On 2016 Jul 24, James Yeh commented:

Editor's Comment

Blood-Pressure Control — Polling Results

James S. Yeh, M.D., M.P.H., Edward W. Campion, M.D., John A. Jarcho, M.D., and Jonathan N. Adler, M.D.

The goal of blood-pressure control is to reduce mortality and morbidity from macrovascular and microvascular causes. The NIH-funded SPRINT study published in the November 26 issue of the Journal suggests that targeting a systolic blood-pressure goal of less than 120 mm Hg, which is lower than current guideline recommendations, is associated with reduced mortality.(1) The study showed that the rate of the primary composite outcome of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes was lower by 0.54 percentage points per year among those who were randomly assigned to a target systolic blood pressure of 120 mm Hg than among those assigned to a target systolic blood pressure of 140 mm Hg (1.65% per yr vs. 2.19% per yr). The difference in the rates was driven mostly by a lower rate of acute heart failure and death from cardiovascular causes among those with the lower systolic blood-pressure target (hazard ratio, 0.62 and 0.57, respectively).

In November, we presented the case of Ms. Weymouth, a 75-year-old woman with a blood pressure of 136/72 mm Hg. Readers were invited to vote on whether her current antihypertensive regimen should be maintained or should be modified to lower the systolic blood pressure further. This patient had a history of well-controlled hypertension, as well as peripheral vascular disease and atrial fibrillation. She was being treated with metoprolol succinate, chlorthalidone, apixaban, aspirin, and atorvastatin.(2) She was a nonsmoker who walked regularly for exercise. Laboratory studies included a total cholesterol level of 174 mg per deciliter (4.5 mmol per liter), a low-density lipoprotein cholesterol level of 87 mg per deciliter (2.2 mmol per liter), a high-density lipoprotein cholesterol level of 65 mg per deciliter (1.7 mmol per liter), a serum creatinine level of 0.9 mg per deciliter (80 μmol per liter), and an estimated glomerular filtration rate of 65 ml per minute per 1.73 meters squared of body-surface area.

A total of 1379 readers from 93 countries responded to the poll. The largest group of respondents, representing one third of the votes, was from the United States and Canada. A vast majority of the readers (81%) voted to maintain the current antihypertensive regimen. This result suggests that the findings of the SPRINT trial did not suddenly change physicians’ approach to treatment, at least for a patient such as the one described in the case vignette.

A substantial proportion of the 94 Journal readers who submitted comments emphasized caution for older patients, given concerns about side effects such as hypotension, which could cause injurious falls. Many commented on the “small benefit” seen with blood-pressure reduction. Some readers argued in favor of further reduction of systolic blood pressure, observing that this benefit is not inconsequential, given the mortality outcome over the short period of time that patients were followed. Similarly, some readers noted that physicians currently recommend treatments for other disease conditions that provide similar or less benefit. Readers who advocated further adjustment of her blood-pressure regimen generally recommended doing so judiciously, using low doses of medications first, then increasing the doses, with close monitoring for medication side effects.

There were several related recurring themes among the comments submitted. Commenters emphasized the need for individualized risk assessment and the importance of shared decision making regarding the benefit and risk of further blood-pressure reduction. A number of commenters mentioned the importance of recommending further lifestyle modification before changing medication. Readers also emphasized the need to balance the quality of life in the present versus the additional future gains in mortality outcome. Several readers also commented on the variability of blood-pressure measurements depending on the context and the time of measurement. The readers emphasized the importance of obtaining ambulatory blood-pressure measurements to help guide clinical decisions.

REFERENCES [1] SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-2116. [2] Yeh JS, Bakris GL, Taler SJ. Blood-pressure control. N Engl J Med 2015;373:2180-2182.

On 2016 Jul 24, James Yeh commented:

Editor's Comment

Blood-Pressure Control — Polling Results

James S. Yeh, M.D., M.P.H., Edward W. Campion, M.D., John A. Jarcho, M.D., and Jonathan N. Adler, M.D.

The goal of blood-pressure control is to reduce mortality and morbidity from macrovascular and microvascular causes. The NIH-funded SPRINT study published in the November 26 issue of the Journal suggests that targeting a systolic blood-pressure goal of less than 120 mm Hg, which is lower than current guideline recommendations, is associated with reduced mortality.(1) The study showed that the rate of the primary composite outcome of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes was lower by 0.54 percentage points per year among those who were randomly assigned to a target systolic blood pressure of 120 mm Hg than among those assigned to a target systolic blood pressure of 140 mm Hg (1.65% per yr vs. 2.19% per yr). The difference in the rates was driven mostly by a lower rate of acute heart failure and death from cardiovascular causes among those with the lower systolic blood-pressure target (hazard ratio, 0.62 and 0.57, respectively).

In November, we presented the case of Ms. Weymouth, a 75-year-old woman with a blood pressure of 136/72 mm Hg. Readers were invited to vote on whether her current antihypertensive regimen should be maintained or should be modified to lower the systolic blood pressure further. This patient had a history of well-controlled hypertension, as well as peripheral vascular disease and atrial fibrillation. She was being treated with metoprolol succinate, chlorthalidone, apixaban, aspirin, and atorvastatin.(2) She was a nonsmoker who walked regularly for exercise. Laboratory studies included a total cholesterol level of 174 mg per deciliter (4.5 mmol per liter), a low-density lipoprotein cholesterol level of 87 mg per deciliter (2.2 mmol per liter), a high-density lipoprotein cholesterol level of 65 mg per deciliter (1.7 mmol per liter), a serum creatinine level of 0.9 mg per deciliter (80 μmol per liter), and an estimated glomerular filtration rate of 65 ml per minute per 1.73 meters squared of body-surface area.

A total of 1379 readers from 93 countries responded to the poll. The largest group of respondents, representing one third of the votes, was from the United States and Canada. A vast majority of the readers (81%) voted to maintain the current antihypertensive regimen. This result suggests that the findings of the SPRINT trial did not suddenly change physicians’ approach to treatment, at least for a patient such as the one described in the case vignette.

A substantial proportion of the 94 Journal readers who submitted comments emphasized caution for older patients, given concerns about side effects such as hypotension, which could cause injurious falls. Many commented on the “small benefit” seen with blood-pressure reduction. Some readers argued in favor of further reduction of systolic blood pressure, observing that this benefit is not inconsequential, given the mortality outcome over the short period of time that patients were followed. Similarly, some readers noted that physicians currently recommend treatments for other disease conditions that provide similar or less benefit. Readers who advocated further adjustment of her blood-pressure regimen generally recommended doing so judiciously, using low doses of medications first, then increasing the doses, with close monitoring for medication side effects.

There were several related recurring themes among the comments submitted. Commenters emphasized the need for individualized risk assessment and the importance of shared decision making regarding the benefit and risk of further blood-pressure reduction. A number of commenters mentioned the importance of recommending further lifestyle modification before changing medication. Readers also emphasized the need to balance the quality of life in the present versus the additional future gains in mortality outcome. Several readers also commented on the variability of blood-pressure measurements depending on the context and the time of measurement. The readers emphasized the importance of obtaining ambulatory blood-pressure measurements to help guide clinical decisions.

REFERENCES [1] SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-2116. [2] Yeh JS, Bakris GL, Taler SJ. Blood-pressure control. N Engl J Med 2015;373:2180-2182.