Optimal Hypertension Goals:JNC8 vs. SPRINT

Samantha Maples, PharmDPGY1 Pharmacy Resident

Via Christi Hospitals Wichita, Inc.

Disclosures

Samantha Maples, PharmD Nothing to disclose

Objectives

Identify the risks of uncontrolled hypertension (HTN)

Recognize the need for appropriate HTN treatment

Apply JNC8 recommendations and The SPRINT Trial results appropriately in clinical practice

Hypertension Epidemiology

Approximately 75 million adults in the United States have hypertension (HTN)

In 2013, more than 360,000 deaths were attributed to HTN as the primary contributing cause

Merai R, et al. MMWR Morb Mortal Wkly Rep. 2016;65(45):1261-1264.Mozzafarian D, et al. Circulation. 2015;e29-322.

Hypertension Complications

First heart attack: 7/10 people have HTN

First stroke: 8/10

Chronic heart failure: 7/10

Mozzafarian D, et al. Circulation. 2015;e29-322.

Hypertension Complications

Also contributes to Renal failure

Aneurysms

Retinopathy

Peripheral artery disease

Schmieder RE. Dtsh Arztebl Int. 2010;107(49):866-73.

Eighth Joint National Committee

Population Age < 60 years Age > 60 years

General < 140/90 < 150/90

CKD < 140/90

DM

CKD: Chronic kidney diseaseDM: Diabetes

James PA, et al. JAMA. 2014;311(5):507-20.

The SPRINT Trial

Published November 2015

Compared systolic blood pressure goals Intensive: < 120 mmHg Standard: < 140 mmHg

9,361 participants 102 clinical sites in the United States, including Puerto Rico

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Inclusion Criteria

Greater than 50 years old

Baseline systolic blood pressure 130 – 180 mmHg

An increased risk of cardiovascular events

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Exclusion Criteria

Diabetes

Previous stroke

Heart failure

Renal failure

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Primary Outcome

Composite outcome Myocardial infarction

Acute coronary syndrome not resulting in myocardial infarction

Stroke

Acute decompensated heart failure

Death from cardiovascular disease

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Secondary Outcomes

Individual components of primary composite outcome

Death from any cause

Composite of the primary outcome or death of any cause

Renal outcomes

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Interim Analysis

Average achieved systolic blood pressure Intensive: 121.5 mmHg Standard: 134.6 mmHg

Prematurely ended after interim analysis showed significant benefit in intensive treatment group Median follow-up: 3.26 years

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Outcomes

Outcome Hazard Ratio Number Needed to Treat

Primary Outcome 0.75 62

Deaths (any cause) 0.73 86

Deaths (CVD) 0.57 168

CVD: Cardiovascular Disease

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Adverse Effects

Adverse Event Hazard Ratio Number Needed to Harm

Hypotension 2.52 71

Syncope 2.15 93

Electrolyte abnormalities 1.58 97

Acute Kidney Injury 3.14 55

*Defined as an adverse effect that is fatal or life threatening, resulting in significant or persistent disability, requiring or prolonging hospitalization, or required ER visit possibly or definitely related to study intervention; located within supplemental appendix

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Significant Subgroups

> 75 years old

Male

Non-black

No previous CVD or CKD

Baseline SBP < 132 mmHg

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Important Notes

56% of patients required > 3 antihypertensive agents

Did not include participants with diabetes or stroke, under 50 years old, or in nursing homes

Intensive treatment group did not achieve average systolic blood pressure of < 120 mmHg as intended

The SPRINT Research Group. N Engl J Med. 2015; 373:2103-2116.

Example Recommendations

Population Age < 50 years Age 50 - 74 years Age > 75 years

General < 120/80 < 130

< 140High Risk < 130

< 130 CVD or CKD

< 140 DM

CVD: Cardiovascular diseaseCKD: Chronic kidney diseaseDM: Diabetes

Chobanian, AV. JAMA. 2017;317(6):579-580.

Optimal Blood Pressure Goal

Risk Potential

Systolic Blood Pressure

Clinical Practice Considerations

Guidelines are not blanket recommendations

Trials must be taken into consideration, particularly if published after guideline updates

Patient-specific factors always dictate treatment goals

Optimal Hypertension Goals:JNC8 vs. SPRINT

Samantha Maples, PharmDPGY1 Pharmacy Resident

Via Christi Hospitals Wichita, Inc.