Lowering the Target for Blood Pressure Is Best, Study Affirms

PHILADELPHIA — A systolic blood pressure treatment target under 120 mm Hg improved outcomes and saved lives compared with a threshold of 140 mm Hg for higher risk patients with hypertension, the ESPRIT trial from China affirmed.

The more intensive target lowered 3-year incidence of the primary composite endpoint of myocardial infarction, revascularization, heart failure hospitalization, stroke, or cardiovascular death by 12% (3.2% vs 3.6% per year, HR 0.88, 95% CI 0.78-0.99), for a number needed to treat of 74.

Cardiovascular deaths also fell by 39%, and death from any cause by 21% with the lower target, both statistically significant, Jing Li, MD, PhD, of the Chinese Academy of Medical Science National Center for Cardiovascular Disease at Fuwai Hospital in Beijing, reported at the American Heart Association (AHA) annual meeting.

The findings add to those of the SPRINT trial, which also showed cardiovascular event and mortality prevention with a target below 120 versus 140 mm Hg systolic, although measurement issues in that trial appeared to make the lower threshold more in line with ≤130 mm Hg, which is what guidelines committees settled on for the new systolic blood pressure treatment target in 2017.

The ACCORD blood pressure trial in type 2 diabetes and the RESPECT trial in those with prior stroke have also shown cardiovascular risk reduction with the <120 mm Hg target versus <140 mm Hg, noted Paul Whelton, MB, MD, MSc, of Tulane University School of Public Health and Tropical School of Medicine in New Orleans and president of the World Hypertension League.

With four trials now supporting benefit of blood pressure lowering to less than 120 versus less than 140 mm Hg, Whelton said, “guideline committees and clinicians should consider a revised SBP treatment target.”

He pointed to the similar serious adverse event rates in the intensive and standard target groups as well as the rarity of hypotension, syncope, injurious falls, and acute kidney injury or acute renal failure as “reassuring,” saying that the risk-benefit balance “seems very favorable.”

However, the findings highlight the need for implementation of trial results in clinical practice, Whelton urged, noting that only about 40% of U.S. persons with hypertension have blood pressure under control.

ESPRIT was large enough to add important information on subgroups left out of SPRINT, Keith Ferdinand, MD, of Tulane University in New Orleans, commented at an AHA press conference.

The trial included 11,255 patients ages 50 and older (mean 65 years, 41% women) who had a systolic blood pressure of 130-180 mm Hg at baseline when seen at 116 sites in China. Enrollment also required elevated cardiovascular risk, with established cardiovascular disease or at least two major cardiovascular risk factors (age ≥60 male or ≥65 female, diabetes mellitus, dyslipidemia, or current smoking).

Low ejection fraction, postural hypotension, or impaired kidney function were exclusion criteria.

Li drew population characteristic distinctions between ESPRIT and SPRINT, with a 100% Asian population compared with less than 2%, respectively, as well as higher baseline systolic blood pressure (147 vs 140 mm Hg), lower prevalence of kidney disease, more prior stroke (27% vs 0%), and more diabetes (39% vs 0%).

The ESPRIT trial “gives us even more confidence that the 2017 AHA/ACC multisociety guidelines were prescient in that lowering blood pressure to a target less than 130 [mm Hg] actually will benefit a wide range of patients,” Ferdinand said.

Benefits of the lower target were consistent across subgroups with and without coronary heart disease, stroke, and diabetes.

Achieved systolic blood pressure was 120 mm Hg in the intensive lowering arm compared with 136 mm Hg in the higher target arm at 1 year.

Because of the way blood pressure was measured in SPRINT, 120 mm Hg in the trial was deemed the equivalent of about 130 mm Hg in the office. The procedures for measurement appeared similar between that trial and ESPRIT.

“At each office visit, blood pressure was measured by a trained investigator using an electronic blood pressure monitor (Omron HBP-1100),” Li told MedPage Today regarding his trial. “Each participant was measured three times with an interval of 1 minute according to the standard procedure after the participant was seated and had quiet rest for at least 5 minutes. The measurement results were directly transferred into the electronic case report form via universal serial bus connection to a computer. The mean value of the three measurements was used as the blood pressure level.”

Ferdinand noted the AHA/American Medical Association scientific statement on implementation strategies to improve blood pressure control in its recommendation for accurate blood pressure measurement. In real world practice, “it’s done in a very sloppy, at times haphazard way,” he said.

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