Intensive blood pressure lowering to a systolic target <120 mm Hg reduced cardiovascular events in individuals at high risk for cardiovascular disease compared with standard treatment with a target <140 mm Hg in the ESPRIT trial.[1]
“Intensive blood pressure-lowering treatment aimed at a systolic pressure less than 120 mm Hg for 3 years resulted in a 12% lower incidence of serious vascular events, 39% lower cardiovascular mortality, and all-cause mortality. causes 21% lower than standard treatment targeting a systolic pressure less than 140 mm Hg,” reported lead researcher Dr. Jing Li, director of the Department of Preventive Medicine at the National Center for Cardiovascular Diseases in Beijing, China.
The trial included patients with diabetes and a history of stroke, two important groups that were excluded in the previous SPRINT trial of intensive blood pressure reduction. The results indicated that the benefit of intensive blood pressure reduction extends to these groups and results in the prevention of 14 serious vascular events and 8 deaths per 1,000 people treated for 3 years with a systolic pressure <120 mm Hg in instead of <140 mm Hg, at the cost of another three patients suffering the serious adverse effect of syncope, Dr. Li noted.
“Our study generates new evidence on the benefit and tolerability of treatment aimed at achieving a systolic blood pressure less than 120 mm Hg in a diverse Asian population, which is generally consistent with that of other ethnic groups. The application of this treatment strategy Intensive care in high-risk adults can save more lives and reduce the public health burden of heart disease worldwide,” he concluded.
Dr. Ling presented the ESPRIT trial on November 13 at the Congress of the American Heart Association (AHA) 2023, which took place in Philadelphia, United States.
The ESPRIT trial included 11,255 Chinese adults (mean age: 64 years; 41% women) with a baseline systolic blood pressure of 130 to 180 mm Hg (mean: 147 to 183 mm Hg) and established cardiovascular disease or at least two factors. important cardiovascular risk. Thirty-nine percent of the participants had diabetes and 27% had a history of stroke.
They were randomized to receive intensive blood pressure treatment, with a systolic blood pressure goal <120 mm Hg, or standard treatment with a goal measurement <140 mm Hg over a 3-year period. After one year, systolic pressure was reduced to 135.6 mm Hg in the standard treatment group and to 120.3 mm Hg in the intensive treatment group, and the values remained around the same level for the rest of the follow-up.
The primary endpoint was a composite of myocardial infarction, coronary or noncoronary revascularization, hospitalization or admission to the emergency room for heart failure, stroke, or death from cardiovascular causes.
After 3.4 years of follow-up, 624 episodes of the main variable had occurred in the standard group (3.6%) compared to 547 in the intensive group (3.2%), that is, a reduction of 12% (hazard ratio [HR]: 0.88; 95% CI: 0.78 to 0.99). This is equivalent to a number needed to treat to prevent one event of 74.
Death from cardiovascular causes occurred in 0.5% of the standard group compared to 0.3% of the intensive group (HR: 0.61; 95% CI: 0.44 to 0.84) and from any cause in 1.1 % of the standard group versus 0.9% of the intensive group (HR: 0.79; 95% CI: 0.64 to 0.97).
The individual endpoints of myocardial infarction, stroke, and heart failure showed positive trends toward a decrease with intensive blood pressure reduction, but did not reach statistical significance.
Regarding serious adverse events, syncope increased in the intensive group (0.4% vs. 0.1%), but there were no significant differences in hypotension, electrolyte abnormalities, falls resulting in injury, acute kidney injury, or renal failure .
Should 120 mm Hg be the new goal?
Dr. Paul Whelton, professor of Global Public Health at Tulane University School of Medicine in New Orleans, United States, commented on the study to Medscape Medical News stating that the results coincide with those of other trials.
“When we look at the meta-analyses of trials with different levels of blood pressure reduction, all the studies show the same thing: the lower the blood pressure, the better the results, and those who start with higher levels are the ones who get the most benefit from it.” reducing blood pressure,” he said.
“There are four trials that have looked at systolic targets of less than 120 mm Hg versus less than 140 mm Hg (SPRINT, ACCORD BP, RESPECT and now ESPRIT) and when properly analyzed they all show a similar benefit for cardiovascular outcomes with the goal below 120,” noted Dr. Whelton, who led the SPRINT trial.
“ESPRIT is a well-done trial. It is reassuring because it is consistent with the other trials in that it appears that the benefits are much greater than the risk of adverse effects,” he added.
He also noted that there are three more trials to come in which this question is analyzed, two in Brazil (one in individuals with diabetes and another in stroke survivors) and another in China in people with diabetes. “So we will get more information from them.”
He added that guideline committees will have to consider a systolic blood pressure less than 120 mm Hg as the optimal treatment goal. Currently in the United States the goal is 130 mm Hg.
Current US guidelines are based on the SPRINT trial, which demonstrated a reduction in cardiovascular events in patients treated with a systolic goal of 120 mm Hg versus 140 mm Hg.
Dr. Whelton, who was chairman of the hypertension guidelines committee American College of Cardiology (ACC) and the American Heart Association 2017, explained that at the time the guidelines were written there was only one trial, SPRINT, on whose evidence they relied.
“All committee members could comfortably agree on the target of 130 mm Hg, but it was felt that there was not enough data at that time to make a recommendation of 120 mm Hg. But now we have four trials,” he emphasized.
The specialist added that the trials included patients at high risk of cardiovascular disease, but that they all provided some differences: ACCORD BP was carried out in patients with diabetes, SPRINT was enriched with African-American patients, older adults and patients with kidney disease, RESPECT was carried out in stroke survivors and ESPRIT had a mix of Chinese patients.
“I think we have a good mix of different participants and they all show the same signal: that 120 mm Hg is better,” he said.
However, he stressed that although there is now compelling data in favor of lower blood pressure targets, these findings do not apply in clinical practice. “We are doing very badly in terms of application. There is a big gap between science and what happens in the real world.”
Dr. Whelton noted that only 30% of patients in high-income countries are managed to the target of 140/90 mm Hg and that in low- and middle-income countries only 8.8% reach that level, so not to talk about inferior objectives. “The next task is to work on applying these findings,” he said.
He noted that several studies have shown better results in this regard using a team approach, in which non-physicians play an important role in monitoring patients.
This content was originally published in the English edition of Medscape.