Are The New Lower Blood Pressure Targets Right For You?

In 2015 a landmark NIH-sponsored trial looking at outcomes when hypertensive patients (aged >50 years) were randomized to treatment to a higher versus a lower blood pressure goal called the SPRINT trial was completed. 

The data from this trial were so compelling the scientists tasked with monitoring them halted the trial and the NIH issued a press release

“the intervention in this trial, which carefully adjusts the amount or type of blood pressure medication to achieve a target systolic pressure of 120 millimeters of mercury (mm Hg), reduced rates of cardiovascular events, such as heart attack and heart failure, as well as stroke, by almost a third and the risk of death by almost a quarter, as compared to the target systolic pressure of 140 mm Hg”

Upon reading this the skeptical cardiologist stayed true to his moniker and wrote:

I am eagerly awaiting the publication of the SPRINT data which may alter BP treatment dramatically. Until then I’m sticking to the guidelines published two years ago (and which I wrote about here) which aimed for SBP <140 mm Hg for patients less than 60 years and <150 mm Hg for those older than 60.

However, when the SPRINT data were published in late 2015, confirming these improved outcomes, I changed my tune:

This study provides a very powerful argument for shooting for a BP of 120 in many of my patients. And the skeptical cardiologist (who splits BP pills ) will be aiming for a lower BP in himself.

Since then I have been offering most of my patients this more aggressive BP goal.

The SPRINT Trial: Many More Hypertensive Taking More Drugs

The SPRINT trial found that cardiovascular events like stroke and heart attack and death from these cardiovascular causes was lower by 25% in those patients treated intensively.  Overall death was lower by 27%.

Average systolic blood pressure was 121 mm HG in the intensive therapy group and 134 mm Hg in the standard therapy group.

In 2017, based on the SPRINT findings the ACC/AHA guidelines changed the definition of hypertension from 140/90 mm Hg or higher to 130/80 or higher for all age groups. Under the new definition, the number of US adults who have hypertension expanded to 46% of the general population, up from 32% under the prior definition. This meant that 103.3 million US adults now had hypertension, up from 72.2 million.

The final report of SPRINT was published in 2021 and showed that benefits of the intensive BP control occurred in all groups

No differences in response were found in young versus old, with or without kidney disease, irrespective of starting BP, gender, race or prior CV disease.

Getting on Board With SPRINT BP Goals

In general I have found in that most of my hypertensive patients are on board with shooting for the SPRINT BP goal. I base treatment decisions on a 2 week record of home AM and PM blood pressure obtained at rest in a standardized fashion (see here for complete summary of home BP recommendations and here for a discussion of why home BP is superior to office BP.)

The more stringent goal generally requires significant lifestyle changes (weight loss, exercise, stress-reduction) and/or more medication than the looser goal.

Personally, I elected to add a third anti-hypertensive agent to get my average BP below 130/80.  It’s worked for me with minimal side effects but I carefully monitor my BP.

If I notice any symptoms (light-headed, fatigued) suggesting hypotension associated with systolic BP <120 mm Hg I tweak my medical regimen to allow a higher BP.

Like all of my patients I would prefer to be on fewer medications, not more but when it comes to enlightenment about the effects of hypertension, it is now clear that lower is better for most of us in our sixties (and, see below, seventies and eighties) down to at least 130/80.

More Benefits of More Stringent BP Goals

Much has been learned in the last few years from publication of important subsidies of the main SPRINT trial:

-in the 2,636 non-institutionalised SPRINT participants who were aged ≥75 years at baseline, the benefits were similar to the entire group, resulting in prevention of primary outcome events and all-cause mortality for one in every 28 and 41 participants in the intensive treatment arm, respectively (see here).

-The SPRINT MIND trial evaluated cognitive outcomes from SPRINT and was published in 2019. No reduction in “probable dementia”, the primary endpoint. was found. However, there was a significant reduction in mild cognitive impairment which is a strong risk factor for the development of dementia.

