Effect of Lowering Diastolic Pressure in Patients With and Without Cardiovascular Disease: Analysis of the SPRINT (Systolic Blood Pressure Intervention Trial)

Published on May 1, 2018in Hypertension7.713
· DOI :10.1161/HYPERTENSIONAHA.117.10177
Nadia A. Khan39
Estimated H-index: 39
(UBC: University of British Columbia),
Simon W. Rabkin53
Estimated H-index: 53
+ 5 AuthorsKarin H. Humphries65
Estimated H-index: 65
Sources
Abstract
Systolic and diastolic blood pressure thresholds, below which cardiovascular events increase, are widely debated. Using data from the SPRINT (Systolic Blood Pressure Intervention Trial), we evaluated the relation between systolic and diastolic pressure and cardiovascular events among 1519 participants with or 7574 without prior cardiovascular disease. Using Cox regression, we examined the composite risk of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or cardiovascular death, and follow-up systolic and diastolic pressure were analyzed as time-dependent covariates for a median of 3.1 years. Models were adjusted for age, sex, baseline systolic pressure, body mass index, 10-year Framingham risk score, and estimated glomerular filtration rate. A J-shaped relationship with diastolic pressure was observed in both treatment arms in patients with or without cardiovascular disease ( P nonlinearity≤0.002). When diastolic pressure fell P =0.29). The hazard ratios (95% CI) of diastolic pressure P value 0.006 and 1.52 (0.99–2.34), P value 0.06 in patients without and with prior cardiovascular disease, respectively. After adjusting for follow-up diastolic pressure, follow-up systolic pressure was not associated with the outcome in those without prior cardiovascular disease ( P =0.64). In those with cardiovascular disease, adjusting for diastolic pressure, follow-up systolic pressure was associated with the risk in the intensive arm (hazard ratio per 10 mm Hg decrease, 0.86; 95% CI, 0.75–0.99; P interaction=0.02). Although the observed J-shaped relationship may be because of reverse causality in the SPRINT population, we advise caution in aggressively lowering diastolic pressure.
📖 Papers frequently viewed together
12 Citations
12 Citations
1 Citations
References16
Newest
#1Mats Julius Stensrud (University of Oslo)H-Index: 12
#2Susanne Strohmaier (University of Oslo)H-Index: 12
Abstract Background and aims Reducing the diastolic blood pressure (DBP) below a certain threshold may lead to inadequate organ perfusion. This raises some concerns, because pharmacotherapy reduces both systolic and diastolic pressure. We aimed to investigate whether a pathway from intensive systolic blood pressure (SBP) treatment influences cardiovascular outcomes by inducing too low DBP. Methods We had access to data from the Systolic Blood Pressure Intervention Trial (SPRINT) including 9361 p...
10 CitationsSource
#1Monica Ahluwalia (NYU: New York University)H-Index: 4
#2Sripal BangaloreH-Index: 80
Purpose of reviewApproximately one-fourth of the adult population is diagnosed with hypertension, which has been associated with increased cardiovascular morbidity and mortality including cardiovascular death, myocardial infarction, heart failure and stroke. Early detection and treatment is key and
19 CitationsSource
#1Amir Qaseem (American College of Physicians)H-Index: 65
#2Timothy J WiltH-Index: 105
Last. Mary Ann Forciea (UPenn: University of Pennsylvania)H-Index: 16
view all 6 authors...
This jointly developed guideline from the American College of Physicians and the American Academy of Family Physicians provides recommendations about the benefits and harms of higher versus lower b...
176 CitationsSource
#1Emmanuelle Vidal-Petiot (French Institute of Health and Medical Research)H-Index: 19
#2Ian Ford (Glas.: University of Glasgow)H-Index: 150
Last. Philippe Gabriel StegH-Index: 96
view all 10 authors...
Summary Background The optimum blood pressure target in hypertension remains debated, especially in coronary artery disease, given concerns for reduced myocardial perfusion if diastolic blood pressure is too low. We aimed to study the association between achieved blood pressure and cardiovascular outcomes in patients with coronary artery disease and hypertension. Methods We analysed data from 22 672 patients with stable coronary artery disease enrolled (from Nov 26, 2009, to June 30, 2010) in th...
