Reference: JAMA Cardiol. 2022 Nov 1;7(11):1138-1146
Practice Point: The long-term benefits of intensive blood pressure control remain unproven.
EBM Pearl: Be careful not to make assumptions in your interpretation of observational data. Only observations, not explanations, can come from observational data.
Professional organizations disagree about blood pressure treatment targets. While there is abundant observational data suggesting an association between blood pressure control and improved mortality, the benefit of intensive over standard control has not been demonstrated in trial data aside from the SPRINT trial, the generalizability and validity of which have been questioned based on the non-real world methods of blood pressure measurement and evidence of performance bias. A recent follow-up analysis of SPRINT published in JAMA Cardiology found that the cardiovascular and all-cause mortality benefits associated with the intensive systolic target in the original trial did not persist in the long term.
Based on data extracted from electronic health records, investigators found that 4.5 years after the trial ended, achieved blood pressure was the same in both groups and there was no longer a difference in cardiovascular death (HR, 1.02; 95% CI, 0.84-1.24) or all-cause mortality (HR, 1.08; 95% CI, 0.94-1.23). Data analyzed was based only on EHR-reported blood pressures without any information on treatment targets or therapies, and included data points during the trial period itself as well as the follow-up period.
The authors conclude that the cardiovascular and all-cause mortality benefits of intensive blood pressure treatment did not persist after the SPRINT trial ended due to the loss of more intensive blood pressure control. However, whether those patients originally randomized to the intensive target group were no longer treated to that target or, rather, actually were treated to the intensive target (given patient preferences and new ACC/AHA blood pressure guidelines) but did not achieve the target blood pressure is unknown. These data could suggest that there is no mortality benefit to treating to an intensive blood pressure target for a few years and then backing off, or could mean that there is no mortality benefit with continued treatment to an intensive target that is not achieved. We still don’t know if the mortality benefit observed in the SPRINT trial would have persisted over time if the intensive targets were maintained.
The greatest take-away from this follow-up analysis of the SPRINT trial may be that the benefits of aggressive blood pressure control achievable only in a clinical trial may not translate to real-world management of hypertension
For more information, see the topic Hypertension Medication Selection and Management in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Nicole Jensen, MD, Family Physician at WholeHealth Medical, and Katharine DeGeorge, MD, MS, Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Dan Randall, MD, Deputy Editor at DynaMed; Vincent Lemaitre, PhD, Senior Medical Writer at DynaMed; and Sarah Hill, MSc, Associate Editor at DynaMed.