Implications of SPRINT: How Should Clinicians Respond?

Cardiology Advisor: What are the implications of the trial for the individual cardiologist or other practitioner? Should they reset BP targets for their patients based on SPRINT findings?

Dr Conroy: I think the implications are that we will have to work harder than we did before on BP management. I am a general internist and have been discussing the SPRINT findings with many of my patients with hypertension. They deserve to know about the results and how they might apply to their clinical care. I think that allows us to talk about what might be the best BP goal for that patient and then how we may reach that goal.

Dr Lewis: All patients who fit the broad group of patients who were studied in SPRINT should be evaluated to have their BP goals reset.

Dr Gradman: In my editorial, I gave my recommendations for dealing with each category of patient included in SPRINT for whom recommendations would change if SPRINT were followed. Generally, I favor adding 1 medication only to each patient and not trying too hard to achieve the <120 mmHg target unless the patient has a high stroke risk or has established cardiovascular disease. I do not favor automatically treating everyone >75 years of age with SBP >130 mmHg.

Cardiology Advisor: Adverse events of hypotension, syncope, electrolyte abnormalities and kidney injury or failure were seen in the intensive treatment group. Do the benefits of lower BP outweigh these risks? How should individual practitioners balance the risks and benefits of aggressive treatment?

Dr Conroy:  These discussions should include risks as well as benefits of a more aggressive treatment course. These conversations will take time (which can be scarce in clinical settings) but are so important as they help us to (re)define what a given patient’s priorities and concerns are.

Dr Lewis: More analyses will be conducted to evaluate the risks of adverse events vs benefits in specific subgroups of patients studied in SPRINT but it is unequivocal that in the group of subjects studied as a whole the benefits far outweigh the risks and the benefits are quite remarkable.

Dr Gradman: As we saw in ACCORD, in some patients (those with diabetes), the risks of adverse effects are greater than the benefit gained by more BP reduction. Physicians need to put the SPRINT results into perspective. One study does not change the world. We cannot throw out the results of previous studies based upon these results—which is not to say that these results are not important. Clearly, for many patients, there are significant benefits to be gained by following the SPRINT results. But for others, the opposite may be true. It is our challenge to figure out into which group the patient sitting before us in our office falls.

RELATED SLIDESHOW: Hypertension: Evidence-Based Treatment

References

  1. SPRINT Research Group, Wright JT, Williamson JD, et al. A Randomized Trial of Intensive vs Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103-2116. doi:10.1056/NEJMoa1511939.
  2. James PA, Oparil S, Carter BL, 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(5):507-520. doi:10.1001/jama.2013.284427.
  3. Gradman AH. SPRINT: To Whom Do the Results Apply? J Am Coll Cardiol. 2016;67(5):473-475. doi:10.1016/j.jacc.2015.12.006.
  4. ACCORD Study Group, Gerstein HC, Miller ME, et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011;364(9):818-828. doi:10.1056/NEJMoa1006524.