What is the recommended blood pressure target and management strategy for adults with hypertension, particularly those at high risk for cardiovascular events, in light of the SPRINT (Systolic Blood Pressure Intervention Trial) trial?

SPRINT Trial: Blood Pressure Management in High-Risk Patients

For adults with hypertension at high cardiovascular risk (10-year ASCVD risk ≥10%) without diabetes, initiate antihypertensive therapy at BP ≥130/80 mmHg and target a blood pressure <130/80 mmHg using standardized automated measurement protocols. 1, 2

Key Evidence from SPRINT

The SPRINT trial demonstrated that intensive blood pressure lowering to a systolic target <120 mmHg (measured by automated protocol) reduced:

• Cardiovascular events by 25% (HR 0.75; 95% CI 0.64-0.89) 2, 3
• All-cause mortality by 27% (HR 0.73; 95% CI 0.60-0.90) 2, 3
• Heart failure incidence by 62% (HR 0.62; 95% CI 0.45-0.84) 3

These benefits were consistent across subgroups, including patients with and without CKD, and in older adults aged ≥75 years 1, 2.

Critical Blood Pressure Measurement Requirements

You cannot apply SPRINT findings without using the correct measurement technique. SPRINT used automated oscillometric BP measurement following AHA guidelines, which yields readings approximately 10-15 mmHg lower than routine office measurements 1, 2.

The required protocol includes 2:

• Validated automated oscillometric device
• 5 minutes of quiet rest before measurement
• Patient seated alone or with staff present (unobserved preferred)
• Take 3 readings and average them

This standardized approach is essential because the SPRINT target of <120 mmHg systolic correlates with the guideline target of <130 mmHg when measured by conventional office methods 1.

Who Qualifies for Intensive Treatment

Initiate treatment at BP ≥130/80 mmHg and target <130/80 mmHg for patients with: 1, 2

• 10-year ASCVD risk ≥10% (Class I, Level B-RSR recommendation)
• Known cardiovascular disease (prior MI, stroke, peripheral vascular disease)
• Chronic kidney disease (eGFR <60 mL/min/1.73m²)
• Age ≥65 years (automatically high-risk; assume ≥10% ASCVD risk)

For older adults specifically, the target is SBP <130 mmHg for noninstitutionalized, ambulatory, community-dwelling adults aged ≥65 years 1, 4.

Populations Where SPRINT Does NOT Apply

Exercise extreme caution or use different targets in: 2

• Patients with diabetes (excluded from SPRINT; use ACCORD data instead—target remains <130/80 mmHg but evidence is weaker) 1, 3
• History of stroke (excluded from SPRINT)
• Dementia or cognitive impairment (excluded from SPRINT)
• Heart failure (excluded from SPRINT)
• Institutionalized patients (excluded from SPRINT)
• Age <50 years (excluded from SPRINT)

For older adults with high comorbidity burden and limited life expectancy, clinical judgment is reasonable, though intensive treatment showed benefit even in frail community-dwelling elderly in both SPRINT and HYVET 1.

Medication Strategy

Start with ≥2 antihypertensive medications from different classes if BP is >20/10 mmHg above target 2, 3.

Preferred first-line agents: 2, 3

• Thiazide diuretics (especially chlorthalidone)
• ACE inhibitors or ARBs (e.g., enalapril, candesartan, losartan)
• Calcium channel blockers (e.g., amlodipine)

The combination of ACE inhibitors/ARBs with thiazide diuretics was most effective in SPRINT analysis, independently reducing cardiovascular events (HR 0.75; 95% CI 0.61-0.92) 3.

Titrate medications monthly until BP control is achieved 2, 3.

Safety Monitoring and Adverse Events

Intensive treatment increases specific adverse events, though overall serious adverse events were not significantly different in SPRINT 1, 2:

• Hypotension and syncope (1.0-1.5% absolute increase)
• Electrolyte abnormalities (hyperkalemia)
• Acute kidney injury (1.0-1.5% absolute increase)
• Elevated serum creatinine

Critical monitoring requirements: 2, 4, 3

• Monthly evaluation until BP control achieved
• Measure BP in both sitting and standing positions at every visit to assess orthostatic hypotension
• Avoid diastolic BP <60 mmHg, as DBP <60 mmHg independently increases cardiovascular events (HR 1.36; 95% CI 1.07-1.71) even when SBP is controlled 3
• Do not target <120/80 mmHg in clinical practice—mean achieved BP below this threshold increases adverse events 3

Importantly, intensive treatment did not increase orthostatic hypotension, syncope, or falls in those aged ≥75 years in SPRINT 1.

Practical Translation Algorithm

1. Confirm hypertension using standardized automated BP measurement or out-of-office monitoring (home BP or ambulatory BP) 1, 2

2. Assess cardiovascular risk:

   • Age ≥65 years = automatically high-risk 1
   • Calculate 10-year ASCVD risk if <65 years 1
   • Check for established CVD or CKD 1

3. If high-risk (≥10% ASCVD risk or age ≥65) and BP ≥130/80 mmHg:

   • Initiate ≥2 medications if BP >150/90 mmHg 2
   • Target <130/80 mmHg (measured by standardized automated protocol) 1, 2

4. Titrate monthly with careful monitoring for adverse effects, especially in older adults 2, 3

5. Implement home BP monitoring with target <135/85 mmHg to confirm adequate control between visits 4

Common Pitfalls to Avoid

• Do not accept suboptimal dosing—titrate to standard therapeutic doses before adding additional agents 4
• Do not use age alone as a reason to accept higher BP targets in community-dwelling elderly 4
• Do not apply SPRINT targets without standardized BP measurement—conventional office BP readings are 10-15 mmHg higher 1
• Do not aggressively lower BP in patients with limited life expectancy (<1-3 years)—time to benefit is approximately 9 months to prevent 1 event per 500 patients 5

Evidence Quality and Nuances

The 2017 ACC/AHA guideline provides a Class I, Level B-RSR recommendation for the <130/80 mmHg target in high-risk patients, based on systematic reviews of randomized controlled trials including SPRINT 1. However, the guideline recommends <130 mmHg rather than <120 mmHg because BP measurements in clinical practice are typically higher than the automated unobserved measurements used in SPRINT 1.

A 2020 Cochrane review found "probably little to no difference" in total mortality or cardiovascular mortality with lower targets in patients with established CVD, but this analysis predated full incorporation of SPRINT data and used different target definitions 6. The preponderance of evidence, including meta-analyses of 42 trials with 144,220 patients, demonstrates a linear association between achieved SBP and CVD mortality risk, with lowest risk at 120-124 mmHg 1.