Impact of Intensive BP Therapy on Patient-Reported Outcomes

BACKGROUND:
The Systolic Blood Pressure Intervention Trial (SPRINT), funded by NIH with additional VA support, demonstrated that intensive blood pressure therapy that targeted a systolic blood pressure (SBP) <120 mmHg as compared to therapy that targeted SBP <140 mmHg led to reduced cardiovascular morbidity and mortality in older adults with hypertension and high cardiovascular disease risk. However, the adoption of this lower blood pressure target into clinical practice may be limited by concerns regarding its impact on patient-reported outcomes (i.e., health status, quality of life, and satisfaction with care). This multicenter randomized controlled trial compared two strategies for managing systolic blood pressure in older adults (n=9,361, approximately 20% Veterans) with hypertension – an intensive strategy with an SBP target of <120 mmHg (n=4,678) versus a standard care strategy targeting <140 mmHg (n=4,683) – and whether such intensive therapy affects patient-reported outcomes. Participants were 50 years or older and were recruited between November 2010 and March 2013. Patient-reported outcomes included physical and mental health-related quality of life, depressive symptoms, self-reported satisfaction with care, and medication adherence. Scores for intensive vs standard therapy among all study participants also were analyzed and stratified by physical and cognitive function.

FINDINGS:

• Intensive therapy resulted in a 14.8 mmHg lower blood pressure compared to standard therapy; however, this had little impact on changes in patient-reported outcomes and adherence.
• Mean outcome scores were relatively stable over a median of three years of follow-up, with no significant differences between treatment groups. Moreover, no differences by treatment group were noted when stratified on the basis of older age, multiple comorbidities, frailty, or lower physical or mental function.
• The majority of participants in both groups reported that they were satisfied or very satisfied with their blood pressure care: 89% vs 88% in intensive and standard groups respectively.
• Overall, 44% of participants reported high adherence with blood pressure medications at 12 months, and no differences were noted between the intensive and standard treatment groups.

IMPLICATIONS:
Results provide reassurance that intensive hypertension therapy not only reduces cardiovascular morbidity and mortality, but will be well-tolerated, even in older patients with multiple comorbidities.

LIMITATIONS:

• The greatest negative impact could have occurred during the first several months of treatment intensification, and investigators would have missed such a transient effect.
• Study participants were not blinded to treatment group, thus knowledge regarding their treatment might have impacted their perceptions of health.

AUTHOR/FUNDING INFORMATION:
Drs. Berlowitz and Kazis are part of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR), Bedford and Boston, MA.

Berlowitz D, Foy C, Kazis L, et al., for the SPRINT Research Group. Impact of Intensive Blood Pressure Therapy on Patient-Reported Outcomes. The New England Journal of Medicine. August 24, 2017;377(8):733-44.