Pros and Cons of Intensive Systolic Blood Pressure Lowering

Mechanisms of Hypertension (M Weir, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Mechanisms of Hypertension

Abstract

Purpose of Review

The Systolic Blood Pressure Intervention Trial demonstrated significant decreases in cardiovascular events and total mortality with intensive systolic blood pressure lowering in adults with high cardiovascular risk in the absence of diabetes but benefits were accompanied by increased risk of adverse events.

Recent Findings

Over 100,000 deaths and 46,000 cases of heart failure may be prevented annually if intensive systolic blood pressure lowering is implemented in 17 million US adults who are age 50 years and older, and have high cardiovascular risk in the absence of diabetes and meet eligibility for the Systolic Blood Pressure Intervention Trial. However, the benefits of intensive SBP lowering will be accompanied by an excess of 43,000 cases of electrolyte abnormalities and 88,000 cases of acute kidney injury.

Summary

Physicians should consider implementation of intensive systolic blood pressure lowering in appropriate patients who understand the risks and benefits of this intervention.

Keywords

Blood pressure Intensive systolic blood pressure lowering SPRINT trial Adverse events Cardiovascular mortality Mortality Heart failure Acute kidney injury 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

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.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Society of Actuaries. Build and blood pressure study. Chicago: Society of Actuaries; 1959.Google Scholar
  2. 2.
    Wiehl DG. Review: build and blood pressure. The Milbank Memorial Fund Quarterly. 1960;38(2):180–3.  https://doi.org/10.2307/3348783.CrossRefGoogle Scholar
  3. 3.
    Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.CrossRefPubMedGoogle Scholar
  4. 4.
    •• Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA 1967 Dec 11; 202 (11):1028–1034. First randomized clinical trial of blood pressure lowering for prevention of cardiovascular events and mortality. Google Scholar
  5. 5.
    Freis ED. Changing attitudes to hypertension. Ann Intern Med. 1973;78(1):141–2.  https://doi.org/10.7326/0003-4819-78-1-141.CrossRefPubMedGoogle Scholar
  6. 6.
    The Joint National Committee on Detection. Evaluation and treatment on high blood pressure. The 1980 report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. A cooperative study. JAMA. 1977;237:255–61.CrossRefGoogle Scholar
  7. 7.
    Cooper R, Sempos C, Hsieh SC, Kovar MG. Slowdown in the decline of stroke mortality in the United States, 1978–1986. Stroke. 1990;21(9):1274–9.  https://doi.org/10.1161/01.STR.21.9.1274.CrossRefPubMedGoogle Scholar
  8. 8.
    •• Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT study group. Lancet. 1998;351(9118):1755–62.  https://doi.org/10.1016/S0140-6736(98)04311-6. One of the largest clinical blood pressure lowering trials to date which examined the association between three different diastolic blood pressure targets and cardiovascular outcomes. CrossRefPubMedGoogle Scholar
  9. 9.
    •• SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265(24):3255–64. First clinical trial to examine whether lowering blood pressure in older adults with isolated elevated systolic blood pressure reduces stroke risk. CrossRefGoogle Scholar
  10. 10.
    •• Veterans Administration Cooperative Study Group on Anti-hypertensive Agents. Effects of treatment on morbidity in hypertension: II-results in patients with diastolic blood pressure averaging 90 through114 mmHg. JAMA. 1970;213:1143–52. Second phase of the first clinical trial of blood pressure lowering for prevention of cardiovascular outcomes. CrossRefGoogle Scholar
  11. 11.
    • Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO. Morbidity and mortality in the Swedish trial in old patients with hypertension (STOP-Hypertension). Lancet. 1991;338(8778):1281–5.  https://doi.org/10.1016/0140-6736(91)92589-T. This trial examined the value of lowering blood pressure in adults age 70-84 years with a average SBP between 180-230 mmHg and a DBP of 90 mmHg or higher. CrossRefPubMedGoogle Scholar
