Blood pressure reduction and anti‐hypertensive treatment choice: A post‐hoc analysis of the SPRINT trial

BACKGROUND: Uncontrolled blood pressure (BP) increases the risk of major adverse cardiovascular events. In SPRINT an intensive versus standard BP lowering strategy resulted in a lower rate of cardiovascular events and death. Whether BP reduction only or also the choice of anti‐hypertensive drugs is associated with outcomes remains to be elucidated. AIMS: We aim to study the association of BP and different anti‐hypertensive drugs with several cardiovascular outcomes. METHODS: Time‐updated Cox and mixed‐effects models. The primary outcome was a composite of first myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death. RESULTS: A total of 9361 patients were included. The anti‐hypertensive agents most frequently used were ACEi/ARBs, with an almost 20% higher prescription rate in the intensive arm (80% vs. 61%), followed by thiazide‐type diuretics (65% vs. 42%), calcium‐channel blockers (57% vs. 39%), and beta‐blockers (52% vs. 26%). Mineralocorticoid receptor antagonists were rarely used (≤7% of the observations). In multivariate analysis, the use of ACEi/ARBs, especially in combination with thiazides, were independently associated with a lower primary outcome event‐rate (HR [95%CI] 0.75 [0.61–0.92], p = .006), whereas a DBP <60 mmHg was independently associated with a higher event‐rate (HR [95%CI] 1.36 [1.07–1.71], p = .011). SBP <120 mmHg was associated with lower rate of cardiovascular and all‐cause death on intensive treatment but not on the standard arm (interaction p < .05 for both). CONCLUSIONS: In SPRINT, an intensive therapy strategy achieving SBP <120 mmHg with a DBP ≥60 mmHg, and using ACEi/ARBs plus thiazides was associated with a lower event‐rate.