Elsevier

The American Journal of Medicine

Volume 131, Issue 12, December 2018, Pages 1463-1472.e7
The American Journal of Medicine

Clinical Research Study
Optimal Systolic Blood Pressure Target in Resistant and Non-Resistant Hypertension: A Pooled Analysis of Patient-Level Data from SPRINT and ACCORD

https://doi.org/10.1016/j.amjmed.2018.08.005Get rights and content

Abstract

Background

Prior studies suggest benefits of blood pressure lowering on cardiovascular risk may be attenuated in patients with resistant hypertension compared with the general hypertensive population, but prospective data are lacking.

Methods

We assessed intensive (<120 mm Hg) versus standard (<140 mm Hg) systolic blood pressure targets on adverse outcome risk according to baseline resistant hypertension status, using Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Systolic Blood Pressure Intervention Trial (SPRINT) patient-level data. Patients were categorized as having baseline apparent resistant hypertension (blood pressure ≥130/80 mm Hg while using 3 antihypertensive drugs or use of ≥4 drugs regardless of blood pressure) or non-resistant hypertension (all others). Cox regression was used to assess effects of treatment assignment, resistant hypertension status, their interaction, and other covariates, on first occurrence of 2 outcomes: myocardial infarction, stroke, cardiovascular death ± heart failure, and the same outcomes plus all-cause death, individually.

Results

Among 14,094 patients, 2710 (19.2%) had baseline apparent resistant hypertension. In adjusted models, an intensive target reduced risk of both outcomes (myocardial infarction/stroke/cardiovascular death: hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.71-0.93; myocardial infarction/stroke/heart failure/cardiovascular death: HR 0.78; 95% CI, 0.69-0.88) as well as stroke (HR 0.72; 95% CI, 0.55-0.94) and heart failure (HR 0.73; 95% CI, 0.59-0.91). An intensive target also appeared to reduce myocardial infarction, cardiovascular death, and all-cause death risk. Benefits were observed irrespective of baseline resistant hypertension status.

Conclusions

Our findings provide the first evidence to support guidance to treat resistant hypertension to the same blood pressure goal as non-resistant hypertension.

Section snippets

Methods

The design and principal findings of SPRINT16, 18 and the ACCORD blood pressure trial (ACCORD-BP)17, 19 are published. Briefly, SPRINT was a prospective, randomized, open-label, blinded-endpoint (PROBE) trial enrolling 9361 hypertensive individuals with elevated cardiovascular risk, but without diabetes or stroke. Participants were assigned to a target systolic blood pressure <120 mm Hg (“intensive”) or <140 mm Hg (“standard”). They were aged ≥50 years, with hypertension and ≥1 additional

Results

Excluding one ACCORD-BP patient with missing baseline data, 14,093 participants were pooled in the analysis: 9,361 (66.4%) from SPRINT and 4,733 (33.6%) from ACCORD-BP (Supplemental Figure S1, available online). Of these, 2,710 (19.2%) met apparent resistant hypertension criteria and 11,383 (80.8%) had non-resistant hypertension at baseline, with approximately equal proportions assigned to the intensive or standard arms in each cohort (Table 1). Baseline characteristics were well-balanced

Discussion

While we understand the importance of controlling blood pressure among patients with resistant hypertension, concrete information on blood pressure targets in this high-risk population remains sparse. To a large degree, our insight is hindered by hurdles related to extrapolation of data from studies of the general hypertensive population.13, 20,21 For the first time, we demonstrate that patients with apparent resistant hypertension benefit similarly from an intensive systolic blood pressure

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    • Funding: This manuscript was prepared using data obtained from the National Heart, Lung, and Blood Institute. SMS is supported by the National Heart, Lung and Blood Institute (K01 HL138172). CJP is supported by the National Heart, Lung, and Blood Institute (UM1 HL087366, R01 HL132448, R01 HL033610), the National Center for Advancing Translational sciences (UL1 TR000064), and the US Department of Defense (CDMRP PR161603).

    Conflict of Interest: None.

    Authorship: All authors had access to the data presented herein and contributed to interpretation of the analyses and manuscript drafting or revision.

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