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Zhan R, Zhang J, Chen X, Liu T, He Y, Zhang S, Liao X, Zhuang X, Tian T, Feng L. Targeting the Efficacy of Intensive Blood Pressure Treatment in Hypertensive Patients - An Exploratory Analysis of SPRINT. Circ J 2023; 87:1212-1218. [PMID: 37100596 DOI: 10.1253/circj.cj-23-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND Hypertensive patients show highly heterogeneous treatment effects (HTEs) and cardiovascular prognosis, and not all benefit from intensive blood pressure treatment.Methods and Results: We used the causal forest model to identify potential HTEs of patients in the Systolic Blood Pressure Intervention Trial (SPRINT). Cox regression was performed to assess hazard ratios (HRs) for cardiovascular disease (CVD) outcomes and to compare the effects of intensive treatment among groups. The model revealed 3 representative covariates and patients were partitioned into 4 subgroups: Group 1 (baseline body mass index [BMI] ≤28.32 kg/m2and estimated glomerular filtration rate [eGFR] ≤69.53 mL/min/1.73 m2); Group 2 (baseline BMI ≤28.32 kg/m2and eGFR >69.53 mL/min/1.73 m2); Group 3 (baseline BMI >28.32 kg/m2and 10-year CVD risk ≤15.8%); Group 4 (baseline BMI >28.32 kg/m2and 10-year CVD risk >15.8%). Intensive treatment was shown to be beneficial only in Group 2 (HR 0.54, 95% confidence interval [CI] 0.35-0.82; P=0.004) and Group 4 (HR 0.69, 95% CI 0.52-0.91; P=0.009). CONCLUSIONS Intensive treatment was effective for patients with high BMI and 10-year CVD risk, or low BMI and normal eGFR, but not for those with low BMI and eGFR, or high BMI and low 10-year CVD risk. Our study could facilitate the categorization of hypertensive patients, ensuring individualized therapy.
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Affiliation(s)
- Rongjian Zhan
- Cardiology Department, The First Affiliated Hospital of Sun Yat-Sen University
- Zhongshan School of Medicine, Sun Yat-sen University
| | - Jing Zhang
- Department of Cardiology, Zhongshan People's Hospital
| | - Xuanyu Chen
- School of Mathematics, Sun Yat-sen University
| | - Tong Liu
- Department of Cardiology, Zhongshan People's Hospital
| | - Yangsheng He
- Department of Cardiology, Zhongshan People's Hospital
| | - Shaozhao Zhang
- Cardiology Department, The First Affiliated Hospital of Sun Yat-Sen University
- NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University
| | - Xinxue Liao
- Cardiology Department, The First Affiliated Hospital of Sun Yat-Sen University
- NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University
| | - Xiaodong Zhuang
- Cardiology Department, The First Affiliated Hospital of Sun Yat-Sen University
- NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University
| | - Ting Tian
- School of Mathematics, Sun Yat-sen University
| | - Li Feng
- Department of Cardiology, Zhongshan People's Hospital
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Wu Y, Bai J, Zhang M, Shao F, Yi H, You D, Zhao Y. Heterogeneity of Treatment Effects for Intensive Blood Pressure Therapy by Individual Components of FRS: An Unsupervised Data-Driven Subgroup Analysis in SPRINT and ACCORD. Front Cardiovasc Med 2022; 9:778756. [PMID: 35187120 PMCID: PMC8850629 DOI: 10.3389/fcvm.2022.778756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/04/2022] [Indexed: 11/21/2022] Open
Abstract
Background Few studies have answered the guiding significance of individual components of the Framingham risk score (FRS) to the risk of cardiovascular disease (CVD) after antihypertensive treatment. This study on the systolic blood pressure intervention trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes blood pressure trial (ACCORD-BP) aimed to reveal previously undetected association patterns between individual components of the FRS and heterogeneity of treatment effects (HTEs) of intensive blood pressure control. Methods A self-organizing map (SOM) methodology was applied to identify CVD-risk-specific subgroups in the SPRINT (n = 8,773), and the trained SOM was utilized directly in 4,495 patients from the ACCORD. The primary endpoints were myocardial infarction (MI), non-myocardial infarction acute coronary syndrome (non-MI ACS), stroke, heart failure (HF), death from CVD causes, and a primary composite cardiovascular outcome. Cox proportional hazards models were then used to explore the potential heterogeneous response to intensive SBP control. Results We identified four SOM-based subgroups with distinct individual components of FRS profiles and the CVD risk. For individuals with type 2 diabetes mellitus (T2DM) in the ACCORD or without diabetes in the SPRINT, subgroup I