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Effect of Intensive Blood Pressure Control on Stroke: A Prespecified Secondary Analysis of the ESPRIT Trial
Jingkuo Li1, Lubi Lei1, Yan Li1
1National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Insights
Intensive blood pressure treatment targeting systolic blood pressure (SBP) <120 mm Hg significantly reduced hemorrhagic stroke risk compared to standard treatment (SBP <140 mm Hg). The stroke-preventing effect became apparent after one year.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Clinical Trials
Background:
- Elevated systolic blood pressure (SBP) is a primary risk factor for stroke, contributing significantly to the global burden of the condition.
- Lowering SBP is a critical intervention for stroke prevention.
Purpose of the Study:
- To evaluate the impact of intensive SBP treatment (<120 mm Hg) versus standard treatment (<140 mm Hg) on stroke incidence.
- To analyze effects on stroke subtypes, including ischemic and hemorrhagic stroke.
Main Methods:
- The ESPRIT trial randomized high-risk hypertensive patients to intensive or standard SBP treatment arms.
- Follow-up duration was 3.4 years, with Cox proportional hazards regression models used for outcome analysis.
- Secondary outcomes included stroke incidence, with post hoc analyses for stroke subtypes and landmark analyses.
Main Results:
- Intensive SBP treatment (<120 mm Hg) resulted in a 49% reduction in hemorrhagic stroke risk (HR: 0.51; 95% CI: 0.31-0.85; P=0.009).
- No significant increase in ischemic stroke risk was observed with intensive treatment (HR: 0.93; 95% CI: 0.78-1.11; P=0.423).
- Landmark analysis revealed that the stroke-preventing benefit emerged after 1 year, with a hazard ratio of 0.75 (95% CI: 0.60-0.94; P=0.011) for the period beyond one year.
Conclusions:
- Targeting SBP <120 mm Hg effectively halved hemorrhagic stroke risk without increasing ischemic stroke risk compared to targeting SBP <140 mm Hg.
- The beneficial effect on stroke prevention became evident after one year of intensive intervention.
- Further research is warranted to validate these findings in diverse populations.
Background:
Elevated systolic blood pressure (SBP) accounts for one-half of the population attributable fraction for stroke, so lowering SBP is the most important treatment for preventing stroke.
Objectives:
In this study, the authors sought to assess the effects of intensive treatment targeting SBP <120 mm Hg on stroke compared with standard treatment targeting SBP <140 mm Hg.
Methods:
In the ESPRIT trial, hypertensive patients with high cardiovascular risk were randomly assigned to intensive treatment or standard treatment and followed for 3.4 years. We fitted Cox proportional hazards regression models to examine the effects on the incidence of stroke, one of the prespecified secondary outcomes. In addition, we performed post hoc analyses including effects on stroke subtypes and the landmark analyses about stroke and stroke subtypes.
Results:
We randomized 11,255 participants (3,022 with previous stroke). Their mean age was 64.6 ± 7.1 years, and 4,650 (41.3%) were female. During the follow-up, the mean SBP was 119.1 ± 11.1 mm Hg in the intensive arm and 134.8 ± 10.5 mm Hg in the standard arm. Stroke occurred in 262 participants (4.7%) in the intensive arm and 303 (5.4%) in the standard arm (HR: 0.86; 95% CI: 0.73-1.02; P = 0.083), ischemic stroke in, respectively, 243 (4.3%) vs 261 (4.6%) (HR: 0.93; 95% CI: 0.78-1.11; P = 0.423), and hemorrhagic stroke 23 (0.4%) vs 45 (0.8%) (HR: 0.51; 95% CI: 0.31-0.85; P = 0.009). Landmark analysis showed that the risk difference in stroke emerged after 1 year, and the HR for the period of longer than 1 year was 0.75 (95% CI: 0.60-0.94; P = 0.011). There were no interactions across all subgroups of baseline characteristics, including demographics, region, lifestyle, diastolic blood pressure, orthostatic hypotension, and comorbidities (all P interaction >0.05).
Conclusions:
Compared with targeting <140 mm Hg, targeting <120 mm Hg halved the risk of hemorrhagic stroke and did not increase that of ischemic stroke. The stroke-preventing effect emerged after 1 year of intervention. Future studies are needed to confirm these findings.
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