What is the recommended blood pressure target and treatment approach for patients with hypertension, particularly those with additional cardiovascular risk factors such as diabetes or kidney disease, in light of the Sprint study highlights?

SPRINT Trial Highlights: Blood Pressure Management in High-Risk Patients

Core SPRINT Findings

The SPRINT trial demonstrated that intensive blood pressure lowering to a systolic target <120 mmHg reduces cardiovascular events by 25% and all-cause mortality by 27% compared to standard treatment targeting <140 mmHg in high-risk patients without diabetes. 1

Primary Outcomes

• Cardiovascular composite outcome reduced by 25% (HR 0.75; 95% CI 0.64-0.89; P<0.001), including myocardial infarction, acute coronary syndromes, stroke, heart failure, or cardiovascular death 1, 2
• All-cause mortality reduced by 27% (HR 0.73; 95% CI 0.60-0.90) 1, 2
• Heart failure incidence reduced by 62% (HR 0.62; 95% CI 0.45-0.84) 2
• Stroke showed non-significant 11% reduction (0.41% vs 0.47% per year; HR 0.89), though the trial excluded prior stroke patients 3

Achieved Blood Pressures

• Intensive group achieved mean SBP of 121 mmHg 3
• Standard group achieved mean SBP of 136 mmHg 3
• Average difference was 14.8 mmHg between groups 3

Critical Blood Pressure Measurement Protocol

SPRINT used standardized automated BP measurement following AHA guidelines, which is essential for translating results to practice. 3, 1

Required Measurement Technique

• Use validated automated oscillometric device 1
• 5 minutes of quiet rest before measurement 1
• Patient seated alone or with staff present (unobserved preferred) 1
• Take 3 readings and average them 1
• Support arm at heart level 3
• Use appropriate cuff size for upper-arm circumference 3

Clinical Translation Caveat

The automated, standardized BP measurement in SPRINT typically yields readings 5-10 mmHg lower than routine office measurements, meaning a SPRINT BP of 120 mmHg approximates a conventional office BP of 130 mmHg. 3

Current Guideline-Recommended Blood Pressure Targets

For High-Risk Patients WITHOUT Diabetes

Initiate treatment at BP ≥130/80 mmHg and target <130/80 mmHg based on SPRINT evidence. 3, 1, 2

• This applies to patients with 10-year ASCVD risk ≥10% 3
• Do NOT target <120/80 mmHg in clinical practice, as mean achieved BP below this threshold increases adverse events 3, 4, 2

For Patients WITH Diabetes

Initiate treatment at BP ≥130/80 mmHg and target <130/80 mmHg, but recognize this is based on ACCORD BP trial, not SPRINT (which excluded diabetes). 3, 4

• ACCORD BP showed 41% stroke reduction with intensive treatment (SBP <120 mmHg target, achieved 119 mmHg) 3, 4
• ACCORD BP did NOT show significant reduction in primary composite cardiovascular outcome 3
• Meta-analysis suggests SPRINT and ACCORD findings are consistent 3

For Patients WITH Chronic Kidney Disease

Initiate treatment at BP ≥130/80 mmHg and target <130/80 mmHg based on SPRINT CKD subset showing mortality benefit (HR 0.72; 95% CI 0.53-0.99). 3, 1

• Benefits were consistent in patients with and without CKD (interaction P=0.36) 1

For Older Adults (≥65 Years)

Target <130/80 mmHg for community-dwelling, ambulatory, non-institutionalized older adults. 3, 2

• SPRINT participants ≥75 years showed 28% lower stroke incidence (HR 0.72; 95% CI 0.43-1.21, not statistically significant) 3
• Titrate slowly and monitor closely for dizziness, syncope, orthostatic hypotension, or organ hypoperfusion 3
• For frail or high comorbidity burden older adults, target SBP 130-139 mmHg 2

Treatment Initiation and Intensification Strategy

Starting Therapy

Begin with ≥2 antihypertensive medications from different classes if BP is >20/10 mmHg above target (i.e., BP ≥150/90 mmHg when targeting <130/80 mmHg). 3, 1

• For stage 2 hypertension (BP ≥160/100 mmHg), treat promptly with combination therapy 3