characterized by male with the lowest concentrations for total cholesterol (TC) and high-density lipoprotein (HDL) cholesterol measures, experienced the highest risk for major CVD. Conversely, subgroup III characterized by a female with the highest values for these measures represented as the lowest CVD risk. Furthermore, subgroup II, with the highest systolic blood pressure (SBP) and no antihypertensive agent use at baseline, had a significantly greater frequency of non-MI ACS under intensive BP control, the number needed to harm (NNH) was 84.24 to cause 1 non-MI ACS [absolute risk reduction (ARR) = −1.19%; 95% CI: −2.08, −0.29%] in the SPRINT [hazard ratio (HR) = 3.62; 95% CI: 1.33, 9.81; P = 0.012], and the NNH of was 43.19 to cause 1 non-MI ACS (ARR = −2.32%; 95% CI: −4.63, 0.00%) in the ACCORD (HR = 1.81; 95% CI: 1.01–3.25; P = 0.046). Finally, subgroup IV characterized by mostly younger patients with antihypertensive medication use and smoking history represented the lowest risk for stroke, HF, and relatively low risk for death from CVD causes and primary composite CVD outcome in SPRINT, however, except stroke, a low risk for others were not observed in ACCORD. Conclusion Similar findings in patients with hypertensive with T2DM or without diabetes by multivariate subgrouping suggested that the individual components of the FRS could enrich or improve CVD risk assessment. Further research was required to clarify the potential mechanism.
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Affiliation(s)
- Yaqian Wu
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
| | - Jianling Bai
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
- Key Laboratory of Medical Big Data Research and Application, Nanjing Medical University, Nanjing, China
| | - Mingzhi Zhang
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
| | - Fang Shao
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
| | - Honggang Yi
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
| | - Dongfang You
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
- Dongfang You
| | - Yang Zhao
- Department of Biostatistics, Nanjing Medical University, Nanjing, China
- Key Laboratory of Medical Big Data Research and Application, Nanjing Medical University, Nanjing, China
- Jiangsu Provincial Key Laboratory of Biomarkers of Cancer Prevention and Control, Nanjing Medical University, Nanjing, China
- Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, China
- Key Laboratory of Modern Toxicology, Nanjing Medical University, Nanjing, China
- *Correspondence: Yang Zhao
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Cheng Y, Li J, Ren X, Wang D, Yang Y, Miao Y, Sheng CS, Tian J. Visit-to-visit office blood pressure variability combined with Framingham risk score to predict all-cause mortality: A post hoc analysis of the systolic blood pressure intervention trial. J Clin Hypertens (Greenwich) 2021; 23:1516-1525. [PMID: 34216524 PMCID: PMC8678842 DOI: 10.1111/jch.14314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022]
Abstract
We aim to determine if visit‐to‐visit blood pressure variability (BPV) adds prognostic value for all‐cause mortality independently of the Framingham risk score (FRS) in the systolic blood pressure intervention trial (SPRINT). We defined BPV as variability independent of the mean (VIM) and the difference of maximum minus minimum (MMD) of the systolic blood pressure (SBP). Multivariable Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI). Based on FRS stratification, there were 1035, 2911, and 4050 participants in the low‐, intermediate‐, and high‐risk groups, respectively. During the trial, 230 deaths occurred since the 12th month with an average follow‐up of 2.5 years. In continuous analysis, 1‐SD increase of SBP VIM and MMD were significantly associated with all‐cause mortality (HR 1.18, 95% CI 1.05–1.32, p = .005; and HR 1.21, 95% CI 1.09–1.35, p < .001, respectively). In category analysis, the highest quintile of BPV compared with the lowest quintile had significantly higher risk of all‐cause mortality. Cross‐tabulation analysis showed that the 3rd tertile of SBP VIM in the high‐risk group had the highest HR of all‐cause mortality in total population (HR 4.99; 95% CI 1.57–15.90; p = .007), as well as in intensive‐therapy group (HR 7.48; 95% CI 1.01–55.45; p = .05) analyzed separately. Cross‐tabulation analysis of SBP MMD had the same pattern as VIM showed above. In conclusion, visit‐to‐visit BPV was an independent predictor of all‐cause mortality, when accounting for conventional risk factors or FRS. BPV combined with FRS conferred an increased risk for all‐cause mortality in the SPRINT trial.
