In ancient Rome,
the gladiator games served as the
West End and Broadway shows of the
day, existing for their entertainment
value. In this case, though, instead
of “West Side Story,” you had actual
armed combatants viciously fighting
each other or animals, sometimes to
the death. A defeated gladiator’s life
was spared if he (or she, in an early
attempt at workplace equality) was
deemed to have fought well. Be glad
you’re not a gladiator!
It may seem strange to fashion a medical conference debate forum after this brutal bit of history,
but that’s what the European Society of Cardiology
(ESC) did with “The Gladiators Arena,” debuted at
this year’s (when in Rome…) conference.
However, while the gladiators of yore were often
slaves or otherwise socially marginalized individuals, the ESC gladiators comprised an impressive
group of top researchers and clinicians taking pro
and con positions in traditional debate sessions on
topical and controversial clinical questions facing
cardiologists today. Fortunately, for the gladiators
and viewers alike, the ESC arena proved more genteel and non-violent, with the fates of the combatants determined by a show of audience thumbs up
or down – and the winner being crowned with a
garland of leaves. Hail Caesar, indeed!
Will the moniker remain when the ESC’s annual
meeting moves to Barcelona in 2017, or will we see
a name change to something more Spain-centric?
The Gaudi Games or Las Ramblas Rumble? Please,
just not The Spanish Inquisition!
with coronary artery disease and hypertension,
including patients aged 65 to 79 years of age. The
statement also suggested considering a BP level of <
130/80 mm Hg as “reasonable” in selected patients,
including those with previous myocardial infarction (MI), stroke/transient ischemic attack (TIA), or
coronary artery disease (CAD) risk equivalents.3
To date, only the Canadian hypertension
guidelines, which are updated annually, have said
that the lower target of < 120 mm Hg “should be
considered” for high-risk individuals, age ≥ 50 years
with systolic BP levels ≥130 mm Hg.4
Running into Controversy
Enter the SPRINT trial, presented at AHA.15 and
published in November 2015, which showed that
more intensive treatment to < 120 mm Hg reduced
the rate of adverse clinical outcomes in patients at
high cardiovascular risk compared to the standard
< 140 mm Hg target.5 More aggressive treatment
was associated with a significant reduction in the
primary composite endpoint of myocardial infarction
(MI), other acute coronary syndromes (ACS), stroke,
heart failure (HF), or death from cardiovascular
causes. While there were no significant differences in
the rates of MI, other ACS events, or stroke between
groups, acute decompensated HF was significantly
reduced in the study arm. All-cause mortality was
also significantly lower in the intensive-treatment
group, but the patients in the study arm experienced
higher rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute
FIGURE
Number of U.S. Adults Meeting Each Sequential SPRINT Eligibility Criterion
U.S. Adults:
219.4 Million
Age ≥ 50 Years:
Should Guidelines “SPRINT” to Lower BP
Targets?
With prevalence so high, hypertension walks
around with a bull’s eye on its back. The 2013 European Society of Hypertension/European Society
of Cardiology guidelines set a target blood pressure
(BP) of < 140/90 mm Hg for all patients regardless of cardiovascular (CV) risk.1 There is a more
conservative target for the elderly and some modest
support for a more aggressive target of < 130 mm
Hg in a few specific high CV risk situations.
Controversial updated U.S. guidelines suggested
a BP goal of < 150/90 mm Hg for individuals aged
60 years or older and < 140/90 mm Hg for younger
patients.2 However, a Scientific Statement from the
American Heart Association, American College of
Cardiology, and American Society of Hypertension
released in 2015, agreed with ESC and suggested
a target of < 140/90 mm Hg for most patients
ACC.org/CSWN
kidney injury or failure.
Not surprisingly, SPRINT has generated much
discussion on whether BP targets should be officially
lowe red. In this debate session, SPRINT investigator
William C. Cushman, MD, (University of Tennessee, Memphis) argued for lowering BP targets, while
Sverre E. Kjeldsen, MD, PhD, (Oslo University
Hospital Ullevaal, Oslo, Norway) argued against
changing BP targets. The discussion was rounded out
by introductory remarks given by Giuseppe Mancia,
MD, (University of Milan, Italy) and concluding remarks from ESC program committee member Bryan
Williams, MD, (University College London).
Dr. Mancia suggested that there is solid reasoning
for the current BP targets, mainly that the trials done
to date have showed benefit to treating BP to 140
mm Hg, with no trial showing benefit from active
treatment to < 130 mm Hg. He also noted, however,
that there are several remaining gaps in our knowledge of optimal BP targets. For example, there are
very limited data on how to treat younger patients
who have not yet accumulated much CV risk. Also
unknown: how optimal BP targets might be specific
to the individual patient or vary within a patient
group, perhaps according to age or according to the
presence or absence of organ damage.
For his part, Dr. Cushman mostly summarized
the SPRINT findings and offered some thoughts
as to where he might like to see the BP guidelines
changed. (Certainly, applying the SPRINT results to
the U.S. population would impact a lot of patients.
See the FIGURE.)
95.1 Million
SBP ≥ 130 mm Hg:
37.3 Million
SPRINT Eligible:
16.8 Million
High CVD Risk:
26.4 Million
No SPRINT
Exclusion Criteria
Population
Number in Millions
Percent (95% CI) SPRINT Eligible
All U.S. Adults
219.4
7.6% (7.0% - 8.3%)
Hypertension
68.5
20% (18.6% - 21.5%)
Treated Hypertension
49.5
16.7% (15.2% - 18.3%)
Bress, A.P. et al. J Am Coll Cardiol. 2016; 67(5):463-72.
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