Intensive BP lowering confers mortality benefit in Asian cohort
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Key takeaways:
- A systolic BP target of less than 120 mm Hg reduced CV and all-cause mortality among Asian patients.
- Compared with standard care, syncope was more common with the intensive strategy.
PHILADELPHIA — An intensive systolic BP target of less than 120 mm Hg for Asian patients with hypertension reduced risk for CV and all-cause mortality over 3 years vs. standard care, a speaker reported.
The results of the open-label, randomized-controlled ESPRIT trial were presented at the American Heart Association Scientific Sessions.
Image: Adobe Stock
“Blood pressure lowering is one of the most effective treatments to prevent risk of cardiovascular disease. Reducing systolic blood pressure to below 140 mm Hg is well established and considered as standard treatment,” Jing Li, MD, PhD, director of the department of preventive medicine at the National Center for Cardiovascular Diseases in Beijing, said during a press conference. “The SPRINT trial is the only trial to prove that targeting systolic blood pressure below 120 mm Hg reduces risk of major adverse vascular events than standard treatment in patients with high cardiovascular risk, but it included few from the Asian population and excluded patients with diabetes or history of stroke. Meta-analyses drew controversial conclusions because of limitations in methods. Currently, the optimal target for systolic blood pressure remains uncertain, especially in Asian population and patients with diabetes and history of stroke.”
Li and colleagues designed the ESPRIT trial to evaluate whether intensive BP lowering with a target of less than 120 mm Hg provided greater protection from CV events compared with a target systolic BP of less than 140 mm Hg.
The researchers enrolled 11,255 patients in China (mean age, 65 years; 41% women; 39% with diabetes) with systolic BP of 130 mm Hg to 180 mm Hg at elevated CV risk, defined as having established CVD or at least two major CV risk factors. Participants were randomly assigned to intensive BP lowering or standard care.
The primary outcome was a composite of MI, revascularization, HF hospitalization, stroke or CV death. Secondary outcomes included the individual components of primary outcome plus all-cause death and a composite of the primary outcome or all-cause death.
Mean systolic BP at baseline was 147 mm Hg in both groups and the rate of statin therapy and aspirin use was similar between the intensive BP lowering and standard care groups.
At 1 year, the average systolic BP in the intervention arm was 120.3 mm Hg compared with 135.6 mm Hg in the standard care arm.
During a median follow-up of 3.4 years, Li and colleagues observed significantly lower risk for the primary outcome in the intensive BP lowering group compared with standard care (HR = 0.88; 95% CI, 0.78-0.99; number needed to treat, 74) as well as lower risk for all-cause death (HR = 0.79; 95% CI, 0.64-0.97; number needed to treat, 132).
The researchers also reported reduced risk for the composite secondary outcome in the intensive BP lowering group, an observation primarily driven by lower rates of CV death (0.3% vs. 0.5%; HR = 0.61; 95% CI, 0.44-0.88) and all-cause death (0.9% vs. 1.1%; HR = 0.79; 95% CI, 0.64-0.97) compared with standard care.
The benefits of intensive BP lowering were consistent across all prespecified subgroups, including those grouped by history of CHD, stroke or diabetes and baseline systolic BP.
Similar to the SPRINT trial, results of the present study demonstrated increased risk for hypotension (0.3% vs. 0.1%; HR = 3.4; P < .05) and syncope (0.5% vs. 0.2%; HR = 2.17; P < .05) in the intensive care groups compared with standard care.
“In hypertensive participants with high risk of cardiovascular disease and the normal or mildly reduced renal function, intensive blood pressure-lowering treatment targeting systolic blood pressure below 120 mm Hg for 3 years resulted in 12% lower incidence of major vascular events, 39% lower cardiovascular mortality and 21% lower all-cause mortality than the standard treatment,” Li said during a press conference. “Meanwhile, three persons will experience serious adverse events of syncope. The effects of preventing major vascular events were consistent regardless of diabetes status or history of stroke. Our study generates new evidence about benefit and the safety of treatment targeting systolic blood pressure below 120 mm Hg among a diverse Asian population, which is generally consistent with those from other ethnicities.”
Perspective
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We have the ACCORD trial [The ACCORD Study Group. N Engl J Med. 2010;doi:10.1056/NEJMoa1001282.] in the past where we did not see as much of a signal in terms of benefit of intensive BP lowering in patients with diabetes. So this is the first time we've had the opportunity to see that. In the ACCORD trial though, there was a lot of concern that there was issue with contamination because it was a 2x2 factorial trial where people receiving simvastatin were randomized to receive either fenofibrate or placebo.
The difference is that this time there's no contamination from the other group. So this is the first opportunity we get to get to see that, I don't know if they looked at a subgroup analyses of diabetic vs. nondiabetic and if the effect was more intensive in the diabetics perhaps.
This gives us additional data than what we had from ACCORD because it's a cleaner study, in that we are not dealing with this potential contamination from the other randomization. It's reassuring and I think that it definitely reinforces that intensive BP control is important as a major preventive factor in terms of CV events.
With regard to the syncope aspect and the fall aspect, much like what we saw in SPRINT and ACCORD, I think it comes down to specific counseling of patients. Finding the right patients to recommend this in and close monitoring of these adverse events. If people seem that they're developing risk factors, this is why judgment trumps data in that regard and that we should always, of course, make sure that we're selecting the right patients for intensive BP lowering.
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Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
The ESPRIT study is a new study out of China, and it builds on what we already know with SPRINT. First of all, it has 100% Asian patients, who were somewhat underrepresented in the SPRINT trial. But more importantly, the sample size is very robust, over 11,000 patients, and it includes some patients that were left out of SPRINT, including those persons with diabetes, those persons with a history of previous stroke, and it had more women because SPRINT tended to enroll in the VA where we had an overrepresentation of men.
What I think it does is it tells us that intensive BP reduction with a goal of less than 120 mm Hg vs. the conventional 140 mm Hg really is the correct thing to do in patients who are at high risk.
It also tells us that the ACCORD study, which suggested that intensive BP reduction was not as beneficial in persons with diabetes, is not really accurate, because in the population who had diabetes looking at a forest plot, they had the same benefit from intensive BP lowering as those who did not have diabetes. The same was true also for persons with a history of previous stroke.
What it adds to is our understanding that, as tolerated of course, lower is better, and treating BP down to a goal of clearly less than 130 mm Hg, target of 120 mm Hg may be beneficial, especially in high-risk patients, if it can be done safely and effectively.
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Li J, et al. LBS.07. From local to global: Achieving equity in prevention. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.
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