232 CitationsSource
#1Sverre E. Kjeldsen (University of Oslo)H-Index: 104
#2Giuseppe Mancia (University of Milano-Bicocca)H-Index: 166
The Systolic Blood Pressure Intervention Trial (SPRINT) enrolled 9300 participants age 50 years and older without diabetes or previous stroke in ∼100 expert medical centres and clinical practices throughout the USA.1 Between 2010 and 2013, the SPRINT investigators randomly allocated the study participants into a standard treatment group receiving an average of two different blood pressure (BP) medications to achieve a systolic BP (SBP) target of <140 mmHg, and an intensive treatment group receiv...
24 CitationsSource
#1Jan Filipovský (Charles University in Prague)H-Index: 26
#2Jitka Seidlerová (Charles University in Prague)H-Index: 18
Last. Otto Mayer (Charles University in Prague)H-Index: 21
view all 6 authors...
AbstractWe studied the relationships of automated blood pressure (BP), measured in the healthcare centre, with manual office BP and home BP. Stable outpatients treated for hypertension were measured automatically, seated alone in a quiet room, six times after a 5 min rest with the BpTRU device, and immediately afterwards using the auscultatory method. Home BP was measured in a subgroup during 7 days preceding the visit. The automated, office and home BP values were 131.2 ± 21.8/77.8 ± 12.1 mmHg,...
101 CitationsSource
#1Jackson T. Wright (Case Western Reserve University)H-Index: 63
#2Jeff D. Williamson (Wake Forest University)H-Index: 80
Last. Walter T. Ambrosius (Wake Forest University)H-Index: 59
view all 18 authors...
BACKGROUND The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain. METHODS We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocar...
3,183 CitationsSource
#1Simon W. Rabkin (UBC: University of British Columbia)H-Index: 53
#2Aiza WaheedH-Index: 1
Last. David R. WoodH-Index: 81
view all 4 authors...
Background:The target blood pressure (BP) in patients with hypertension and coronary artery disease (CAD) has been controversial. Whether patients with both diabetes mellitus and CAD should follow targets for either diabetes mellitus or CAD is uncertain. Focusing only on one determinant of coronary
27 CitationsSource
#1Sripal Bangalore (NYU: New York University)H-Index: 80
#2Franz H. Messerli (Mount Sinai St. Luke's and Mount Sinai Roosevelt)H-Index: 69
Last. John C. LaRosa (SUNY Downstate Medical Center)H-Index: 50
view all 7 authors...
Aim In patients with coronary artery disease (CAD), a J-curve relationship has been reported between blood pressure (BP) and future cardiovascular events. However, this is controversial. The purpose of the study was to determine the relationship between on-treatment BP and cardiovascular outcomes in patients with CAD. Methods and results We evaluated 10 001 patients with CAD and a low-density lipoprotein (LDL) cholesterol level <130 mg/dL, randomized to atorvastatin 80 vs. 10 mg, enroled in the ...
281 CitationsSource
#1Stanley S. Franklin (UCI: University of California, Irvine)H-Index: 68
#2Victor A. LopezH-Index: 10
Last. Daniel LevyH-Index: 241
view all 7 authors...
Background— The utility of single versus combined blood pressure (BP) components in predicting cardiovascular disease (CVD) events is not established. We compared systolic BP (SBP) and diastolic BP (DBP) versus pulse pressure (PP) and mean arterial pressure (MAP) combined and each of these 4 BP components alone in predicting CVD events. Methods and Results— In participants in the original (n=4760) and offspring (n=4897) Framingham Heart Study who were free of CVD events and BP-lowering therapy, ...
234 CitationsSource
Cited By25
Newest
#1Chuoxin Ma (University of Manchester)
#2Jianxin Pan (University of Manchester)H-Index: 16
Source
#1Emma E.F. Kleipool (VUMC: Vanderbilt University Medical Center)H-Index: 2
#2Eva S Rozendaal (VUMC: Vanderbilt University Medical Center)
Last. Majon Muller (VUMC: Vanderbilt University Medical Center)H-Index: 6
view all 8 authors...
