Reconciling Systolic Blood Pressure Intervention Trial With Eighth Joint National Commission

A Nuanced View of Optimal Hypertension Control in the Chronic Kidney Disease Population

Ekamol Tantisattamo; Anum Hamiduzzaman; Peter Sohn; Rebecca Ahdoot; Ramy M. Hanna

Disclosures

Curr Opin Nephrol Hypertens. 2022;31(1):57-62. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: Universally lowering blood pressure (BP) may adversely affect some populations especially in the older population. Recent landmark trials revealed cardiovascular benefits of tight controlling systolic BP (SBP) more than several recent BP targets. Implementing the evidence from the studies and guidelines in some populations is reviewed.

Recent Findings: Eighth Joint National Commission (JNC-8) on hypertension issued conservative guidelines that provided an evolutionary change to BPcontrol in the elderly. However, intensive BP control with SBP < 120 mmHg in Systolic Blood Pressure Intervention Trial (SPRINT) focuses on the improvement of cardiovascular and cerebrovascular outcomes. Although increasingly guidelines are trending toward the SPRINT results, it is noteworthy that not all populations show a favorable outcome with intensive BP control given hypotensive risks to memory, kidney function, orthostasis, and morbidity risks.

Summary: Some populations may benefit from implementing the more intensive SBP target, whereas others such as elderly hypertensive patients may benefit from a more liberal SBP target. In the spirit of 'Primum non Nocere', we call for and suggest that a marriage of both SPRINT and JNC-8 recommendations be undertaken to champion the most cardiovascular protections for the greatest number of patients possible whereas preventing complications in vulnerable populations such as the elderly. Among the chronic kidney disease (CKD) population, SBP < 120 mmHg may not necessarily lead to favorable CKD outcomes.

Introduction

Hypertension control was not always recognized as a critical part of clinical medicine. A case in point is that when President Franklin Delano Roosevelt had a cerebrovascular accident (CVA) in the closing years of World War II, it was dubbed as lightning from a clear blue sky. This was despite his known systolic blood pressure (SBP) of >200 mmHg.[1] In the ensuing years, the debate of what constitutes hypertension led to the definitions of hypertension staging (stages I and II), as well as the development of the concept of prehypertension.[2] This concept was likely brought on by the explosion of hypertension diagnoses related to metabolic syndrome and the western high salt diet that is increasingly problematic in our society today.[3,4]

The importance of hypertension control to current medical practice, however, is obvious and cannot be overstated. Hypertension contributed to the death of nearly 270,000 people per year in 2018–2020.[5] In financial terms, hypertension costs the US medical system 48.6 billion dollars according to CDC data.[6]

As such consensus on the importance of blood pressure (BP) control targets is important, but given the fragmented (nonholistic) nature of US specialty care, some difficulties have arisen. Although true that in general control of BP is a positive development the degree of control desired is not universally agreed upon.[7] The Eighth Joint National Commission (JNC-8) guidelines and the Systolic Blood Pressure Intervention Trial (SPRINT) results have both spurred guidelines pushing the hypertension world toward polarization.[8,9]

Interventionalists in cardiology and neurology have both argued that maximal BP reduction is desirable to reduce cardiovascular and cerebrovascular events.[10] Nephrologists and geriatricians have in general cautioned about various theoretical and practically observed side effects related to more stringent hypertension control. These include the effect of more strict hypertensive control[11] and the phenomenon of reduced glomerular filtration rate (GFR) observed in SPRINT data.[9] Further, other studies have pointed out that strict control of BP may result in either increased mortality in chronic kidney disease (CKD) (if hypotension occurs),[12] or in no additional benefit to CKD progression except patients with proteinuria.[13–15] Other concerns brought up in SPRINT data include the increased risk of falls[16] and cognitive complaints,[9] though other studies seem that cognitive side effects are not uniformly observed.[10]

It has become apparent that the polarization resulting from two distinct sets of recommendations for hypertension management cry out for a reconciliation and a nuanced approach to assigning guidelines. The purpose of this article is to first review the existing guidelines and to make a case that a nuanced set of guidelines are necessary. Strict BP control (SPRINT trial recommendations) may be lifesaving in groups of patients who stand to benefit the most, following JNC-8 recommendations may be the most appropriate in subgroups of patients who have the highest risk of iatrogenic harm from an intensive pharmacotherapy strategy.

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