When the SPRINT trial ended almost a year early and its results were released, it created quite a stir in the world of hypertension. Findings indicated that perhaps the ACCORD trial and JNC 8 guidelines had set systolic blood pressure targets too high. This lower vs higher systolic target conundrum has led to debate and speculation; and those with high blood pressure are left wondering if their current blood pressure is low enough. Yikes. Cue the rollercoaster of recommendations.
Get your ticket
The medical community had been coasting along since 2004 when the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure released the JNC 7 guidelines. Things got a little rousing in 2008 when the ACCORD trial was published with data showing that there was no significant difference in outcomes between those who had their blood pressure intensively managed and the standard treatment group. Fast forward to the next big downhill: two years ago the JNC 8 guidelines were published. These new guidelines called for a relaxation in systolic blood pressure targets to 150 for those 60 and over and to 140 for people aged 30-59. Previously these thresholds were set at 140 for those 60+ and 130 for those aged 30-59. Which bring us to the results of the SPRINT trial.
I feel like I’ve ridden this before
Because you have. The SPRINT trial reinvigorates the discussion surrounding high blood pressure which consistently takes a back seat to obesity, cholesterol, glucose. Its been good to rev things up in the world of blood pressure because it remains the most important risk factor for stroke and heart failure. The ACCORD trial coupled with the JNC 8 guidelines presented major challenges for clinicians working to follow the new 150 and 140/90 guidelines as the recs can leave as many as one-third to one-half of all Americans with high blood pressure “uncontrolled.” Many in the medical community wondered how these two studies came to such different conclusions. The answers were varied, but one of the most common thoughts was that the ACCORD trial may have been underpowered and may have shown results similar to the SPRINT trial had the study population been larger. An editorial in the New England Journal of Medicine added that, “It is possible, but unlikely, that there is an inherent difference in cardio vascular disease benefits of intensive systolic blood pressure lowering in diabetic and non-diabetic adults.” This leaves clinicians in wondering what the safest target is for systolic blood pressure.
I just want off this thing
Not so fast. High blood pressure can be difficult to treat and often takes more than one medication (not to mention the potential for several dose adjustments) to control. This can be frustrating to clinicians and patients. Part of our jobs as diabetes educators is to understand the latest research and its implications for those we work with. While the findings of the SPRINT trail are compelling they do not negate ACCORD or the JNC 8 guidelines. In addition, the SPRINT trial did not include people with diabetes, and this is where the water gets muddy. Many doctors have said publicly that would have no problem applying the 120 systolic target to their patients with diabetes but all concur that it would be ideal to conduct another large study and include those with T2DM. Bottom line: SPRINT may prove to be the landmark trial that turns the tide back to tighter systolic recommendations, but until then work with the providers in your clinics, understand their perspective and come up with a solution that best serves your population.