OBJECTIVE assess how many patients with low ambulatory diastolic blood pressure (DBP) are not identified when relying on office DBP alone, and thus have 'masked diastolic hypotension'. DESIGN cross-sectional, retrospective cohort study. SETTING academic hospital. SUBJECTS 848 patients treated for hypertension who received ambulatory blood pressure monitoring (ABPM). METHODS cut-off value between on- and off-target systolic blood pressure (SBP): 140 mmHg. Cut-off for low office and/or ambulatory ...
1 CitationsSource
#1Claudia R.L. Cardoso (UFRJ: Federal University of Rio de Janeiro)H-Index: 28
#2Gil F. Salles (UFRJ: Federal University of Rio de Janeiro)H-Index: 33
J-curve associations with adverse outcomes have never been examined in relation to ambulatory blood pressures (BPs). We aimed to investigate the associations between low-achieved BPs and large BP changes during follow-up with major adverse cardiovascular events and mortality in a cohort of 1474 patients with resistant hypertension who performed serial ambulatory BP monitoring. Multivariable Cox regressions with cubic splines examined associations between continuous BP parameters (time-weighted m...
Source
#1Jingen Li (Beijing University of Chinese Medicine)H-Index: 1
#2Virend K. Somers (Mayo Clinic)H-Index: 117
Last. Lijing Zhang (Beijing University of Chinese Medicine)H-Index: 1
view all 10 authors...
Importance Extremely low diastolic blood pressure has been reported to be associated with increased adverse cardiovascular events (ie, the diastolic J-shape phenomenon); however, current US guidelines recommend an intensive blood pressure target of less than 130/80 mm Hg without mentioning the lower limits of diastolic blood pressure. Objectives To evaluate whether there is a diastolic J-shape phenomenon for patients with an treated systolic blood pressure of less than 130 mm Hg and to explore t...
1 CitationsSource
#1Pil Sang Song (CNU: Chungnam National University)H-Index: 11
#2Seung Hun Lee (SMC: Samsung Medical Center)H-Index: 2
view all 13 authors...
Abstract Background To determine the association between achieved blood pressure at 6-month follow-up and cardiovascular outcomes at two years in patients treated with beta-blockers and renin-angiotensin-aldosterone blockers after acute myocardial infarction (AMI). Methods We analyzed data from 5,503 patients enrolled in the national AMI registry. Patients with myocardial re-infarction (MrI), re-hospitalization for heart failure (rHHF), or stroke before 6-month follow-up were excluded. Achieved ...
Source
#1Steven G. Chrysant (University of Oklahoma Health Sciences Center)H-Index: 11
Source
Background: High blood pressure remains one of the most important risk factors for cardiovascular disease. Although there is no consensus, all the clinical practice guidelines agree on the need to reduce blood pressure levels to minimize the risks. There are many clinical trials conducted to try to find the best pharmacotherapy to achieve this goal. The aim was to compare the main international randomized clinical trials on hypertension in people older than 50 years. Methods: Literature qualitat...
1 CitationsSource
#1Steven G. Chrysant (University of Oklahoma Health Sciences Center)H-Index: 11
The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by other. It is also more common in the young subjects who are at low...
Source
#1Hillel K Sternlicht (WSU: Wayne State University)H-Index: 2
#2Jan Basile (MUSC: Medical University of South Carolina)H-Index: 34
PURPOSE OF REVIEW This article will summarize the effects of more intensive blood pressure (BP) control on cardiovascular, cognitive, and renal outcomes among elderly (age ≥75 years) individuals at high risk for cardiovascular events. Subsets of patients who may not benefit and obstacles to implementation will be addressed. The authors' insights will conclude the review. RECENT FINDINGS A burst of new research regarding the effects of lower BP targets on cardiovascular, cognitive, and renal endp...
1 CitationsSource
The problem with high sBP combined with low dBP requires attention because sBP is directly and continuously related to the most important criterion - all-cause mortality - whereas dBP becomes inversely related to it after the age of 50-60 years. The 2018 European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) guidelines for hypertension (HTN) are very helpful to recommend a lower level of safety of in-treatment dBP. To prevent tissue hypoperfusion, HTN guidelines reco...
Source