JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 67, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2015.12.006
EDITORIAL COMMENT
SPRINT To Whom Do the Results Apply?* Alan H. Gradman, MD
F
or the past several years, many physicians have
findings from 17,085 participants in the National
been puzzled by the rapidly changing recom-
Health and Nutrition Examination Survey to the U.S.
mendations for the treatment of hypertension.
population to estimate the number of individuals
The belief that “lower is better” has been challenged,
whose treatment would be altered if the SPRINT
and emphasis has been placed upon the risks accompa-
results were implemented. Of the 16.8 million people
nying excessive blood pressure (BP) reduction. In most
who meet the SPRINT inclusion criteria, antihyper-
recent guideline revisions, higher thresholds for initi-
tensive therapy would be initiated or intensified in
ating treatment and less aggressive BP targets have
6.6 million with SBP 130 to 139 mm Hg. Additionally,
been adopted for patients with diabetes or chronic kid-
the authors project that 25.5 million U.S. persons age
ney disease (CKD) and the elderly (1). These decisions
>50 years with SBP >120 mm Hg are at increased CV
were prompted by meta-analyses of clinical trials,
risk. They speculate that if a BP target 130 mm Hg. Placebo-controlled tri-
untreated individuals not classified as hypertensive
als on which the treatment of hypertension in the
by conventional criteria. Unlike patients cared for by
elderly are based enrolled only subjects with baseline
most cardiologists, a relatively small proportion
SBP $160 mm Hg (9). Although risk reduction in
(16.7%) had established CV disease. The differing re-
SPRINT for subjects $75 years of age was substantial
sults of SPRINT and ACCORD, 2 studies of similar
(33%), the number of untreated patients must have
design conducted by the same research group evalu-
been small, as 92% of participants were receiving
ating the same BP targets, are likely due to the
antihypertensive drugs at baseline. Although the
composition of the 2 patient populations. Although
SPRINT results are consistent with the possibility of
the SPRINT results are likely valid for the study as a
significant benefit, they must be considered pre-
whole, its therapeutic implications cannot be auto-
liminary and insufficient to mandate universal drug
matically applied to every patient who met the in-
therapy. Treatment is definitely an acceptable option
clusion criteria. A patient may belong to a subgroup
given the safety and tolerability of available drugs.
(e.g., patients with CAD) that made a very small
Additional clinical trials specifically designed to
statistical contribution to the overall results. It is
evaluate the effects of BP reduction in older subjects
possible that a study conducted exclusively in that
with untreated SBP 130 to 160 mm Hg constitute an
subgroup would yield very different results.
important public health priority.
It is important to recognize that the choice of SBP
Because of the small number of untreated patients
target as 120 mm Hg and
the basis of prior evidence. I favor the addition of 1
increased CV risk.
(only) additional agent from a different pharmacologic class without further pursuit of SBP
VOL. 67, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2015.12.006
EDITORIAL COMMENT
SPRINT To Whom Do the Results Apply?* Alan H. Gradman, MD
F
or the past several years, many physicians have
findings from 17,085 participants in the National
been puzzled by the rapidly changing recom-
Health and Nutrition Examination Survey to the U.S.
mendations for the treatment of hypertension.
population to estimate the number of individuals
The belief that “lower is better” has been challenged,
whose treatment would be altered if the SPRINT
and emphasis has been placed upon the risks accompa-
results were implemented. Of the 16.8 million people
nying excessive blood pressure (BP) reduction. In most
who meet the SPRINT inclusion criteria, antihyper-
recent guideline revisions, higher thresholds for initi-
tensive therapy would be initiated or intensified in
ating treatment and less aggressive BP targets have
6.6 million with SBP 130 to 139 mm Hg. Additionally,
been adopted for patients with diabetes or chronic kid-
the authors project that 25.5 million U.S. persons age
ney disease (CKD) and the elderly (1). These decisions
>50 years with SBP >120 mm Hg are at increased CV
were prompted by meta-analyses of clinical trials,
risk. They speculate that if a BP target 130 mm Hg. Placebo-controlled tri-
untreated individuals not classified as hypertensive
als on which the treatment of hypertension in the
by conventional criteria. Unlike patients cared for by
elderly are based enrolled only subjects with baseline
most cardiologists, a relatively small proportion
SBP $160 mm Hg (9). Although risk reduction in
(16.7%) had established CV disease. The differing re-
SPRINT for subjects $75 years of age was substantial
sults of SPRINT and ACCORD, 2 studies of similar
(33%), the number of untreated patients must have
design conducted by the same research group evalu-
been small, as 92% of participants were receiving
ating the same BP targets, are likely due to the
antihypertensive drugs at baseline. Although the
composition of the 2 patient populations. Although
SPRINT results are consistent with the possibility of
the SPRINT results are likely valid for the study as a
significant benefit, they must be considered pre-
whole, its therapeutic implications cannot be auto-
liminary and insufficient to mandate universal drug
matically applied to every patient who met the in-
therapy. Treatment is definitely an acceptable option
clusion criteria. A patient may belong to a subgroup
given the safety and tolerability of available drugs.
(e.g., patients with CAD) that made a very small
Additional clinical trials specifically designed to
statistical contribution to the overall results. It is
evaluate the effects of BP reduction in older subjects
possible that a study conducted exclusively in that
with untreated SBP 130 to 160 mm Hg constitute an
subgroup would yield very different results.
important public health priority.
It is important to recognize that the choice of SBP
Because of the small number of untreated patients
target as 120 mm Hg and
the basis of prior evidence. I favor the addition of 1
increased CV risk.
(only) additional agent from a different pharmacologic class without further pursuit of SBP