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Affiliation(s)
- Yi Cheng
- Department of Cardiovascular Medicine, Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Key Lab of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Li
- Clinical Research Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xinping Ren
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Wang
- Department of Cardiovascular Medicine, Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Key Lab of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yulin Yang
- State Key Laboratory of Medical Genomics, Clinical Trial Center, Department of Endocrinology and Metabolism, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ya Miao
- State Key Laboratory of Medical Genomics, Clinical Trial Center, Department of Endocrinology and Metabolism, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chang-Sheng Sheng
- Department of Cardiovascular Medicine, Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Key Lab of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jingyan Tian
- State Key Laboratory of Medical Genomics, Clinical Trial Center, Department of Endocrinology and Metabolism, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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The Effects of Intensive Blood Pressure Control on Cardiovascular Outcomes Based on 10-Year ASCVD Risk Score: An Analysis of a Clinical Trial. Cardiol Res Pract 2021; 2021:6635345. [PMID: 34055403 PMCID: PMC8133861 DOI: 10.1155/2021/6635345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
There is still controversy about whether clinicians should include cardiovascular disease (CVD) risk stratification into the consideration for treatment of hypertension. This was a post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). A total of 9361 nondiabetic patients without a history of stroke were randomly assigned to the intensive-treatment group (with an SBP target of <120 mm Hg) and the standard-treatment group (with an SBP target of <140 mm Hg). The patients were categorized into four groups based on the Atherosclerotic Cardiovascular Disease (ASCVD) risk score. The groups contained participants with ASCVD < 7.5%, 7.5% ≤ ASCVD <10%, 10% ≤ ASCVD < 15%, and ASCVD ≥ 15%. The incidence of the primary outcome, secondary outcome, and serious adverse events was compared between the two groups. The primary outcome was a composite of nonfatal myocardial infarction (MI), acute coronary syndrome (ACS) not resulting in MI, stroke, acute decompensated heart failure (HF), or death from cardiovascular causes. The secondary outcomes consisted of the individual components of the primary outcome and all-cause death. Intensive blood pressure (BP) control significantly reduced the incidence of primary outcome event in patients with 10% ≤ ASCVD < 15% (hazard ratio (HR) 0.593; 95% confidence interval (CI) 0.361-0.975; P = 0.039) and ASCVD ≥ 15% (HR 0.778; CI 0.644-0.940; P = 0.009). Intensive BP control was also beneficial for the primary prevention of cardiovascular events in patients with an ASCVD risk of 7.5-10% (HR 0.187; 95% CI 0.040-0.862; P = 0.032). However, intensive treatment was associated with higher incidence of hypotension and acute renal failure in participants with ASCVD ≥ 15%. In patients without diabetes mellitus and prior stroke who had a 10-year risk of cardiovascular events above 10% based on the ASCVD risk score, intensive BP control played an important role in the reduction of major cardiovascular events. Additionally, intensive treatment would be beneficial for primary prevention in patients with ASCVD ≥ 7.5% without previous history of any cardiovascular disorders. Trial registration: ClinicalTrials.gov number; the trial is registered with NCT01206062.
