This news was exciting, and somewhat unexpected. According to preliminary reports from SPRINT, targeting a systolic BP of less than 120 mm Hg may reduce the huge morbidity and mortality burden associated with hypertension.
The public and practicing clinicians have now heard from NHLBI that, contrary to controversial declarations made in medical papers over the last 2 years, a treatment strategy aimed at reducing systolic BP to a lower goal, rather than loosening our treatment approaches, may help older individuals live longer and avoid catastrophic CVD events. Analysis of outcomes in pre-specified subgroups will be of particular interest, given the disproportionate morbidity and mortality with hypertension among patients with chronic kidney disease (eGFR <60), age of 75 years or older and black race (vs. non-black). Clearly, age is a powerful risk factor for hypertension complications, especially in blacks, women and other high-risk groups.
Hopefully, this recent good news will dampen the potential harm from the 2014 JAMA hypertension guideline by the JNC 8 original panel, which was the only hypertension guideline in the world recommending backing off on BP control among patients aged as young as 60 years.
Although rigorously evidence-based and developed by highly respected researchers and clinicians, the so-called JNC 8 panel report was never proposed as a true JNC guideline. As noted in the text by the authors themselves, the 2014 report should never have been assigned the credibility of past JNC guidelines. The panel was originally formed by NHLBI, similar to other JNCs, but the JAMA report did not go through the approval process required for endorsement by NHLBI and other organizations that had endorsed previous JNCs. Often overlooked, also, is the fact that the grade-A recommendation of loosening BP goals for patients aged 60 years or older caused serious consternation within the JNC 8 panel, and was voted against by five of the 17 voting members (Wright J, et al. Ann Intern Med. 2014;160:499.).
This is not simply an academic point, but unveils the caution necessary when making major public health pronouncements and suggesting substantial changes to how quality-assurance programs, third-party payers and clinical pathways should push clinicians to practice the art of medicine.
In a State-of-the-Art Review published in JACC on the implications of higher goals for hypertension in older adults, I and several other authors strongly disagreed with the new 2014 recommendations to raise the threshold for initiating drug treatment and target systolic BP for older persons, specifically because of the implications for women, who comprise the majority of this elderly hypertensive population; and for blacks, who already suffer disparities from the ravages of poorly treated hypertension. This JACC report was, perhaps, prescient in its concern about potentially exacerbating existing sex and racial/ethnic disparities in CVD morbidity and mortality (Krakoff LR, et al. J Am Coll Cardiol. 2014;64:394–402).
Cautious clinicians who desire to translate the high-level preliminary reports from SPRINT should await final publication in a high-impact medical journal with peer review, detailing specific event rates and the absolute reduction in risk for any of the endpoints, including the primary composite endpoint of MI, ACS, stroke, HF or CVD death.
Major SPRINT exclusion criteria did not include several high-risk groups, including patients with prior stroke, diabetes, congestive HF, nephrotic range proteinuria, CKD with eGFR below 25 mL/min/1.73m2 (MDRD), polycystic kidney disease and glomerulonephritis. Nevertheless, the reduction in event rates was sufficiently large enough for the SPRINT data safety and monitoring board to stop the trial early. Impressively, CV events were cut by 30% and intensive BP reduction reduced all-cause mortality by nearly 25% compared with patients treated to a target of 140 mm Hg.
Fortunately, the American Heart Association and the American College of Cardiology will be updating their high BP guidelines later in 2015 or 2016, and SPRINT may add to the evidence base they can utilize. In the meantime, clinicians must be aware that it is dangerously inappropriate to abandon the target of less than 140/90 mm Hg in patients younger than 80 years of age — especially in women, blacks and other high-risk groups.
Keith C. Ferdinand, MD, FACC
Cardiology Today Editorial Board member
Professor of clinical medicine,
Tulane University School of Medicine, New Orleans
Disclosures: Ferdinand reports no relevant financial disclosures.