Determination of optimal on‐treatment diastolic blood pressure range using automated measurements in subjects with cardiovascular disease—Analysis of a SPRINT trial subpopulation

Abstract

Automated office blood pressure measurement (AOBPM) is recommended for diagnosing hypertension; however, optimal treatment targets using this method are not established. Discrepancies between automated and office measurements of blood pressure have been described, producing uncertainty regarding the use of AOBPM in clinical practice. The Systolic Blood Pressure Intervention Trial (SPRINT) results improved our understanding of target AOBPM systolic blood pressure (SBP) levels; however, diastolic blood pressure (DBP) targets remain unknown. Therefore, we sought to determine the optimal on‐treatment DBP range. The analysis was performed on the participants of the SPRINT trial who had hypertension and prior cardiovascular disease. We analyzed the data of 1470 participants (mean age 70.3 ± 9.3 years, 24.1% female) selected from the SPRINT trial database of National Heart, Lung and Blood Institute. The mean achieved SBP and DBP were 127.9 ± 10.7 and 68.3 ± 9.4 mm Hg, respectively. Most of the participants (57.4%) had a DBP lower than 70 mm Hg, while only 11.7% had DPB ≥80 mm Hg. Clinical composite endpoint was defined as myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure or death from cardiovascular causes. There were 159 (10.8%) clinical endpoint events. The participants with on‐treatment AOBPM DBP range of 68.6‐78.6 mm Hg showed the lowest hazard risk of a clinical composite endpoint. These results correspond to the office DBP range of 70‐80 mm Hg recommended in ESC guidelines. This is the first attempt to determine the range of optimal DBP values using population‐based AOBPM in patients with prior cardiovascular disease.

Determination of the optimal on-treatment diastolic blood pressure range using automated office measurements in patients without cardiovascular disease

“…In the first approach (10 mm Hg-wide optimal DBP range), in accordance with the current ESC guidelines, the optimal on-treatment DBP range should be 10 mm Hg wide. Such approach was successfully applied previously in the group of SPRINT participants with CVD [10].…”

“…The European Society of Cardiology recommended the target DBP range of 70-79 mm Hg for all patients; however, more studies are warranted to evaluate this issue [6]. Using the SPRINT data, we previously reported that in the subpopulation with CVD, the optimal DBP using AOBPM ranged between 68.6 and 78.6 mm Hg [10]. Both elevated and extremely low on-treatment DBP values were associated with unfavourable outcomes.…”

Optimal diastolic blood pressure range in intensive systolic targets: Resolving the controversy between observational and intention‐to‐treat analyses

“…The outcome of this analysis was similar to the primary composite cardiovascular outcome of main SPRINT analysis. By applying hazard ratio plots with cubic spline regression, the analysis showed a U‐shaped relationship between achieved diastolic BP and the risk for the composite cardiovascular outcome . Participants with achieved diastolic BP ranging from 68.6 to 78.6 mm Hg appeared to carry the lowest risk for the composite cardiovascular outcome.…”

“…In this issue of the Journal of Clinical Hypertension , Sobieraj et al report a non‐prespecified, post hoc analysis of 1470 SPRINT participants with prior cardiovascular disease aiming to explore the association of achieved diastolic BP with clinical outcomes. The predictor in this analysis was defined as the mean on‐treatment (achieved) diastolic BP from the follow‐up visit at 6 months till the trial completion.…”

“…When the study population was stratified into subgroups according to the level of achieved diastolic BP, 33.8% of participants were within the “optimal” diastolic range, whereas 51.5% and 14.9% of participants had an achieved diastolic BP lower and higher than the optimal range, respectively. Notably, those with a lower than “optimal” achieved diastolic BP were older in age, had more common history of chronic kidney disease (CKD), and had higher pulse pressure (PP) levels at baseline …”