From Pages to Practice

By Lisa Caulley, MD MPH FRCS

Published August 23, 2017


John, a 72-year-old man with a long-standing history of hypertension, presents to your clinic for his annual health assessment with a log of his most recent outpatient systolic blood pressure (BP) readings in hand. He reports consistent readings of 135–140 mmHg, but asks, “How low does my blood pressure have to be, Doc?”

The 2015 Systolic Blood-Pressure Intervention Trial (SPRINT) demonstrated significant reductions in cardiovascular disease and all-cause mortality with intensive BP control (<120 mmHg), compared to standard treatment (BP<140 mmHg). This study gained nationwide recognition and since then, many patients undoubtedly have asked their primary care physician how the findings apply to them. However, in the era of increasing pressure about healthcare costs, clinicians must not only pursue the most effective treatment strategies, but also recognize the most cost-effective treatment strategy.

In this week’s NEJM, Bress and colleagues compared the lifetime health benefits and health care cost of intensive versus standard systolic BP treatment. The authors used the results of the SPRINT study to estimate probabilities of cardiovascular disease events and treatment-related adverse events of systolic-BP treatment in a hypothetical cohort of SPRINT-eligible adults. In a simulated health care model, they estimated lifetime direct medical costs and applied the health effects and costs of the SPRINT intensive-treatment strategy compared to standard systolic BP treatment.

The intensive treatment strategy cost an additional $47,000 per quality-adjusted life year (QALY) gained, assuming there was a reduction in adherence and treatment effects after 5 years. The probability that intensive systolic BP treatment was a cost-effective strategy (<$50,000 per QALY) was 54% to 79%, compared to standard therapy, regardless of the assumptions about the persistence of treatment effects after 5 years.

Intensive BP control has demonstrated the potential to decrease adverse cardiovascular events and prolong life in hypertensive patients at levels below common thresholds used to define cost-effectiveness. For a patient like John, be prepared to engage in a discussion about reassessing his blood pressure target and know that a strategy of targeting a lower blood pressure goal is likely to be cost-effective.

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Lisa is a 2017-2018 NEJM Editorial Fellow. An otolaryngologist-head and neck surgeon by training, she graduated from the University of Toronto Medical School and completed her residency training at the University of Ottawa. She has a Master's in Public Health from the Harvard T. H. Chan School of Public Health.