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Hypertension: Scandal? Or Just Normality?
Almost 2 years before, in the first 2014 issue of this Journal, I stated that it is abnormal that almost all the important world hypertension (HT) guidelines just issued at that moment considered that the universal therapeutic target for blood pressure (BP) lowering in ”non-old” patient population should be 140/90 mm Hg (1). The 2013, ESC/ESH Guidelines admitted only for diabetes a slightly lower target – 140/85 mm hg, while both American guidelines (JNC 8 and ASH/ISH Guidelines, issued in 2014) gave a target of 140/90 mm Hg even for diabetics. This was so in the conditions in which just a few years before the target in Europe and America was for HT diabetics 130/80 mm Hg and even lower when kidney were involved. In my paper I considered that in HT people not considered old the target should be lower, because they do not generally have the risk of hypotension and their benefit on long term should be greater with low levels of blood pressure (1).
In November this year an important argument for our point of view was published in New England Journal of Medicine (2). The SPRINT trial clearly showed that in a population of less than 75 years of age a therapeutic blood pressure target of 120 mm Hg gave a significant better outcome at 3.26 years than the standard today target of 140 mm hg for the systolic blood pressure. There are many details which endorse this conclusion. The number of patients was consistent – 9361 patients. The cardiovascular risk of patients was high, but patients with diabetes, previous stroke or kidney involvement were excluded. The planned duration of the study was 5 years, but the results were so clearly better for the 120 mm Hg target group that the steering committee ended the study only after 3.26 years, considering is was un-ethical to continue for the group of 140 mm Hg target BP. Last, but not least, the powerful NHLBI (National Heart Lung and Blood Institute), which retired in 2014 from the group ellaborating the Joint National Committee 8 Guidelines, considering there are too many unanswered questions regarding that guidelines, was now one of the sponsors of the study.
So, contrary to all the actual main Hypertension Guidelines, the best systolic blood pressure target in a consistent HT population was found to be 120 mm Hg and not the guideline target of 140 mmHg. The SPRINT Study demonstrated that death from any cause, death from cardiovascular causes or the composite primary otcome were significantly lower when treating to a target of 120 mm Hg. In the mean time, the serious adverse effects were simmilar in the two groups.
Many positive comments appeared almost instantaneously . Starting with the first paper on Perspective in Medicine in the same issue of New Engl J Med (3) and continuing with two out of three Editorials of the same issue of the Journal. Attention! It is hard to find (if really can be found) another subject with four papers in the same issue of the prestigious Number 1 Journal of Clinical Medicine in the world! The main American bood pressure journal made a comment in 4 days (!) after the electronic publising of the SPRINT Study (4). It is funny to see that the main European journal of hypertension, by the voice of Alberto Zanchetti, the Editor in Chief of the journal and one of the main contributors to the 2013 ESC/ESH Guidelines on HT, did not say any comment on the SPRINT study, even in the first 2016 issue of their journal. Zanchetti only makes some comments on Japanese and Korean studies (5)
It happens rarely that a study conducted under the most serious auspices seriously contradicts all the acting guidelines in the field, ellaborated also under serious auspices. However, as we considered some time ago, those guidelines contradict the common clinical good sense. Their guilt could be that they did not comment in any manner that the conclusions of the available Evidence Based Medicine of that moment were not totally logical and some correction has to be expected. By the SPRINT study, this correction was clearly done.
We have to be very attentive to the evolution of the quarell and the possible implication on the Hypertension Guidelines.