Saturday, April 9, 2016

Walk, don't run to implement SPRINT findings in primary care

This the second part of a two-part commentary that I wrote in collaboration with Dr. Stephen Martin and Dr. John Mandrola. The first part is posted here.


In real-world practice, where measured blood pressure often skews high, the harm of overtreating patients whose clinic pressure is high due to artifact (but normal at home) is greater. And because adherence rates are typically lower in primary care practice, the incremental benefit of more intense blood pressure treatment will likely be smaller, or could even be outweighed by the harms.

We don’t know how effective treating to lower blood pressure targets will be when scaled into real-world practice. SPRINT’s limitations should give us pause before rushing to revise the Eighth Joint National Committee (JNC 8) evidence-based guidelines for hypertension treatment, as some have already called for. In practice, the high-risk inclusion criteria for SPRINT are likely to be broadened to those at lower risk. Quality metrics that rely on cut point outcomes, such as blood pressure (e.g., 140/90 mm Hg or 120/80 mm Hg), are especially vulnerable to “one-size-fits-all” efforts, which may cause harm when scaled to heterogeneous primary care populations.

We are also concerned that the momentum for more intense blood pressure control has not elicited calls for greater emphasis on lifestyle interventions or shared decision making. The word “lifestyle” appeared in the SPRINT publication exactly one time, which is remarkable for a study of hypertension treatment. Patients will be exposed to less harm with more intense blood pressure control if it is achieved with diet, exercise and sleep hygiene; with medication, over one-third of participants in both SPRINT trial arms experienced a serious adverse event. And in 2016, there is a broad consensus that high-quality care means aligning care with patients’ goals. Some patients may be willing to accept the risk of more intensive treatment. Others, when told of the absolute benefits and risks, may not want the extra burden of therapy. Rather than set absolute blood pressure targets, revised hypertension guidelines should recommend shared decision-making.

Although high blood pressure is the most commonly diagnosed medical condition in the U.S., it is not itself a disease, only a risk factor for poor cardiovascular outcomes. SPRINT suggests that selected people may be able to slightly reduce their risks for these outcomes with more intense treatment of blood pressure. The immense challenge will be translating SPRINT’s findings to primary care without breaking the number one rule of medicine—first, do no harm.