Abstract

Hypertension is a leading risk factor for premature death and disability. It can be controlled through lifestyle changes and use of antihypertensive medication. This review looks at intensive blood pressure reduction trials in non-diabetic, diabetic, and mixed patient populations. The primary hypothesis for the Systolic Blood Pressure Intervention Trial (SPRINT) is that treating to a systolic blood pressure target of < 120 mmHg (the intensive intervention) compared to a systolic blood pressure target of < 140 mmHg (the standard intervention) will reduce the primary composite outcome. Lowering systolic blood pressure more rigorously to 120 mmHg instead of the standard 140 mmHg can give substantial benefit according to the SPRINT. SPRINT showed efficacy in older patients above age 75 years. The ACCORD trials did not show efficacy for reducing primary outcomes with intensive therapy in a diabetic population with central obesity not being a significant factor. ACCORD found that intensive blood pressure reduction therapy benefited patients with atrial fibrillation, p-wave indices and left ventricular hypertrophy. Cerebrovascular protection was afforded diabetic subjects, but there was no additive advantage to tighter blood pressure control on microvascular outcomes. The 2014 Eighth Joint National Committee panel re-evaluated their own recommendation of relaxing initiation therapy for those over age 60 from systolic blood pressure of 140 mmHg to 150 mmHg with a post hoc analysis of INVEST (INternational VErapamil SR Trandolapril STudy) data that showed a more relaxed initiation standard would cause more harm to patients. The delicate balance of reducing cardiovascular morbidity and mortality with intensive blood pressure control while avoiding adverse events is an area of concern for clinicians. Many factors must be considered and the studies that address the intense versus standard therapy conundrum are discussed herein.

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