Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2015
Identifying new practice-changing articles is challenging. To determine the 2015 practice-changing articles most relevant to outpatient general internal medicine, 3 internists independently reviewed the titles and abstracts of original articles, synopses of single studies and syntheses, and databases of syntheses. For original articles, internal medicine journals with the 7 highest impact factors were reviewed: New England Journal of Medicine,Lancet, Journal of the American Medical Association (JAMA), British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine. For synopses of single studies and syntheses, collections in American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine were reviewed. For databases of synthesis, Evidence Updates and the Cochrane Library were reviewed. More than 100 articles were identified. Criteria for inclusion were as follows: clinical relevance, potential for practice change, and strength of evidence. Clusters of important articles around one topic were considered as a single-candidate series. The 5 authors used a modified Delphi method to reach consensus on inclusion of 7 topics for in-depth appraisal.
Lower Systolic Blood Pressure Goals in Patients at High Cardiovascular Risk
Current guidelines do not recommend treating systolic blood pressures below 140 mm Hg.2 However, observational data demonstrate an increased risk of cardiovascular outcomes when systolic blood pressure exceeds 115 mm Hg.3 The Systolic Blood Pressure Intervention Trial (SPRINT), a randomized, controlled, open-label study, compared outcomes between groups with a targeted systolic blood pressure goal of <120 mm Hg (intensive) or <140 mm Hg (standard) in nondiabetic patients at high risk of cardiovascular events.
There were 9361 patients ≥50 years of age at high risk of cardiovascular events and with prestudy systolic blood pressures from 130-180 mm Hg randomized to the intensive or standard treatment group. High risk was defined as clinical/subclinical cardiovascular disease other than stroke, an estimated glomerular filtration rate of 20-60 mL/min, a Framingham 10-year risk score of >15%, or age ≥75 years. Patients with difficult-to-control blood pressure, diabetes mellitus, or prior stroke were excluded. With a median follow-up of 3.26 years, the intensive treatment group achieved a mean systolic blood pressure of 121.4 mm Hg; the standard treatment group achieved a mean systolic blood pressure of 136.2 mm Hg. The primary outcome, a composite endpoint of myocardial infarction, nonmyocardial infarction acute coronary syndrome, stroke, heart failure, or cardiovascular-related death, was significantly reduced in the intensive treatment group, with a hazard ratio of 0.75 (95% confidence interval [CI], 0.64-0.89). Secondary outcomes showed a reduction in heart failure, death from cardiovascular causes, death from any cause, and overall mortality. Adverse events in the intensive group included hypotension, electrolyte abnormality, and acute kidney injury. There were no statistically significant serious adverse outcomes.
The trial was initially planned to follow patients for 6 years, but was stopped early. The intensive group failed to reach a mean or median systolic blood pressure of <120 mm Hg. Patients with diabetes mellitus, strokes, and those residing in assisted living or nursing home facilities were excluded, as were patients <50 years of age, which limits generalizability.
Implications for Practice
SPRINT supports a systolic blood pressure goal of approximately 120 mm Hg in patients without diabetes mellitus or stroke who are at high risk of cardiovascular events. Because the intensive blood pressure control group reached a mean systolic blood pressure of 121.4 mm Hg, targeting a systolic blood pressure <130 mm Hg and >120 mm Hg in these patients is reasonable until guidelines are updated. The benefits and risks of intensive blood pressure control should be considered for each patient, rather than a blanket approach of intensifying treatment in all older adults.
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-Jason H. Szostek, MD, Mark L. Wieland, MD, MPH, Jason A. Post, MD, Karna K. Sundsted, MD, Karen F. Mauck, MD, MSc
This article originally appeared in the August 2016 issue of The American Journal of Medicine.