Applying the Systolic Blood Pressure Intervention Trial Results to Older Adults

Mark A. Supiano, MD; Jeff D. Williamson, MD, MHS

Disclosures

J Am Geriatr Soc. 2017;65(1):16-21. 

In This Article

Abstract and Introduction

Abstract

The Systolic Blood Pressure Intervention Trial (SPRINT; ClinicalTrials.gov, NCT01206062) was stopped early because of significantly lower risk of cardiovascular disease in participants randomized to a systolic blood pressure target of 120 mmHg (intensive) than in those randomized to 140 mmHg (standard). The cardiovascular outcome benefit was also identified in subjects aged 75 and older assigned to the intensive arm—34% lower than in the standard arm—in addition to 33% lower all-cause mortality at 3.14 years of follow-up. These beneficial outcomes held in older participants characterized as frail or with impaired gait speed. This article addresses several questions that need to be considered in applying the SPRINT results to the clinical care of older adults: Why are the SPRINT results discordant from those of epidemiological studies? Do the SPRINT findings generalize to the frail, older adults that I care for? Were there more adverse events in the intensive treatment group? What about cognitive and kidney outcomes? What are future considerations, and how low should we go?

Introduction

The complexities inherent in caring for older adults necessitate that careful attention be paid to applying results from randomized controlled clinical trials (RCTs) to this heterogeneous population. Results from the Systolic Blood Pressure Intervention Trial (SPRINT; ClinicalTrials.gov, NCT01206062), which randomized participants to usual (<140 mmHg) or intensive (<120 mmHg) systolic blood pressure (SBP) targets suggest that a lower SBP target may be recommended for individuals with high cardiovascular disease (CVD) risk, including those aged 75 and older.[1,2] SPRINT included 2,636 community-living subjects aged 75 and older (28% of the entire study population) who were assessed for frailty status and usual gait speed. In the group of older adults randomized to the intensive arm, there was a 34% lower risk of developing the primary composite CVD outcome and a 33% lower risk of all-cause mortality at 3.14 years of follow-up when the trial ended early because of its highly positive outcome (numbers needed to treat of 27 and 41, respectively, over the relatively short trial duration). These results did not differ for the frailest subgroup or for those with impaired gait speed.[2] Although the incidence of some adverse events was higher in the intensive group, there was no difference in serious adverse events including injurious falls and no group difference in self-assessed health-related quality of life regardless of frailty status.[3] These findings challenge some long-held assumptions of healthcare providers about older adults—including the authors of the current article—about the safety and efficacy of intensive blood pressure (BP) lowering in this population. Many appropriate questions regarding the risk–benefit balance and generalizability of the SPRINT results to the clinical care of older adults have been raised. Acknowledging and setting aside these assumptions is critical if practitioners are to apply these findings to the people with hypertension that they treat. This commentary from two geriatricians involved in the SPRINT trial will address several of the important questions that geriatric healthcare providers will need to consider with respect to applying this intensive target to their patients.

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