The question of BP targets of antihypertensive treatment has been debated in recent guidelines, and reopened by publication of SPRINT. Although interpretation of SPRINT is made difficult by a preferential effect of more intense BP lowering on heart failure rather than stroke and myocardial infarction, and by a different method of BP measurement, recent meta-analyses by my group have shown SBP reduction <130 mmHg can reduce risk of cardiovascular (CV) outcomes further, but absolute benefit is smaller than that achieved across the 140 mmHg cutoff, and treatment discontinuations for adverse events become greater.
Even more difficult is answering the question of BP targets in CKD. In this condition risks of CV events and renal failure are both particularly elevated. Unfortunately, evidence available from trials is rather confusing. SPRINT has included a consistent number of hypertensive patients with CKD, and found a trend, albeit non-significant, toward a reduction of CV events and no effect on risk of renal failure by more intense BP lowering. When SPRINT results are analyzed together with those of other trials on CKV, it appears that the benefits of BP lowering on the risk of CV mortality and morbidity are, at best, lesser than in patients with normal renal function, and the response of renal function is quite variable from trial to trial, possibly depending on the nature of CKD (diabetic or non-diabetic, with or without proteinuria) and on the type of antihypertensive drugs used (renin-angiotensin system blockers or other classes). The issue of antihypertensive treatment in CKD needs to be investigated in greater depth and with precise questions.
Istituto Auxologico Italiano and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di Milano, Italy