Preferred Medication Classes

Use ACE inhibitors or ARBs combined with thiazide diuretics (especially chlorthalidone) as first-line therapy. 2

• This combination independently reduced cardiovascular events (HR 0.75; 95% CI 0.61-0.92) in SPRINT analysis 2
• Calcium-channel blockers are also effective first-line agents 1

Monitoring and Adjustment

Evaluate monthly until BP control achieved, then adjust medications to reach target <130/80 mmHg. 3, 1, 2

Adverse Events and Safety Monitoring

Common Adverse Events with Intensive Treatment

Intensive BP lowering increases specific adverse events that require vigilant monitoring: 3, 1, 2

• Hypotension (2.4% vs 1.4% in intensive vs standard) 3
• Syncope (2.3% vs 1.7%) 3
• Electrolyte abnormalities (hyponatremia, hypokalemia, hyperkalemia) 3, 1
• Acute kidney injury 3, 1
• ≥30% reduction in eGFR (more common in intensive group) 3
• Bradycardia 1

Critical Safety Thresholds

Maintain 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. 2

• Deintensify therapy for BP <90/60 mmHg 3

Monitoring for Orthostatic Hypotension

Check orthostatic BP at initial visit and as indicated, especially in older adults and those with autonomic neuropathy. 3

• Interestingly, orthostatic hypotension was MORE common in the standard group (P=0.13), with no significant difference in symptomatic orthostatic hypotension 3

Populations Where SPRINT Evidence Does NOT Apply

Exercise extreme caution or use different targets in the following excluded populations: 1

• Patients with diabetes (use ACCORD data instead) 3, 1, 4
• History of stroke 3, 1
• Dementia or cognitive impairment 1
• Heart failure 1
• Institutionalized patients 1
• Age <50 years 1

Practical Implementation Algorithm

Step 1: Identify SPRINT-Eligible Patients

High-risk patients ≥50 years with SBP 130-180 mmHg and increased cardiovascular risk (CKD, Framingham Risk Score ≥15%, or CVD) but WITHOUT diabetes, stroke, or end-stage renal disease. 1

Step 2: Implement Standardized BP Measurement

Adopt automated BP measurement protocols to ensure accurate readings comparable to SPRINT methodology. 3, 1

Step 3: Set Target Based on Population

• High-risk without diabetes: <130/80 mmHg 3, 1, 2
• With diabetes: <130/80 mmHg (based on ACCORD) 3, 4
• With CKD: <130/80 mmHg 3, 1
• Older adults (ambulatory): <130/80 mmHg 3, 2

Step 4: Initiate or Intensify Treatment

Start with ≥2 medications if BP >20/10 mmHg above target, using ACE inhibitor/ARB + thiazide diuretic or calcium-channel blocker. 3, 1, 2

Step 5: Monitor Monthly Until Control

Adjust medications monthly, screening for adverse events (hypotension, syncope, electrolyte abnormalities, AKI, orthostatic symptoms). 3, 1, 2

Step 6: Avoid Over-Treatment

Do not target <120/80 mmHg and maintain DBP ≥60 mmHg to prevent increased adverse events. 3, 4, 2

Key Nuances and Pitfalls

The "120 vs 130" Confusion

SPRINT targeted <120 mmHg using automated measurement, but guidelines recommend <130 mmHg using conventional office measurement. 3, 1 These are approximately equivalent due to measurement technique differences. 3

Renal Function Changes

Expect ≥30% eGFR reduction more commonly with intensive treatment, but average difference is only ~3 mL/min/m². 3 This likely reflects hemodynamic effects of ACE inhibitors/ARBs dilating efferent arterioles, not true kidney injury. 3

Stroke Benefit Uncertainty

SPRINT showed non-significant stroke reduction (11%), possibly because it excluded prior stroke patients and was a primary prevention population. 3 However, ACCORD showed significant 41% stroke reduction in diabetics. 3

Elderly and Frail Patients

SPRINT included community-dwelling elderly but excluded institutionalized patients. 3, 1 For frail elderly with high comorbidity, lower slowly and consider less aggressive targets (130-139 mmHg) to avoid loss of cerebral autoregulation and borderzone infarcts. 3, 2