Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

SBP Target and CVD Outcomes in Older Adults

JAMA; ePub 2016 May 19; Williamson, Supiano, et al

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Treating to a systolic blood pressure (SBP) target of <120 mm/Hg compared with an SBP target of <140 mm/Hg among ambulatory adults aged ≥75 years resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause. This according to a study of 2,636 participants (mean age, 79.9 years) in the Systolic Blood Pressure Intervention Trial (SPRINT) randomized to an SBP target of <120 mm/Hg (intensive treatment group, n=1,317) or an SBP target of <140 mm/Hg (standard treatment group, n=1,319). Researchers found:

• At median follow-up of 3.14 years, there was a significantly lower rate of the primary composite outcome (102 events in the intensive treatment group vs 148 events in the standard treatment group; HR=0.66), and all-cause mortality (73 deaths vs 107 deaths, respectively; HR=0.67).

• The overall rate of serious adverse events was not different between treatment groups.

• Absolute rates of hypotension were 2.4% in the intensive treatment group vs 1.4% in the standard treatment group (HR=1.71), 3.0% vs 2.4%, respectively, for syncope (HR=1.23), 4.0% vs 2.7% for electrolyte abnormalities (HR=1.51), 5.5% vs 4.0% for acute kidney injury (HR=1.41), and 4.9% vs 5.5% for injurious falls (HR=0.91).

Citation: Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years. [Published online ahead of print May 19, 2016]. JAMA. doi:10.1001/jama.2016.7050.

Commentary: Over 75% of individuals age 75 or older have hypertension, so decisions about blood pressure control are made every day in most of our offices.1 The results of this study show an impressive benefit with approximately 40% decrease in cardiovascular events and mortality, and relatively small increase in adverse events. This result is different than the result of the blood pressure arm of the ACCORD study, which showed a benefit on intensive BP treatment for stroke, but not for other CV endpoints in patients with diabetes.2 The editorial to this study is worth reading and discusses that 40% of individuals with HTN do not have their systolic BP controlled to below 140 mm/Hg. Given that, the editorial continues, perhaps the goals for treatment should be incremental, first trying to achieve a systolic BP of <140 mm/Hg, then if that can be achieved and well-tolerated, an incremental goal of <130 mm/Hg might be considered. This recommendation seems sensible, though given the discrepancy between ACCORD and SPRINT, it would be nice to see another trial looking at a BP goal of <120 mm/Hg before making this a recommendation across the board. —Neil Skolnik, MD

1. Chobanian AV. SPRINT results in older patients: How low to go? [Published online ahead of print May 19, 2016]. JAMA. doi:10.1001/jama.2016.7070.

2. Cushman WC, Evans GW, Byington RP, et al. ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585.

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