Everyone keeping blood pressure low because of the SPRINT trial is practicing bad medicine
SPRINT is a flawed study
SPRINT is a large randomized trial that has changed practice and led many providers to lower blood pressure beyond prior targets. Here is the conclusion of the paper:
But is this trial reliable?
I always say that a clinical trial can only change your practice if the control arm is your practice. SPRINT messed this up. The trial didn’t just target less than 140 in the control arm — it did something beyond this. If, by chance, you got lucky and controlled someone’s BP easily — taking them lower than 140, the trial design made you dose reduce their pills. This was a non-standard maneuver that might cause harm. Marc Pfeffer at Harvard saw it, and asked how often it happened. Check it out:
If it happened a lot, it would be a big problem.
And here was the reply.
Wow! 87% of people in the control arm of SPRINT had BP pills dose reduced even though they felt fine. This is not consistent with clinical practice, and a huge group of people. As such, it isn’t just a trial of aiming for <140 vs <120, but a trial of sabotaging people to keep them >135 vs aiming for less than 120.
Of course, the latter is better, but that’s not what doctors were doing.
It might still be best to aim for <140 and not <120. We don’t know.
Sadly SPRINT was poorly designed and interpreted poorly.
This is a huge problem and renders the trial useless IMO.
Completely agree!
The down titration makes this trial less of a clinical trial and more of a physiology experiment in my opinion. The results are achieved in an unethical manner but aren’t invalidated. I don’t think it changes clinical practice massively but I think having this trial is a nice reference point. Lower BP is associated with better outcomes.