SPRINT Cost Effectiveness: Lower BP or Better Diuretic Therapy?!
N Engl J Med. 2017 Aug 24;377(8):745-755. doi: 10.1056/NEJMsa1616035.
Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control.
In the Systolic Blood Pressure Intervention Trial (SPRINT), adults at high risk for cardiovascular disease who received intensive systolic blood-pressure control (target, <120 mm Hg) had significantly lower rates of death and cardiovascular disease events than did those who received standard control (target, <140 mm Hg). On the basis of these data, we wanted to determine the lifetime health benefits and health care costs associated with intensive control versus standard control.
We used a microsimulation model to apply SPRINT treatment effects and health care costs from national sources to a hypothetical cohort of SPRINT-eligible adults. The model projected lifetime costs of treatment and monitoring in patients with hypertension, cardiovascular disease events and subsequent treatment costs, treatment-related risks of serious adverse events and subsequent costs, and quality-adjusted life-years (QALYs) for intensive control versus standard control of systolic blood pressure.
We determined that the mean number of QALYs would be 0.27 higher among patients who received intensive control than among those who received standard control and would cost approximately $47,000 more per QALY gained if there were a reduction in adherence and treatment effects after 5 years; the cost would be approximately $28,000 more per QALY gained if the treatment effects persisted for the remaining lifetime of the patient. Most simulation results indicated that intensive treatment would be cost-effective (51 to 79% below the willingness-to-pay threshold of $50,000 per QALY and 76 to 93% below the threshold of $100,000 per QALY), regardless of whether treatment effects were reduced after 5 years or persisted for the remaining lifetime.
In this simulation study, intensive systolic blood-pressure control prevented cardiovascular disease events and prolonged life and did so at levels below common willingness-to-pay thresholds per QALY, regardless of whether benefits were reduced after 5 years or persisted for the patient's remaining lifetime. (Funded by the National Heart, Lung, and Blood Institute and others; SPRINT ClinicalTrials.gov number, NCT01206062 .).
As the only beneficial effect shown by SPRINT is a reduction in fluid overload and the associated mortality due to Heart Failure; Cost effectiveness would be even higher with better use of DIURETIC THERAPY in those at risk.
This was shown in the ALLHAT study where treatment with the thiazide diuretic Chlorthalidone had a similar life year gain at a much lower cost!
Authors and Researchers of SPRINT will carry on trying to misguide the medical community that lower'"intensive"BP is life saving, whilst the findings of their study is that lower-intensive BP does NOT reduce the risk of CAD or Strokes in their study. This, is in fact at odd with the bulk of the literature; as SPRINT in the only study that showed that reducing BP does not prevent or reduce the incidence of strokes...
All the SPRINT study shows is that more appropriate and effective use of diuretic therapy prevents fluid overload and decreases the associated mortality (Heart Failure).
And, by clever statistical manipulation involving combined endpoints including heart failure as well as overall mortality...the heart failure-diuretic effect gives the misleading impression that mortality is primarily decreased, when in reality it is linked to heart failure and the beneficial effect of diuretics on heart failure, heart failure-associated CVD mortality and "all cause" mortality (that includes heart failure-CVD mortality!).
Effective diuretic therapy is key to prevention of Heart Failure and minimising its complications, including hospitalisations, morbidity and mortality. They are often poorly prescribed and mismanaged.