4 Hypertension Highlights / Journal of the American Society of Hypertension 11(1) (2017) 35
truly prove the concept that these strategies lower blood pres-
sure without the confounding issue of medication adherence.
In routine clinical practice, the importance of careful
screening for pseudoresistance cannot be stressed enough.
The discrepancy between reported adherence and measured
adherence suggests that we need better technology for easily
and accurately assessing adherence both in research and clin-
ical practice.
Michael J. Bloch, MD, FACP, FASH, FNLA, FSVM
Department of Medicine
University of Nevada School of Medicine
Reno, NV, USA
Department of Vascular Care
Renown Institute of Heart and Vascular Health
Reno, NV, USA
http://dx.doi.org/10.1016/j.jash.2016.11.006
References
1. Azizi M, Sapoval M, Gosse P, Monge M, Bobrie G,
Delsart P, et al. Optimum and stepped care standardized
antihypertensive treatment with or without renal dener-
vation for resistant hypertension (DENERHTN): a
multicenter, open-label, randomized controlled trial.
Lancet 2015;385:195765.
2. Azizi M, Pereira H, Hamdidouche I, Gosse P, Monge M,
Bobrie G, et al. Adherence to antihypertensive treatment
and the blood pressure lowering effects of renal denerva-
tion in the renal denervation for hypertension (DE-
NERHTN) trial. Circulation 2016;134(12):84757.
DOES SPRINT SUPPORT A CHANGE IN BLOOD
PRESSURE TARGETS? THE IMPORTANCE OF
TWO IMPLICIT ASSUMPTIONS AND BLOOD
PRESSURE MEASUREMENT METHODS
The Systolic Blood Pressure Intervention Trial (SPRINT)
is a landmark study, which was designed to determine if a
systolic blood pressure (SBP, mm Hg) <120 was better
than a SBP target of <140 for reducing a composite cardio-
vascular outcome.1 In fact, the primary outcome of myocar-
dial infarction, other acute coronary syndrome, stroke, heart
failure, and cardiovascular death was reduced (hazard ratio,
0.75; 95% confidence interval: 0.640.89; P < .0001). The
authors stated that SPRINT now provides evidence of
benefits for an even lower SBP target than that currently
recommended in most hypertensive patients. An editorial
written by key editors of the NEJM stated that This clin-
ical trial (SPRINT) will change practice.2
These disruptive conclusions rest upon two implied
assumptions. First, standard treatment with a SBP goal
<140 mm Hg in SPRINT led to SBP values comparable
to those of treated hypertensives in the United States. If
standard treatment led to a higher SBP than usual care,
then the impact of SPRINT intensive treatment could be
overestimated. Since the authors expanded SPRINT find-
ings to most hypertensive patients, it seems appropriate to
compare SBP values with SPRINT standard treatment to
all treated hypertensives in the United States. In NHANES
20092012, mean SBP for all treated adults with hyperten-
sion was 130.1, which is 6.1 mm Hg lower than SPRINT
standard treatment mean at 1 year and 4.5 mm Hg lower
than the trial mean.3 The higher mean SBP with SPRINT
standard treatment than with usual treatment in the United
States is most likely explained by the study protocol, which
required reducing antihypertensive medications if SBP was
<130 on any single visit or <135 on consecutive visits in
standard treatment participants. This protocol is not typical
of usual care. In fact, 87% of patients in SPRINT standard
treatment had antihypertensive medications reduced at least
once.4
The second key implied assumption is that intensive treat-
ment led to a lower SBP than that in adults with treated hyper-
tension who attained a SBP <140 mm Hg. If this is not true,
then the rationale for lowering target SBP to <130 or <120
is weakened and the rationale for controlling a greater percent-
age of treated hypertensives to SPB <140 strengthened. Adults
in the United States with treated hypertension and SBP <140
attained a mean SBP of 120.9 in 20092012,3 which is slightly
lower than the 1-year mean of 121.4 and the all trial mean of
121.5 with SPRINT intensive treatment.
The blood pressure (BP) measurement method in
SPRINT was rigorous but not representative of usual care
or most clinical trials in hypertension. SPRINT measured
BP after subjects rested 5 minutes alone in the examination
room, that is, unattended automated office BP (AOBP). As
noted,3 a previous ambulatory BP monitoring (ABPM)
study showed that unattended AOBP after 5-minute rest
produces SBP values w7 mm Hg lower than daytime
ABPM values, which is comparable to findings in the
SPRINT APBM substudy among intensively treated pa-
tients. If we assume that NHANES-attended BP measure-
ments approximate daytime ABPM values, then the
superiority of SBP in all treated hypertensive adults to stan-
dard treatment and all treated adults with controlled hyper-
tension to intensive treatment is even greatera difference
further magnified if NHANES-attended BP values are
higher than daytime ABPM.
SPRINT remains a landmark study which provides ev-
idence for a SBP goal <140, particularly in older adults
where the evidence for SBP <140 versus <150 was
debated.1 If future guidelines lower the SBP goal based
on SPRINT, then it would seem prudent to recommend
 Hypertension Highlights / Journal of the American Society of Hypertension 11(1) (2017) 35 5

that BP should be measured using SPRINT methods, References

that is, unattended AOBP after 5-minute rest, a method-
ology which may be challenging in usual primary care 1. The SPRINT Research Group. A randomized trial of
settings. intensive versus standard blood-pressure control. N
Engl J Med 2015;373:210316.
Brent M. Egan, MD 2. Drazen JM, Morrissey S, Campion EW, Jarcho JA. Editorial:
Department of Medicine a SPRINT to the finish. N Engl J Med 2016;373:21745.
University of South Carolina School of 3. Egan BM, Li J, Wagner CS. SPRINT and target systolic
MedicineGreenville, Care Coordination Institute blood pressure in future hypertension guidelines. Hyper-
Greenville, SC, USA tension 2016;68:31823.
began@ccihealth.org 4. Wright Jr JT, Whelton PK, Reboussin DM. Correspon-
dence: a randomized trial of intensive versus standard
http://dx.doi.org/10.1016/j.jash.2016.12.001 blood-pressure control. N Engl J Med 2016;374:2294.