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Leontsinis I, Mantzouranis M, Tsioufis P, Andrikou I, Tsioufis C. Recent advances in managing primary hypertension. Fac Rev 2020; 9:4. [PMID: 33659936 PMCID: PMC7894269 DOI: 10.12703/b/9-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.
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Affiliation(s)
- Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Manos Mantzouranis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Panagiotis Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Ioannis Andrikou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
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Camafort M, Redón J, Pyun WB, Coca A. Intensive blood pressure lowering: a practical review. Clin Hypertens 2020; 26:21. [PMID: 33292735 PMCID: PMC7603713 DOI: 10.1186/s40885-020-00153-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022] Open
Abstract
According to the last Hypertension guideline recommendations, it may be concluded that intensive BP lowering is only advisable in a subgroup of patients where there is a clear net benefit of targeting to lower BP goals. However, taking into account the relevance of correct BP measurement, estimates of the benefits versus the harm should be based on reliable office BP measurements and home BP measurements. There is still debate about which BP goals are optimal in reducing morbidity and mortality in uncomplicated hypertensives and in those with associated comorbidities. In recent years, trials and meta-analyses have assessed intensive BP lowering, with some success. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. This article reviews the evidence on and controversies about intensive BP lowering in general and in specific clinical situations, and the importance of obtaining reliable BP readings in patients with hypertension and comorbidities.
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Affiliation(s)
- Miguel Camafort
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain. .,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain. .,Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.
| | - Josep Redón
- Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.,Hypertension Clinic. Hospital Clinico, University of Valencia, Valencia, Spain
| | - Wook Bum Pyun
- Department of Cardiology, Ewha Womans University. Seoul Hospital, Seoul, South Korea
| | - Antonio Coca
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain
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J-shaped relationship between cardiovascular risk and efficacy of intensive blood pressure reduction: A post-hoc analysis of the SPRINT trial. PLoS One 2020; 15:e0240102. [PMID: 33002071 PMCID: PMC7529282 DOI: 10.1371/journal.pone.0240102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/19/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In the 2017 ACC/AHA hypertension guidelines, a 10-year risk of more than 10% is considered for initiation of intensive blood pressure reduction. The current study aimed to determine which cut off limit of cardiovascular risk for starting intensive blood pressure reduction is beneficial. DESIGN A Secondary Analysis of Systolic Blood Pressure Intervention Trial (SPRINT). METHODS Data from the SPRINT Trial was obtained from the NHLBI Data Repository Center. In the SPRINT, non-diabetic participants with SBP of ≥ 130 mmHg were randomly assigned to intensive and standard treatment arms with SBP targets of < 120 and < 140 mmHg, respectively. This study analyzed data from non-diabetic participants less than 75 years of age without cardiovascular or chronic kidney disease. The primary composite outcome was myocardial infarction, and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Cox regression models were used to examine the risk of the occurrence of the SPRINT primary composite outcome. To identify the relationship between BP values and the log hazards, natural cubic spline functions were performed. RESULTS In the analysis, 4292 patients were enrolled. The results demonstrated a clear J-shaped relationship between the effect of intensive blood pressure control and the risk of CVD events and 10-year Framingham cardiovascular risk levels at a cut-off limit of approximately <7%. CONCLUSIONS This post-hoc secondary analyses of the SPRINT trial showed that a cut off value of more than 7% may be useful in selecting patients suitable for initiation of blood pressure reduction.
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Brouwer TF, Collard D, van den Born BJH. Blood pressure lowering treatment and the Framingham score: Do not fear risk. J Clin Hypertens (Greenwich) 2019; 21:1821-1822. [PMID: 31670866 PMCID: PMC6973292 DOI: 10.1111/jch.13716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tom F Brouwer
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Didier Collard
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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