Hi Neal - well said and very much agree - none of this research (including SPRINT) shows that the magnitude of the benefit of treating HTN substantially outweighs the potential harms, costs and inconvenience enough to justify black and white recommendations
as to who to treat and to what threshold.
Unfortunately, as we showed recently with the latest American and European diabetes guidelines
http://www.ncbi.nlm.nih.gov/pubmed/26294778, writers of these guidelines basically
refuse to provide information in a way that would allow clinicians to discuss the risk, benefits and harms in a balanced and thoughtful way. The simple message is still high blood pressure and high glucose are bad and if one has them they should be treated
- even if they are only "pre-numbers"
What an interesting world it would be if guideline writers had to have as their mandate the distribution of guidelines that distill the evidence into a way that allows clinicians to simply inform patients of the risks, benefits and harms. This
seems like such a simple thing yet I believe I will retire (or die) well before this ever happens.
James
I agree Rod (as you’d expect).
The NICE hypertension guideline found 8 RCTs of more vs less intensive BP control all of low to moderate quality on the GRADE criteria (and I think they were generous with the moderate).
The NICE guideline development group concluded in 2011 that “the evidence specifically examining optimal treatment targets for hypertension is inadequate and consequently the optimal
treatment target could not be clearly defined with certainty.” They still made a recommendation of course, which is incorporated into the QOF. Don’t start me off re pay for performance again http://blogs.bmj.com/bmj/2015/08/12/neal-maskrey-what-will-replace-qof/
At least people with the same characteristics as those recruited to SPRINT now have a new option of a 120mmHg systolic target (as Harlan Krumholz blogged). Its a small absolute benefit
of bad things happening (I make the annual NNT 183 for the primary end point) and they’ll need to set that against an annual NNH of 163 for serious
adverse events possibly or definitely attributed to the intervention and an annual NNH of 116 for a >30% reduction in eGFR if they don’t have CKD at baseline. People will make different choices.
IMHO the task is to interpret these results and support a shared decision, not extrapolate that approach to the majority of people with hypertension to which this approach does not
apply (especially those people with T2 diabetes), and to deploy clinical expertise and dissuade people who do meet the SPRINT higher CV risk characteristics and want to go for 120mmHg but on the basis of their individual characteristics are unlikely to do
well with a further 20mmHg drop in blood pressure.
Best wishes to all
Neal
Neal Maskrey
Visiting Professor of Evidence-informed decision making, Keele University
Co-Lead ADVOCATE Field Studies, University of Amsterdam
Mobile: 07976276919
Dear Juan and colleagues. The key difference between SPRINT and most other BP-lowering trials in primary prevention (i.e those in the Cochrane Review) is that the investigators appropriately chose high risk patients. The observational study evidence
on the relationship between BP and CVD and trials in diabetic and secondary prevention suggest that lowering SBP down to 120-130mmHg is appropriate. However if a person is at very low risk, the benefit will be very small. That's why the Cochrane review found
nothing - the power was very low. SPRINT adds to the evidence demonstrating that it's time to take the main focus off BP thresholds and targets and focus on treating people at high risk.
Regards Rod Jackson
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sent from my phone
-many of you probably have follow the SPRINT publications, at least these three:
-un saludo juan gérvas