  12. 12.
    •• UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317(7160):703–13. One of the first clinical trials examining the cardiovascular benefits of intensive blood pressure lowering in adults with diabetes. CrossRefPubMedCentralGoogle Scholar
  13. 13.
    • Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager 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(9080):757–64.  https://doi.org/10.1016/S0140-6736(97)05381-6. An additional clinical trial of blood pressure reduction with a calcium channel blocker vs. placebo in adults age > 60 years ith isolated elevations in systolic blood pressure. CrossRefPubMedGoogle Scholar
  14. 14.
    •• Appel LJ, Wright JT Jr, Greene T, Agodoa LY, Astor BC, Bakris GL, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363(10):918–29.  https://doi.org/10.1056/NEJMoa0910975. Landmark clinical trial examining intensive vs. standard blood pressure lowering in African Americans with chronic kidney disease clinically attributed to hypertension. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    • Estacio RO, Coll JR, Tran ZV, Schrier RW. Effect of intensive blood pressure control with valsartan on urinary albumin excretion in normotensive patients with type 2 diabetes. Am J Hypertens. 2006;19(12):1241–8.  https://doi.org/10.1016/j.amjhyper.2006.05.011. One of the first clinical trials examining benefits of lowering SBP below 140 mmhg in adults with type 2 diabetes. CrossRefPubMedGoogle Scholar
  16. 16.
    • Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care. 2000;23(Suppl 2):B54–64. This clinical trial examined the risk of microvascular complications with a diastolic blood pressure goal of 75 mmHg vs. a diastolic blood pressure goal of 80-89 mmHg in adults with type 2 diabetes and a diastolic blood pressure => 90 mmHg. PubMedGoogle Scholar
  17. 17.
    • Schrier R, McFann K, Johnson A, Chapman A, Edelstein C, Brosnahan G, et al. Cardiac and renal effects of standard versus rigorous blood pressure control in autosomal-dominant polycystic kidney disease: results of a seven-year prospective randomized study. J Am Soc Nephrol. 2002;13(7):1733–9.  https://doi.org/10.1097/01.ASN.0000018407.60002.B9. This trial examined benefits of standard vs. intensive blood pressure lowering in adults with polycystic kidney disease.
  18. 18.
    • Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int. 2002;61(3):1086–97.  https://doi.org/10.1046/j.1523-1755.2002.00213.x. One of the early trials examining the benefits of intensive systolic blood pressure lowering in adults with type 2 diabetes. CrossRefPubMedGoogle Scholar
  19. 19.
    •• SPS3 Study Group, Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382(9891):507–15. Clinical trial examined the efficacy of a systolic blood pressure target < 130 mmHg vs. 130–149 mmHg for secondary stroke prevention. CrossRefGoogle Scholar
  20. 20.
    •• Mancia G. Effects of intensive blood pressure control in the management of patients with type 2 diabetes mellitus in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Circulation. 2010;122(8):847–9.  https://doi.org/10.1161/CIRCULATIONAHA.110.960120. Landmark trial which examined intensive systolic blood pressure lowering vs. standard control in adults with type 2 diabetes. CrossRefPubMedGoogle Scholar
  21. 21.
    •• Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of diet in renal disease study group. N Engl J Med. 1994;330(13):877–84.  https://doi.org/10.1056/NEJM199403313301301. This clinical trial compared a mean arterial blood pressure of 92 mmHg vs. 107 mmHg in 1, 585 adults with glomerular filtration rates between 25 to 55 ml/min/1.73 m2 body surface area.
  22. 22.
    Lewis JB. Blood pressure control in chronic kidney disease: is less really more? J Am Soc Nephrol. 2010;21(7):1086–92.  https://doi.org/10.1681/ASN.2010030236.CrossRefPubMedGoogle Scholar
  23. 23.
