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15 Mar | Categories : Cardiovascular Start a topic Comment Mail Share Download


15 Mar | Categories : Cardiovascular Start a topic Comment Mail Share Download


15 Mar | Categories : Cardiovascular Start a topic Comment Mail Share Download


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18 Feb | Categories : Internal Medicine Start a topic Comment Mail Share Download
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29 Jan | Categories : Cardiovascular Start a topic Comment Mail Share Download


29 Jan | Categories : Cardiovascular Start a topic Comment Mail Share Download
Wang S, Khera R, Das SR, Vigen R, Wang T, Luo X, et al. Usefulness of a Simple Algorithm to Identify Hypertensive Patients Who Benefit from Intensive Blood Pressure Lowering.  Am J Cardiol. 2018 Jul 15;122(2):248-254

 

Key Points:

To assess whether cardiovascular disease (CVD) risk stratification can identify patients with a more favorable risk-benefit profile for intensive BP lowering, patient-level data were used from 2 trials that tested intensive versus standard BP lowering, namely Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes (ACCORD).

Study protocol:  Out of all SPRINT patients, a subset of patients at the extremes of major adverse cardiovascular event rates were studied to develop a decision tree using recursive partitioning modeling. Its predictive effects in the remaining ‘intermediate’ SPRINT subset (n = 8,357) and externally in ACCORD (n = 2,258) were validated. Recursive partitioning produced 3-variables consisting of age ≥74 years, urinary albumin-creatinine ratio (UACR) ≥34, and history of clinical CVD which classified 48.6% of SPRINT and 55.3% of ACCORD patients as “high-risk.” Patients who met 1 or more of 3 criteria, age ≥74 years, UACR ≥34, or history of clinical CVD, were predicted to be at high risk for major cardiovascular events, and the remainder were classified as low risk.

Results:  Intensive BP lowering was associated with lower rates of major adverse cardiovascular event in the high-risk population in both SPRINT cross-validation data (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.52 to 0.85) and ACCORD (HR 0.67, 95% CI 0.50 to 0.90), but not in the remaining low-risk patients (SPRINT: HR 0.83, 95% CI 0.56 to 1.25; ACCORD: HR 1.09, 95% CI 0.64 to 1.83).  Additionally, intensive BP lowering did not confer an excess risk of serious adverse events in the high-risk group.

Conclusion: A 3-step decision tree composed of age ≥74 years, UACR ≥34, and history of prior CVD differentiated patients at high from low risk of major adverse cardiovascular event (MACE) who had a significant risk reduction with intensive versus standard BP treatments, without an increase in serious adverse events.

Comments and clinical relevance:

Both Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes (ACCORD) tested intensive versus standard BP lowering in two different sets of patients, namely non- diabetic high risk patients and diabetic patients respectively.

Whereas the Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated improvement in the rates of major adverse cardiovascular events (MACE) in nondiabetic hypertensive patients treated with intensive BP lowering to a systolic BP goal of <120 mm Hg, as opposed to a standard systolic BP goal of <140 mm Hg, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial did not show a significant difference in MACE with intensive versus standard BP lowering.  Besides, the risk of adverse events, such as hypotension, syncope, electrolyte abnormalities, and acute kidney injury, seen with intensive treatment in SPRINT puts utility of intensive treatment in question.

Hence it becomes important to ask, which hypertensive patients will really benefit from aggressive BP reduction.

This trial, with some short comings attempts to answer that question.

The main short coming of the trial is that it is a retrospective analysis of 2 trials that included only high risk people.

It would be interesting to use this algorithm in treating high risk hypertensive patients. Of course, a prospective clinical study that shows that it actually improves cardiovascular outcomes would be a shot in its arm.

 

Suggested Readings: 

1.  Lonn EM et al. Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target? An Antagonist View From the HOPE-3 Trial (Heart Outcomes Evaluation-3). Circulation. 2016 Nov 1;134(18):1311-1313.

2.  Oparil S et al.  Should Patients with Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target? A Protagonist View From the SPRINT trial (Systolic Blood Pressure Intervention Trial). Circulation. 2016 Nov 1;134(18):1308-1310.

3.   Wright JT Jr et al.  A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26;373(22):2103-16.

4.   Margolis KL et al.  Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care. 2014 Jun;37(6):1721-8

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26 Jan | Categories : Dermatology Start a topic Comment Mail Share Download
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