovascular risk hypertension intensive SPRINT target

Get full access to this article

View all access options for this article.

References

Lim

Vos

Flaxman

et al.

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–2260.

Danaei

Finucane

Lin

et al.

National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet 2011; 377: 568–577.

Lewington

Clarke

Qizilbash

et al.

Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903–1913.

Law

Wald

. Risk factor thresholds: their existence under scrutiny. BMJ 2002; 324: 1570–1576.

Jackson

Lawes

Bennett

et al.

Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365: 434–441.

Stone

Robinson

Lichtenstein

et al.

2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63: 2889–2934.

Tonkin

Barter

Best

et al.

National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: position statement on lipid management – 2005. Heart Lung Circ 2005; 14: 275–291.

Piepoli

Hoes

Agewall

et al.

European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR). Eur J Prev Cardiol 2016; 23: NP1–NP96.

Avanzini

Marzona

Baviera

et al.

Improving cardiovascular prevention in general practice: results of a comprehensive personalized strategy in subjects at high risk. Eur J Prev Cardiol 2016; 23: 947–955.

10.

James

Oparil

Carter

et al.

2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311: 507–520.

11.

Sundstrom

Arima

et al.

Blood Pressure Lowering Treatment Triallists' Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet 2014; 384: 591–598.

12.

Zanchetti

Grassi

Mancia

. When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal. J Hypertens 2009; 27: 923–934.

13.

Lonn

Bosch

Lopez-Jaramillo

et al.

Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374: 2009–2020.

14.

Whelton

Carey

Aronow

et al.

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71: e127–e248.

15.

Bakris

Sorrentino

. Redefining hypertension – assessing the new blood-pressure guidelines. N Engl J Med 2018; 378: 497–499.

16.

Wright

Jr Whelton

Reboussin

. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2016; 374: 2294.

17.

Penaloza-Ramos

Jowett

Barton

et al.

Cost-effectiveness analysis of different systolic blood pressure targets for people with a history of stroke or transient ischaemic attack: economic analysis of the PAST-BP study. Eur J Prev Cardiol 2016; 23: 1590–1598.

18.

Krause

Lovibond

Caulfield

et al.

Management of hypertension: summary of NICE guidance. BMJ 2011; 343: d4891.

19.

Montgomery

Fahey

Ben-Shlomo

et al.

The influence of absolute cardiovascular risk, patient utilities, and costs on the decision to treat hypertension: a Markov decision analysis. J Hypertens 2003; 21: 1753–1759.

20.

Gaziano

Steyn

Cohen

et al.

Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk versus blood pressure level. Circulation 2005; 112: 3569–3576.

21.

Liu

Zhang

Liu

et al.

The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 2005; 23: 2157–2172.

22.

Sundstrom

Arima

Jackson

et al.

Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med 2015; 162: 184–191.

23.

Diao

Wright

Cundiff

et al.

Pharmacotherapy for mild hypertension. Cochrane Database Syst Rev 2012, pp. CD006742.

24.

Group

Cushman

Evans

et al.

Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362: 1575–1585.

25.

Thomopoulos

Parati

Zanchetti

. Effects of blood-pressure-lowering treatment on outcome incidence in hypertension. 11. Effects of total cardiovascular risk and achieved blood pressure: overview and meta-analyses of randomized trials. J Hypertens 2017; 35: 2138–2149.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.89 MB