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

Primary Recommendation

For adults with hypertension at high cardiovascular risk (10-year ASCVD risk ≥10%) without diabetes, target a blood pressure <130/80 mmHg using intensive antihypertensive therapy, as this reduces major cardiovascular events by 25% and all-cause mortality by 27% compared to standard targets of <140/90 mmHg. 1, 2, 3

Key SPRINT Trial Findings

The SPRINT trial demonstrated compelling mortality and morbidity benefits from intensive blood pressure control in high-risk patients:

• Primary cardiovascular composite outcome reduced by 25% (HR 0.75; 95% CI 0.64-0.89), including myocardial infarction, acute coronary syndromes, stroke, heart failure, and cardiovascular death 2, 3
• All-cause mortality reduced by 27% (HR 0.73; 95% CI 0.60-0.90) 2, 3
• Heart failure incidence reduced by 62% (HR 0.62; 95% CI 0.45-0.84) 3
• Benefits consistent across all subgroups, including patients with and without CKD (interaction P=0.36) 2

Who Qualifies for Intensive Treatment

Initiate antihypertensive therapy at BP ≥130/80 mmHg and target <130/80 mmHg for patients meeting ANY of these high-risk criteria 1, 2:

• 10-year ASCVD risk ≥10% (calculated using pooled cohort equations)
• Age ≥65 years (automatically qualifies as high-risk)
• Chronic kidney disease (eGFR <60 mL/min/1.73m²)
• Pre-existing cardiovascular disease (prior MI, stroke, peripheral vascular disease)
• Framingham 10-year CVD risk score ≥15%

Critical Blood Pressure Measurement Protocol

SPRINT used standardized automated BP measurement, which reads approximately 10-15 mmHg lower than routine office measurements—this is essential for proper interpretation and implementation. 1, 2

The required measurement protocol includes 1, 2:

• Validated automated oscillometric device (not manual auscultation)
• 5 minutes of quiet rest before measurement
• Patient seated alone or with staff present but not interacting
• Take 3 readings and average them
• Proper positioning: back supported, feet flat on floor, arm at heart level

Treatment Strategy and Medication Selection

Initial Therapy

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

Preferred first-line combination based on SPRINT analysis 3, 4:

• Thiazide or thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide for greater potency)
• ACE inhibitor or ARB (e.g., enalapril, lisinopril, candesartan, losartan)
• Calcium channel blocker (e.g., amlodipine) as third agent if needed

This combination independently reduced cardiovascular events (HR 0.75; 95% CI 0.61-0.92) in SPRINT analysis 3

Titration Protocol

• Monthly medication adjustments until BP goal achieved 2, 3
• Monthly evaluation visits until control achieved, then less frequent monitoring 1, 3
• Home BP monitoring with target <135/85 mmHg to confirm adequate control between visits 5

Safety Monitoring and Adverse Events

Intensive treatment increases specific adverse events that require vigilant monitoring 2, 3:

Common Adverse Events (1.0-1.5% higher incidence in intensive group):

• Hypotension and syncope
• Electrolyte abnormalities (hyperkalemia, hyponatremia)
• Acute kidney injury (transient creatinine elevation)
• Bradycardia

Essential Safety Checks at Every Visit

• Orthostatic blood pressure measurement (sitting and standing) to detect orthostatic hypotension 1, 5
• Serum creatinine and electrolytes monitoring
• Symptoms of hypoperfusion: dizziness, weakness, falls, syncope 6

Critical Safety Thresholds

Avoid excessive BP lowering below these thresholds 3, 6:

• Do NOT target <120/80 mmHg in routine clinical practice (guideline target is <130/80 mmHg, not <120 mmHg) 2, 3
• Maintain diastolic BP ≥60 mmHg—DBP <60 mmHg independently increases cardiovascular events (HR 1.36; 95% CI 1.07-1.71) even when SBP is controlled 3

Special Populations

Older Adults (≥65 Years)

Intensive BP control is safe and effective in older adults, including those ≥75 years, without increased falls or orthostatic hypotension. 1, 5

• Target SBP <130 mmHg for noninstitutionalized, ambulatory, community-dwelling adults ≥65 years (Class I, Level A recommendation) 1, 5
• Both SPRINT and HYVET demonstrated substantial benefit in older adults, including frail but independently living patients 1
• No randomized trial in persons >65 years has ever shown harm or less benefit for older versus younger adults 5
• Careful titration over weeks is safer than aggressive acute reduction 5

Patients with Chronic Kidney Disease

Target BP <130/80 mmHg for patients with CKD based on SPRINT evidence showing mortality benefit (HR 0.72; 95% CI 0.53-0.99) in the CKD subset 1, 2

• Benefits consistent regardless of baseline kidney function 2
• Monitor for acute kidney injury during titration 2, 3

Populations Where SPRINT Evidence Does NOT Apply

Exercise extreme caution or use different targets in these excluded populations 2:

• Diabetes mellitus (excluded from SPRINT; use ACCORD data instead—target <130/80 mmHg but expect less dramatic benefit) 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)

Practical Translation Algorithm

Step 1: Identify High-Risk Patients

• Calculate 10-year ASCVD risk or identify other high-risk features
• Confirm BP elevation with standardized automated measurement

Step 2: Initiate Treatment at BP ≥130/80 mmHg

• Start with 2 medications if BP >20/10 mmHg above target
• Use thiazide diuretic + ACE inhibitor/ARB combination

Step 3: Titrate Monthly

• Adjust medications monthly until target <130/80 mmHg achieved
• Add calcium channel blocker as third agent if needed
• Average of 2.8 medications required in SPRINT intensive arm

Step 4: Monitor for Adverse Events

• Check orthostatic BP at every visit
• Monitor electrolytes and creatinine
• Assess for symptoms of hypoperfusion

Step 5: Maintain Long-Term Control

• Home BP monitoring <135/85 mmHg
• Avoid diastolic BP <60 mmHg
• Continue treatment indefinitely—do not stop based on age alone

Common Pitfalls to Avoid

• Do not accept suboptimal dosing—titrate to full therapeutic doses before adding additional agents 5
• Do not use age alone as a reason to accept higher BP targets in community-dwelling elderly 5
• Do not measure BP incorrectly—standardized automated measurement is essential for proper interpretation 1, 2
• Do not target <120/80 mmHg—the guideline-recommended threshold is <130/80 mmHg 2, 3
• Do not ignore diastolic BP—maintain DBP ≥60 mmHg to avoid increased cardiovascular risk 3

Time to Benefit Considerations

For patients ≥60 years, intensive BP treatment requires adequate life expectancy to derive benefit 7:

• 9.1 months needed to prevent 1 MACE per 500 patients (ARR 0.002)
• 19.1 months to prevent 1 MACE per 200 patients (ARR 0.005)
• 34.4 months to prevent 1 MACE per 100 patients (ARR 0.01)

Intensive BP treatment may be appropriate for adults with life expectancy >3 years but may not be suitable for those with <1 year. 7