Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials

doi:10.1016/j.amjmed.2017.01.004

The American Journal of Medicine

Volume 130, Issue 6, June 2017, Pages 707-719.e8

https://doi.org/10.1016/j.amjmed.2017.01.004 Get rights and content

Abstract

Background

The optimal on-treatment blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg, albeit with an increase in serious adverse effects related to low BP.

Methods

PubMed, EMBASE, and CENTRAL were searched for randomized trials comparing treating with different BP targets. Trial arms were grouped into 5 systolic BP target categories: 1) <160 mm Hg, 2) <150 mm Hg, 3) <140 mm Hg, 4) <130 mm Hg, and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure, and safety outcomes of serious adverse effects were evaluated using a network meta-analysis.

Results

Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (rate ratio [RR] 0.54; 95% confidence interval [CI], 0.29-1.00) and myocardial infarction (RR 0.68; 95% CI, 0.47-1.00) with systolic BP <120 mm Hg (vs <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97%, and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg, and <160 mm, respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death, or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2, respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs <150 mm Hg (RR 1.83; 95% CI, 1.05-3.20) or vs <140 mm Hg (RR 2.12; 95% CI, 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2, respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety.

Conclusions

In patients with hypertension, a on-treatment systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.

Section snippets

Eligibility Criteria

We searched PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) for randomized clinical trials comparing treating to different BP targets. Trials comparing systolic, diastolic, or mean arterial BP targets were selected. The search terms are outlined in Supplementary Table 1 (Appendix, available online). We checked the reference lists of original studies, review articles, and meta-analyses identified by the electronic searches to find other eligible trials. There was no

Results

Our search yielded 17 randomized trials testing various BP targets (Figure 1, Supplementary Figure 1, available online). The trials enrolled 55,163 patients who were followed up for a mean of 3.7 years for a total of 204,103 patient-years of follow-up. The baseline characteristics of the trials, including baseline BP, achieved BP, and risk of bias assessment of the trials, are outlined in Table 2 and Supplementary Table 2, available online. All included trials used office BP measurements.

Discussion

In this analysis of 17 randomized BP target trials that enrolled 55,163 patients with 204,103 patient-years of follow-up, we observed a significant reduction in stroke and myocardial infarction with lower on-treatment systolic BP targets but a significant increase in serious adverse effects with no differences among other outcomes. Systolic BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2, respectively, as the most efficacious targets, whereas systolic BP targets of <140 mm Hg and <150

Conclusions

Data from randomized BP target strategy trials suggest a significant reduction in stroke and myocardial infarction with lower systolic BP targets, such that systolic BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2, respectively, as the most efficacious targets. However, lower systolic BP targets were associated with a significant increase in serious adverse effects such that higher systolic BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2, respectively, as the safest targets.

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: Funding: None.

: Conflict of Interest: None of the authors received any compensation for their work on this manuscript.

: Authorship: All authors had access to the data and a role in writing this manuscript.

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Clinical research studyOptimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials

Abstract

Background

Methods

Results

Conclusions

Section snippets

Eligibility Criteria

Results

Discussion

Conclusions

Lancet

Kidney Int

Am J Hypertens

Lancet

Lancet

Lancet

J Clin Epidemiol

Lancet

The SPRINT study: outcome may be driven by difference in diuretic treatment demasking heart failure and study design may support systolic blood pressure target below 140 mmHg rather than below 120 mmHg

Blood Press

The SPRINT Trial: Cons

A randomized trial of intensive versus standard blood-pressure control

N Engl J Med

Effects of intensive blood-pressure control in type 2 diabetes mellitus

N Engl J Med

Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial

JAMA

Intensive blood-pressure control in hypertensive chronic kidney disease

N Engl J Med

Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial

JAMA

Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial

Nat Clin Pract Nephrol

Effects of medical therapies on retinopathy progression in type 2 diabetes

N Engl J Med

The BBB Study: the effect of intensified antihypertensive treatment on the level of blood pressure, side-effects, morbidity and mortality in “well-treated” hypertensive patients. Behandla Blodtryck Battre

Blood Press

Cardiovascular outcomes in the first trial of antihypertensive therapy guided by self-measured home blood pressure

Hypertens Res

Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS)

Hypertens Res

Clinical research study
Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials