In reference to “How Low To Go: The Continuing Controversy on BP Targets” published in the March 2017 issue:

I was one of the lead investigators for ACCORD and SPRINT and am the principal investigator overseeing the VA clinical center networks for those trials. I was also the VA champion for the 2014 VA/DoD hypertension guidelines and on the 2014 JNC 8 hypertension guideline panel—in both of those guidelines we also recommended the same systolic BP goal (<150 mm Hg) for hypertensive patients age ≥60 years as the 2017 ACP/AAFP hypertension guidelines did.

However, I believe the landscape should have changed because of the results of the large SPRINT randomized controlled trial, published in November 2015, which showed significant reduction in CVD events (-25%) and mortality (-27%) in high-risk hypertensive patients age ≥50 years treated to a systolic BP goal <120 mm Hg vs <140 mm Hg.

The ACP/AAFP guidelines seem to discount SPRINT because it is just one trial. However, the landmark VA Cooperative Hypertension Study of the 1960s proved the treatment of (diastolic) hypertension and SHEP in 1991 proved treating isolated systolic hypertension (systolic BP ≥160 mm Hg) reduced CVD events, and both changed subsequent guidelines as single trials.

I believe it would now be unethical to perform another trial like SPRINT in a similar population just to support a meta-analysis. However, I do believe the meta-analysis accompanying the ACP/AAFP guidelines supports treating to lower levels despite including many trials with much higher BP goals.

The 2016 Canadian and Australian hypertension guidelines have already recommended lower goals in certain high-risk groups and a guideline sponsored by ACC, AHA, ASH, and many other organizations is due out later this year. Hopefully, VA/DoD guidelines will also be updated subsequently as well. I would encourage clinicians to now consider treating patients at high risk for CVD (at least those who are similar to SPRINT participants) to systolic BP levels well below 150 mm Hg.

William C. Cushman, MD
Veterans Affairs Medical Center, Memphis, TN [email protected]