Preventing Heart Failure by Treating Systolic Hypertension: What Does the SPRINT Add?
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Purpose of Review
Previous trials definitively established that lowering systolic blood pressure (BP) to 140 mmHg prevented heart failure (HF) exacerbations, but the potential benefits and risks of further BP reduction remain unclear due to a paucity of trial-based data.
A recent secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) found that in older, high-risk, non-diabetic participants with systolic hypertension, a BP treatment target < 120 mmHg resulted in a 36% lower rate of acute decompensated HF as compared with a BP target < 140 mmHg. Those participants with incident HF had a 26-fold increased risk of subsequent cardiovascular events and death. Based in part on the SPRINT results, the 2017 American Heart Association/American College of Cardiology/HF Society Guideline for the Management of HF acknowledged that targeting a significant reduction in BP in those at increased risk for cardiovascular disease is a novel risk-based strategy to prevent HF.
SPRINT redefines systolic BP target goals in older, high-risk patients and provides a key opportunity for preventing HF in this patient group.
KeywordsHeart failure Systolic hypertension Prevention Systolic blood pressure SPRINT
Compliance with Ethical Standards
Conflict of Interest
Dr. Kitzman declares the following relationships: consultant for Abbvie, Bayer, Merck, Medtronic, GSK, Relypsa, Regeneron, Merck, Corvia Medical, DCRI, and Actavis, research grant funding from Novartis, St. Luke’s Medical Center, and stock ownership in Gilead Sciences. Dr. Upadhya has received research funding from Novartis and Corvia.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 17.Stassen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757–64.CrossRefGoogle Scholar
- 18.The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981–97.CrossRefGoogle Scholar
- 19.ACCORD Study Group, Ginsberg HN, Elam MB, Lovato LC, Crouse JR 3rd, Leiter LA, et al. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med. 2010;363:1563–74.Google Scholar
- 21.• Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16 This multicenter randomized trial of intensive (target < 120/80 mmHg) compared to standard (target < 140/90 mmHg) hypertension treatment in high-risk, non-diabetic patients, showed significant reduction in the primary composite endpoint and in all-cause mortality with intensive treatment. CrossRefGoogle Scholar
- 22.• Upadhya B, Rocco M, Lewis CE, Oparil S, Lovato LC, Cushman WC, et al. Effect of intensive blood pressure treatment on heart failure events in the systolic blood pressure reduction intervention trial. Circ Heart Fail. 2017;10:e003613 A secondary analysis from SPRINT focused on incident heart failure in 6 pre-specified subgrops, and showed significant reduction in risk of incident heart failure with intensive treatment. CrossRefGoogle Scholar
- 23.• Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged >/=75 years: a randomized clinical trial. JAMA. 2016;315:2673–82 A secondary analysis from SPRINT, focusing in participants over 75 years of age at enrollment, showed consistent benefit of intensive treatment for the primary composite outcome and for indicent heart failure. In addition, exploratory analysis suggested that the benefit of intensive BP control was consistent among elderly persons (≥ 75 years) who were frail or had reduced gait speed.CrossRefGoogle Scholar
- 31.Warwick J, Falaschetti E, Rockwood K, Mitnitski A, Thijs L, Beckett N, et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med. 2015;13:78.CrossRefGoogle Scholar
- 33.Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59:383–9.CrossRefGoogle Scholar
- 36.Bress AP, Kramer H, Khatib R, Beddhu S, Cheung AK, Hess R, et al. Potential deaths averted and serious adverse events incurred from adoption of the SPRINT (Systolic Blood Pressure Intervention Trial) intensive blood pressure regimen in the United States: projections from NHANES (National Health and Nutrition Examination Survey). Circulation. 2017;135:1617–28.CrossRefGoogle Scholar
- 37.Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45:142–61.CrossRefGoogle Scholar
- 38.• Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269–324 Guideline document from the American College of Cardiology and the American Heart Association with proposed diagnostic and therapeutic strategies for hypertension. CrossRefGoogle Scholar
- 42.Drawz PE, Pajewski NM, Bates JT, Bello NA, Cushman WC, Dwyer JP, et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure: results from the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory blood pressure study. Hypertension. 2017;69:42–50.CrossRefGoogle Scholar
- 43.Leung AA, Nerenberg K, Daskalopoulou SS, McBrien K, Zarnke KB, Dasgupta K, et al. Hypertension Canada’s 2016 Canadian hypertension education program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2016;32:569–88.CrossRefGoogle Scholar
- 44.National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults - 2016. Melbourne: National Heart Foundation of Australia, 2016; 2016. Ref Type: GenericGoogle Scholar
- 45.• Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the management of heart failure. J Am Coll Cardiol. 2017;70:776–803 Acknowledged that targeting a significant reduction in BP in those at increased risk for CVD is a novel risk-based strategy to prevent HF. The guideline states that in hypertensive patients at increased risk (stage A HF), optimal BP is < 130/80 mmHg. This recommendation reflects the assumption that BP measurements taken in the office setting are typically 5–10 mmHg higher than research-based measurements, as in SPRINT, so the < 130/80 mmHg goal is an approximation of the SPRINT intensive target BP adapted for conventional practice. CrossRefGoogle Scholar