    Sarnak MJ, Greene T, Wang X, Beck G, Kusek JW, Collins AJ, et al. The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study. Ann Intern Med. 2005;142(5):342–51.  https://doi.org/10.7326/0003-4819-142-5-200503010-00009.
  24. 24.
    Davis EM, Appel LJ, Wang X, Greene T, Astor BC, Rahman M, et al. Limitations of analyses based on achieved blood pressure: lessons from the African American study of kidney disease and hypertension trial. Hypertension. 2011;57(6):1061–8.  https://doi.org/10.1161/HYPERTENSIONAHA.111.169367.
  25. 25.
    •• The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16.  https://doi.org/10.1056/NEJMoa1511939. This landmark clinical trial demonstrated significant reductions in mortality with intensive systolic blood pressure lowering (< 120 mmHg) vs. standard systolic blood pressure lowering (< 140 mmHg) in adults with high cardiovascular risk. CrossRefPubMedCentralGoogle Scholar
  26. 26.
    Beckett L, Godwin M. The BpTRU automatic blood pressure monitor compared to 24 hour ambulatory blood pressure monitoring in the assessment of blood pressure in patients with hypertension. BMC Cardiovasc Disord. 2005;5(1):18.  https://doi.org/10.1186/1471-2261-5-18.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Myers MGA. Short history of automated office blood pressure—15 years to SPRINT. J Clin Hypertens (Greenwich). 2016;18(8):721–4.  https://doi.org/10.1111/jch.12820.CrossRefGoogle Scholar
  28. 28.
    • Xie X, Atkins E, Lv J, Bennett A, Neal B, Ninomiya T, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387(10017):435–43.  https://doi.org/10.1016/S0140-6736(15)00805-3. Meta-analysis of trials that examined the cardiovascular and mortality benefits of blood pressure targets below 140 mmHg.
  29. 29.
    Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am coll Cardiol. 2017;S0735-1097(17):41591-1.Google Scholar
  30. 30.
    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(5):569–88.  https://doi.org/10.1016/j.cjca.2016.02.066.
  31. 31.
    Ortiz E, James PA. Let’s not SPRINT to judgment about new blood pressure goals. Ann Intern Med. 2016;165(12):889–90.  https://doi.org/10.7326/L16-0442.CrossRefPubMedGoogle Scholar
  32. 32.
    • 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(17):1617–28.  https://doi.org/10.1161/CIRCULATIONAHA.116.025322. Observational study which estimates that over 100,000 deaths would be prevented annually if intensive systolic blood pressure lowering was implemented in U.S. adults with high cardiovascular risk.
  33. 33.
    Bress AP, Tanner RM, Hess R, Colantonio LD, Shimbo D, Muntner P. Generalizability of SPRINT results to the U.S. adult population. J Am Coll Cardiol. 2016;67(5):463–72.  https://doi.org/10.1016/j.jacc.2015.10.037.CrossRefPubMedGoogle Scholar
  34. 34.
    Mensah GA, Wei GS, Sorlie PD, Fine LJ, Rosenberg Y, Kaufmann PG, et al. Decline in cardiovascular mortality: possible causes and implications. Circ Res. 2017;120(2):366–80.  https://doi.org/10.1161/CIRCRESAHA.116.309115.
  35. 35.
    Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.  https://doi.org/10.1161/CIR.0000000000000485.
  36. 36.
    • Moise N, Huang C, Rodgers A, Kohli-Lynch CN, Tzong KY, Coxson PG, et al. Comparative cost-effectiveness of conservative or intensive blood pressure treatment guidelines in adults aged 35–74 years: the cardiovascular disease policy model. Hypertension. 2016;68(1):88–96.  https://doi.org/10.1161/HYPERTENSIONAHA.115.06814. Study estimates that intensive systolic blood pressure lowering is cost saving in men and cost effective in women.
  37. 37.
    Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension. III. Influence of age, diastolic pressure, and prior cardiovascular disease; further analysis of side effects. Circulation. 1972;45(5):991–104.  https://doi.org/10.1161/01.CIR.45.5.991.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Public Health SciencesLoyola University ChicagoMaywoodUSA
  2. 2.Medicine, Division of Nephrology and HypertensionLoyola University ChicagoMaywoodUSA
  3. 3.Hines VA Medical CenterHinesUSA

Personalised recommendations