Department of Internal Medicine, Kidney Health Research Collaborative San Francisco Veterans Affairs Health Care System and University of California San Francisco San Francisco CA.
Department of Internal Medicine University of California Davis Sacramento CA.
J Am Heart Assoc. 2024 Aug 20;13(16):e033995. doi: 10.1161/JAHA.124.033995. Epub 2024 Aug 13.
There are no shared decision-making frameworks for selecting blood pressure (BP) targets for individuals with hypertension. This study addressed whether results from the SPRINT (Systolic Blood Pressure Intervention Trial) could be tailored to individuals using predicted risks and simulated preferences.
Among 8202 SPRINT participants, Cox models were developed and internally validated to predict each individual's absolute difference in risk from intensive versus standard BP lowering for cardiovascular events, cognitive impairment, death, and serious adverse events (AEs). Individual treatment effects were combined using simulated preference weights into a net benefit, which represents a weighted sum of risk differences across outcomes. Net benefits were compared among those above versus below the median AE risk. In simulations for which cardiovascular, cognitive, and death events had much greater weight than the AEs of BP lowering, the median net benefit was 3.3 percentage points (interquartile range [IQR], 2.0-5.7), and 100% of participants had a net benefit favoring intensive BP lowering. When simulating benefits and harms to have similar weights, the median net benefit was 0.8 percentage points (IQR, 0.2-2.2), and 87% had a positive net benefit. Compared with participants at lower risk of AEs from BP lowering, those at higher risk had a greater net benefit from intensive BP lowering despite experiencing more AEs (<0.001 in both simulations).
Most SPRINT participants had a predicted net benefit that favored intensive BP lowering, but the degree of net benefit varied considerably. Tailoring BP targets using each patient's risks and preferences may provide more refined BP target recommendations.
目前尚无针对高血压患者选择血压目标的共享决策框架。本研究旨在探讨是否可以使用预测风险和模拟偏好来为个体定制 SPRINT（收缩压干预试验）的结果。
在 8202 名 SPRINT 参与者中，建立了 Cox 模型并进行了内部验证，以预测每个个体在强化与标准降压治疗对心血管事件、认知障碍、死亡和严重不良事件（AE）方面的绝对风险差异。使用模拟偏好权重将个体治疗效果合并为净效益，代表跨结局的风险差异的加权总和。在 AE 风险中位数以上和以下的人群中比较净效益。在心血管、认知和死亡事件的权重远大于降压 AE 的模拟中，中位净效益为 3.3 个百分点（四分位距[IQR]，2.0-5.7），100%的参与者具有有利于强化降压的净效益。在模拟中使获益和危害的权重相似时，中位净效益为 0.8 个百分点（IQR，0.2-2.2），87%的参与者具有正净效益。与降压 AE 风险较低的参与者相比，尽管 AE 更多，但风险较高的参与者从强化降压中获得了更大的净效益（在两种模拟中均<0.001）。
大多数 SPRINT 参与者具有有利于强化降压的预测净效益，但净效益的程度差异很大。使用每个患者的风险和偏好来定制 BP 目标可能会提供更精确的 BP 目标建议。
