Optimal Systolic Blood Pressure Target after SPRINT Insights from a Network Meta-Analysis of Randomized Trials

Sripal Bangalore

, MD, MHA

Email the author MD, MHA Sripal Bangalore, 

Bora Toklu

, MD, 

Eugenia Gianos

, MD, 

Arthur Schwartzbard

, MD, 

Howard Weintraub

, MD, 

Gbenga Ogedegbe

, MD, 

Franz H. Messerli

, MD

Published Online: January 18, 2017

DOI: http://dx.doi.org/10.1016/j.amjmed.2017.01.004

Publication stage: In Press Accepted Manuscript

Article Infoclick to expand contents 

Background

The optimal blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg albeit with an increase in serious adverse effects related to low BP.

Methods

PUBMED, EMBASE, and CENTRAL were searched for randomized trials comparing treating to different BP targets. Trial arms were grouped into five systolic BP target categories: 1) <160 mm Hg; 2) <150 mm Hg; 3) <140 mm Hg; 4) <130 mm Hg and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure and safety outcomes of serious adverse effects were evaluated using a network meta-analysis.

Results

Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (RR=0.54; 95% CI 0.29-1.00) and myocardial infarction (RR=0.68; 95% CI 0.47-1.00) with systolic BP <120 mm Hg (vs. <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97% and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg and <160 mm respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2 respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs. <150 mm Hg (RR=1.83; 95% CI 1.05-3.20) or vs. <140 mm Hg (RR=2.12; 95% CI 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2 respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety.

Conclusions

In patients with hypertension, a systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.

Keywords: 

blood pressure, myocardial infarction, systolic, stroke, target

Disclosures: None of the authors received any compensation for their work on this manuscript.