#37 SPRINT don’t walk to Evidence for Specific BP Targets?

CLINICAL QUESTION

QUESTION CLINIQUE

What is the evidence for blood pressure (BP) targets lower than 140/90?

BOTTOM LINE

RÉSULTAT FINAL

Evidence supports BP targets of <140/90 for general hypertension and diabetic/renal subgroups. However, in patients with cardiovascular disease (CVD) risk ≥20% over 10 years, targets ~120 can be (carefully) considered. This does not include diabetics or post-stroke and standing BP should be monitored.

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EVIDENCE

DONNÉES PROBANTES

Outcomes Statistically Significant:

SPRINT:1 Randomized Controlled Trial (RCT) of 9,361 patients (CVD risk ~20% over ten years), target <140 versus <120, x3.3 years. Attained BP 136/76 versus 121/68 and average patient on 2.8 versus 1.8 medications.
- CVD: 25% Relative Risk Reduction (RRR), Number Needed to Treat (NNT)=61.
- Death: 27% RRR, NNT=90.
  - Similar benefits elderly (age ≥75) and other groups (example renal).
- No diabetics, post-stroke, ejection fraction <35%, GFR <20, or standing BP <110.
General Hypertension, three Systematic Reviews (SR).2-4
- Seven RCTs (22,089 patients)2 x3.8 years: Intense BP 4/3 lower.
  - No statistical differences in outcomes.
- Nineteen RCTs (44,989 patients) x3.8 years:3 Attained BP 133/76 versus 140/81.
  - Death: No statistical difference.
  - CVD: RRR 14% (if CVD risk ~20% over 10 year, NNT=36).
- Sixteen RCTs (52,235 patients)4 x3.7 years: Intense BP 8/3 lower, “standardized” to 10/5.
  - CVD: 25% RRR (if CVD risk ~20% over 10 years, NNT=28).
  - Limits: Some early trials not “intense” (example ≤150 systolic versus ≤180).3,4
Type II Diabetes: Two SR of five RCTs (7,314 patients) x4.5 years.5,6 BP Systolic target RCTs 119/64 versus 135/83 and diastolic target RCTs 128/76 versus 133/70.
- Stroke: RRR 35%, NNT ~31 over ten years.
- Death and other CVD: No statistical difference.
- Two SR examined attained BP.7,8
  - Benefits for reduction <140 but ≤130 minimal stroke reductions lost against increased CVD mortality7 or serious adverse events.8
Renal Disease: Two SR of 3-11 RCTs (2,272-9,287 patients)9,10 ~3 years. Systolic BP ~10 lower in intense.
- Mortality or any CVD: No statistical difference.
- Prevent worsening renal function:9 RRR 18%, NNT=247.

Context:

Harms (intense versus standard):¹ Hypotension (Number Needed to Harm (NNH)=72), syncope (NNH=91), acute kidney injury (NNH=56).
Large SR demonstrate absolute benefits of BP reduction are driven largely by baseline risk.^11,12
Guideline¹³ recommended Systolic BP targets vary between 130-150.
If lower targets used: Advise of potential harms, monitor carefully, check standing BP.

Reviewed Mar 25 2016