SPRINTing to a Lower Blood Pressure Target

The SPRINT Trial

Henry R. Black, MD: Hi. I'm Dr Henry Black, adjunct professor of medicine at the Langone New York University School of Medicine. I'm here today with my friend and colleague, Dr Jackson Wright. Jackson, welcome.

Jackson T. Wright, Jr, MD, PhD: Hi. I'm Dr Jackson Wright, professor emeritus at the Department of Medicine at Case Western Reserve University and University Hospitals Case Medical Center.

Dr Black: One of the things that I really want to talk about today is the SPRINT trial, for which you were a principal investigator and one of the leading advocates in its planning and execution. Would you review what the idea was, what the main findings were, and what the new findings are—much of which were presented at the American Society of Hypertension (ASH) Annual Scientific Meeting in May?

Dr Wright: Yes, of course. I am principal investigator of one of the five networks that were a part of SPRINT and was first author for the New England Journal of Medicine paper.^[1] At the ASH meeting, we presented the data on the blood pressure intervention and control, heart failure outcomes in the prespecified subgroups, safety, and quality of life, and an ancillary study comparing clinic vs ambulatory blood pressure readings in SPRINT. Of note, more detailed data from patients aged 75 years or older in SPRINT were presented.^[2] About 28% of the participants in SPRINT were aged 75 years or older. There has been a great deal of concern about both the beneficial effects and safety of aggressively managing systolic blood pressure in older patients.

Dr Black: You were comparing a blood pressure goal of 140 mm Hg systolic with a goal of 120 mm Hg. How many individuals were in that study overall?

Dr Wright: Overall, there were 9361 patients, of whom 28% or about 2600 were 75 years or older. It was a purposeful oversampling of patients aged 75 years or older. At the ASH meeting, we reported the results of the lower blood pressure (ie, systolic < 120 mm Hg) compared with a systolic target < 140 mm Hg in that patient population.

What we found was that patients in that age group did at least as well and numerically did better, with about a 34% reduction in the primary outcome in the subgroup aged 75 years or older compared with a 25% reduction in the overall cohort. All-cause mortality was reduced by 33% vs 27% in those 75 years or older vs those younger than 75 years, respectively. The reduction in the primary outcome was such that whereas the overall cohort's number needed to treat to prevent one of the primary outcomes was 61, the number needed to treat in those 75 years or older was 27.

Dr Black: What were the components of the primary endpoint?

Dr Wright: The components of the primary outcome were heart attack, stroke, cardiovascular death, hospitalized or emergency department decompensated heart failure, and acute coronary syndrome. That was the composite. The number needed to treat in patients 75 years or older was in fact only 27, compared with 61 in the overall cohort.

The number needed to treat to prevent a death from any cause was reduced to 41 in patients aged 75 years or older vs 90 in the overall cohort. In addition, the tolerability of the lower blood pressure target was found to be no greater. In fact, the point estimates for adverse events in the group with a goal blood pressure < 120 mm Hg, with regard to the hazard ratios, were lower in those aged 75 years or older compared with those younger than 75 years.

Dr Black: Were individuals concerned that lowering blood pressure too much in an older person would lead to falls and dizziness or other trouble?

Dr Wright: Similar to the overall cohort, there was about a 1%-2% higher rate of hypotension and syncope, but injurious falls did not increase in patients aged 75 years or older. The tolerability of the lower blood pressure goal in that subgroup was at least as good as in patients in the overall cohort.

Dr Black: How would you advise doctors who have read about SPRINT? You know that a study was very well publicized when a patient comes in and says, "My blood pressure is 125 mm Hg. Should I try to get to 115?" What's your advice to doctors about that?

Dr Wright: As an investigator in this study, our primary objective was to provide the data—data on both benefit and risk—and I think we accomplished that objective with SPRINT. It will fall to guideline panels, as well as the practice community, to consider these data in line with the other data out there, and decide how this should apply to their patient population.

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