BACKGROUND AND PURPOSE:

• Liu et al. (The Lancet, 2024) compared the efficacy and safety of intensive blood pressure lowering treatment targeting systolic BP of <120 mm Hg among participants with high cardiovascular risk and with or without diabetes or previous stroke

METHODS:

• Open-label, blinded-outcome, randomized controlled trial
  • Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events (ESPRIT) trial
  • 116 hospitals or communities in China
• Participants
  • ≥50 years
  • High cardiovascular risk: Established cardiovascular disease or ≥2 major cardiovascular risk factors
• Interventions
  • Intensive treatment: Systolic BP <120 mm Hg
  • Standard treatment: Systolic BP <140 mm Hg
• Study design
  • Follow up: Months 1, 2, and 3 and then every 3 months
  • Medications based on standard office BP measurement
  • Free medications were made available to improve adherence
  • Analysis was by intention-to-treat
• Primary outcome
  • Composite of major vascular events
    • Myocardial infarction | Revascularization | Hospitalization for heart failure | Stroke | Death from cardiovascular causes

RESULTS:

• Intensive treatment: 5624 | Standard treatment: 5631
  • Patients with diabetes: 4359 | Patients with previous stroke: 3022
  • Mean age: 64.6 (SD, 7.1) years
  • Median follow-up: 3.4 years
• Mean systolic BP through follow-up
  • Intensive: 119.1 (SD, 11.1) mm Hg
  • Standard: 134.8 (SD, 10.5) mm Hg
• Over the follow-up period, the primary outcome occurred in fewer patients in the intensive treatment group
  • Intensive: 9.7% | Standard: 11.11%
  • Hazard ratio (HR) 0.88 (95% CI, 0.78 to 0.99) | P=0.028
• There was no heterogeneity of effects due to
  • Diabetes status | Duration of diabetes | History of stroke
• Syncope occurred more frequently in the intensive treatment group
  • Intensive: 0.4% | Standard: 0.1%
  • HR 3.00 (95% CI, 1.35 to 6.68)
• There was no significant between-group difference in other serious adverse events
  • Hypotension | Electrolyte abnormality | Injurious fall | Acute kidney injury
• Intention-to-treat analysis
  • To prevent a primary outcome event: 75 patients need to be treated
  • To prevent a cardiovascular death: 148 patients need to be treated  

CONCLUSION:

• A target systolic BP of 120 mm Hg vs 140 mm Hg reduced adverse cardiovascular events among high-risk hypertensive patients with a slight increase in syncope risk
• Other adverse events did not differ between the groups
• The authors state

Our findings provide new evidence about the benefit and harm of treatment targeting systolic blood pressure of less than 120 mm Hg

Learn More – Primary Sources:

Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial