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Unanswered Questions in SPRINT Study: What Remains Unknown and Where Do We Go From Here?

This article discusses the unanswered questions and implications of the SPRINT study results on blood pressure management, including the generalizability of the results, the impact of various factors on the J-curve relationship, the differences between SPRINT and ACCORD studies, and the future direction for hypertension research.

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Unanswered Questions in SPRINT Study: What Remains Unknown and Where Do We Go From Here?

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  1. Embargoed Until 2 p.m. ET, Monday, Nov. 9, 2015 SPRINT What Remains Unanswered? Where Do We Go From Here?

  2. SPRINT How generalizable are the results?

  3. SPRINT

  4. SPRINT • How generalizable are the results? • How is the J Curve relationship impacted by: • Elevated Blood Pressure? • Age? • Cardiovascular and Cerebrovascular Disease? • Chronic Kidney Disease? • Diabetes Mellitus?

  5. SPRINT • Unanswered questions in need of further studies: • What is the optimal SBP goal for patients with DM? • Did ACCORD answer this?

  6. SPRINT • If the ACCORD results and interpretation are correct… • Is the difference in SPRINT and ACCORD results due to the impact of DM on vasculature?

  7. SPRINT • Diabetes impact on vasculature? • Is DM negatively impacting arteriolar autoregulation in the renal vasculature? • Is this shifting the J curve relationship in patients with DM and HTN?

  8. SPRINT

  9. SPRINT

  10. SPRINT Why different outcomes in SPRINT and ACCORD?

  11. SPRINT • Why different outcomes in SPRINT and ACCORD? • Was ACCORD underpowered? • Young population • Lower risk because of lipid arm • Excluded patients with Cr > 1.5

  12. SPRINT • Why different outcomes in SPRINT and ACCORD? • Was ACCORD underpowered? • Young population • Lower risk because of lipid arm • Excluded patients with Cr > 1.5 • Difference in diuretic use? • ACCORD often used HCTZ • SPRINT primarily used Chlorthalidone

  13. SPRINT • Why different outcomes in SPRINT and ACCORD? • Was ACCORD underpowered? • Young population • Lower risk because of lipid arm • Excluded patients with Cr > 1.5 • Difference in diuretic use? • ACCORD often used HCTZ • SPRINT primarily used Chlorthalidone • Trial Design Complex for ACCORD

  14. SPRINT • Important related questions for diabetes mellitus: • Should another trial in DM be done assuring adequate power? • What SBP goal should the new ACC/AHA guidelines recommend for diabetics? • Should this be 140, 135, 130, or 120? • Recommendation will be based on expert opinion • Adverse events in ACCORD were few

  15. SPRINT • Unanswered questions in need of further trials: • Heart failure with low ejection fraction • Heart failure with preserved ejection fraction • Drug therapy for untreated SBP 120-140? • No benefit in previous trials in patients at this risk level? • Or were there power issues with these trials as well?

  16. SPRINT • Unanswered questions in HTN unrelated to goal SBP: • Will we discover meaningful ways to prevent and treat obesity? • Will precision medicine offer opportunities to refine optimal BP management? • Goal SBP for individuals • More narrowly defined groups

  17. SPRINT • Where do we go from here? • Consider SPRINT results in new ACC/AHA Blood Pressure Management Guidelines • Goal SBP for various groups including DM and lower risk patients including < 50 • Management of SBP 120-140 • Consider Global CV Risk? • Classification of blood pressure?

  18. SPRINT • Where do we go from here? • Continue and increase efforts in hypertension research • basic science • translational science • clinical trials • population science • BP measurement research • BP components research • Test lower goals in younger patients

  19. SPRINT • Where do we go from here? • Continue and increase efforts in related research • Obesity • Precision medicine • Continue efforts to better implement what we know • lifestyle approaches • focus on early prevention • improvement of the environment

  20. SPRINT • Where do we go from here? • Pause momentarily to appreciate the progress in the field of hypertension including the positive results of SPRINT

  21. SPRINT • Acknowledgements • John Hall • Marion Wofford • Lyssa Weatherly • Bill Cushman • Paul Whelton

  22. SPRINT THANK YOU

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