A post-hoc analysis of SPRINT MIND found that higher BP variability was associated with a higher risk of developing dementia in both the intensive control arm and the standard control arm. Like all post-hoc analyses these findings are strictly hypothesis-generating.

-Sadly, a study published in JAMA in last 2022 looked at how SPRINT patients were doing 4.5 years after the trial ended and found there was no longer evidence of benefit for cardiovascular mortality or all-cause mortality. Most likely, this was due to a relaxation of the intensive control when patients went back to their own health care providers.

In a subgroup of participants, in whom blood pressure could be obtained from medical records, the estimated mean outpatient SBP among participants randomized to intensive treatment increased from 133 mm Hg at 5 years to 140 mm Hg at 10 years following randomization.

Ask your health care provider if SPRINT BP goals are right for you. Hopefully choosing the more intensive approach will help you sprint in the direction of a healthy cardiac and cerebrovascular future.

Sprintologously Yours,

-ACP

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3 thoughts on “Are The New Lower Blood Pressure Targets Right For You?”

  1. I posted this 3 days ago on ACP’s blog: It is just as relevant in this post:
    H Robert Silverstein
    April 6, 2023 at 12:58 pm

    ACP does a wonderful job of presenting including diagrams, documentation, and his own thoughts. Several years ago I discussed my Journal of Clinical Hypertension 2008;10: 885 published article on the benefits of using the Omron wrist blood pressure cuff. ACP took me to task as did the authors of the original article that my letter to the editor was in response to. Seems that ACP has come around to my position now with regarding to the benefit of wrist blood pressure cuffs. Verification is essential in any case. For about $40.00 one can obtain such a cuff on the Internet. As I said in my published article, I disagree with the concept of sitting quietly for several minutes before measuring your blood pressure: that has nothing to do with the realities of normal life. I say take your BP anytime of the day. The goal is 110-115/60-70 or even a bit lower, and if on treatment, definitely not above 125/80. Bear in mind that at the 95% level, hypertension is curable. In no sense of hostility, but as an invitation to the freedom of health, the health care provider must find out what the patient is doing to make their high blood pressure occur. Mosty it is diet, salt, and animal protein. Personally, while I believe almost anything except dairy products is acceptable once in a while, being 90+% ideally organic unprocessed whole foods vegan is the right direction to go for cure of HBP as well as resulting in the simultaneous prevention of multiple diseases. Recall I just said 90%, I did not say 100%: 90% = animal protein, such as wild caught fish or cage free organic eggs or a bison hamburger or steak at about a total of 5 times in 2 weeks if one is lean and trim which is difficult to obtain. Replace salt by using substitutes or the juice of half a lemon plus half a lime at the table to give that perfect salt flavor. All of this is an invitation to consider and medication, etc. therapy is available if one is not completely successful in the above goals. There is much more to say.

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  2. My GP told me of a patient he’d lost due to over-prescribing hypertension meds. The fellow lost consciousness while in quite a confined space doing plumbing repairs. Ordinarily a faint would bring one to the horizontal, allowing blood to one’s head. Not so for this poor fellow. Needless to say, my GP has been circumspect since.
    So the question is, should one’s dosing be limited by one’s lowest pressure over several readings or by one’s (dangerously) highest? Seems to me that averages have little meaning here. Weight lifters can test at more than 300 systolic during a lift and go back to “normal” after. Is that momentary peak doing him harm? Is one’s 150/100 while suffering from white coat syndrome in the GP’s office for half an hour doing one harm when one returns to 115/70 afterwards?

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  3. Thanks. The results indicated in the forest plot are indeed compelling. Fortunately, my cardiologist subscribes to the <120/80 guideline. Is there any recommendation for diastolic blood pressure level other than “<80”? My 30-day Omron average is 113/61 and would 61 ever be considered a cause for concern?

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