Effects of Intensive Blood Pressure Lowering Treatment in Reducing Risk of Cardiovascular Events - ESPRIT

Mar 31, 2025
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Fred M. Kusumoto, MD, FACC; Kim A. Eagle, MD, MACC
Trial Sponsor:
Ministry of Science and Technology
Date Presented:
11/13/2023
Date Published:
06/27/2024
Date Updated:
03/31/2025
Original Posted Date:
11/13/2023
References

Highlighted text has been updated as of March 31, 2025.

Contribution To Literature:

The ESPRIT trial showed that intensive blood pressure control improves outcomes.

Description:

The goal of the trial was to evaluate intensive blood pressure (BP) control (systolic BP [SBP] <120 mm Hg) compared with standard BP control (SBP <140 mm Hg) among patients with hypertension.

Study Design

  • Randomized
  • Parallel
  • Blinded

Patients with hypertension were randomized to target SBP <120 mm Hg (n = 5,624) vs. target SBP <140 mm Hg (n = 5,631).

  • Total number of enrollees: 11,255
  • Duration of follow-up: 3.4 years
  • Mean patient age: 65 years
  • Percentage female: 41%

Inclusion criteria:

  • Patients ≥50 years of age
  • SBP 130-180 mm Hg
  • Increased cardiovascular risk, defined as established cardiovascular disease or ≥2 cardiovascular risk factors

Exclusion criteria:

  • Secondary cause of hypertension
  • One-minute standing SBP <110 mm Hg
  • Left ventricular ejection fraction <35%
  • Estimated glomerular filtration rate <45 mL/min/1.73 m2

Other salient features/characteristics:

  • Baseline BP: 147/83 mm Hg
  • Diabetes: 39%
  • Stroke: 27%

Principal Findings:

The primary outcome, cardiovascular death, myocardial infarction, stroke, coronary revascularization, noncoronary revascularization, or hospitalization for heart failure occurred in 3.2% in the SBP <120 mm Hg group vs. 3.6% in the <140 mm Hg group (p = 0.03). The results were the same in tested subgroups (history of stroke or diabetes).

Secondary outcomes:

  • Cardiovascular death: 0.3% in the SBP <120 mm Hg group vs. 0.5% in the SBP <140 mm Hg group (p < 0.05)
  • Stroke: 1.5% in the SBP <120 mm Hg group vs. 1.7% in the SBP <140 mm Hg group (p < 0.05)
  • Syncope: 0.4% in the SBP <120 mm Hg group vs. 0.1% in the SBP <140 mm Hg (p < 0.05)

There was no treatment heterogeneity by diabetes status, duration of diabetes, or history of stroke.

A composite of myocardial infarction, hospitalization for or emergency room visit for heart failure, stroke, or death from cardiovascular diseases was 7.4% in the intensive BP group vs. 8.8% in the standard BP group. All-cause death was 2.8% vs. 3.6%. Composite kidney outcome of end stage renal disease, sustained decline in eGFR to <10 mL/min/1.73m2, death from renal causes or a sustained decline ≥40% in eGFR from baseline: 3.0% vs. 1.8%. Similar benefit with intensive BP control across all frailty status.

Treating 1,000 participants in severe-frail group with intensive BP control for 3.4 years would prevent: 30 MACE, 21 all-cause death and 7 injurious falls, and induce 16 composite kidney outcomes.

Interpretation:

Among Asian patients with hypertension and a large proportion of diabetes and stroke, intensive BP control improves outcomes compared with standard control. Target SBP <120 mm Hg reduced major adverse cardiac events compared with target SBP <140 mm Hg. Intensive BP control was associated with an absolute risk reduction of major adverse events of 0.4%. Intensive BP control was associated with an increased risk of syncope. The results of this trial are in line with the SPRINT trial, which enrolled <2% Asians and excluded subjects with diabetes or stroke.

References:

Presented by Dr. Shitian Li for the ESPRIT Investigators at the American College of Cardiology Annual Scientific Session (ACC.25), March 31, 2025.

Liu J, Li Y, Ge J, et al., on behalf of the ESPRIT Collaborative Group. 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, randomized trial. Lancet 2024;404:245-55.

Presented by Dr. Jing Li at the American Heart Association Scientific Sessions, Philadelphia, PA, November 13, 2023.

Clinical Topics: Prevention, Hypertension, Vascular Medicine

Keywords: AHA23, Antihypertensive Agents, Hypertension, ACC Annual Scientific Session, ACC25


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