Achieving Intensive Blood Pressure Control in High-Risk Patients: Implementation Insights From the ESPRIT Trial

Inadequate blood pressure (BP) control remains a major public health challenge worldwide. Rigorous evidence is lacking on how to implement targeting systolic BP (SBP) <120 mm Hg in real-world settings.

We aimed to examine the implementation and effect heterogeneity of targeting SBP <120 mm Hg in diverse hypertensive patients with high cardiovascular risk, particularly those with longstanding uncontrolled BP.

Using data from the ESPRIT (Effects of intensive Systolic blood Pressure lowering treatment in reducing RIsk of vascular evenTs) trial, we analyzed achieved average BP level, time to intensive control, medication use, clinic visit frequency, major vascular events, all-cause death, and safety outcomes among all participants and across subgroups.

We included 11,255 participants (mean age: 64.6 ± 7.1 years; 41.3% women). The achieved median SBP of the intensive arm was 117 mm Hg (IQR: 113-123 mm Hg) in all participants, with 62.5% of participants in the intensive arm achieving intensive BP control. Older participants, male and those with a higher baseline SBP, longer hypertension duration, history of stroke and diabetes, and used more antihypertensive medications at baseline were less likely to achieve sustained intensive control. The median time to intensive control was 62 days (IQR: 33-96 days), and higher baseline SBP levels, obesity, or diabetes were associated with a longer time to reach intensive control. At the 1-year visit, the medication equivalent was 3.3 in the intensive arm and 2.0 in the standard arm. Male, obese, diabetic patients and those with hypertension duration ≥10 years or baseline SBP ≥140 mm Hg required more medications. Clinic visit frequency in the first year was 6.9 and 5.4 for intensive and standard arms, respectively, and visits decreased during the following years. There was no significant interaction between treatment effects and subgroups of hypertension duration and baseline SBP combination (all P for interaction > 0.05), except for myocardial infarction (P for interaction = 0.019).

For the diverse hypertensive patients with high cardiovascular risk, including those with longstanding uncontrolled BP, sustaining SBP <120 mm Hg is achievable with modest additional medical resources. Applying ESPRIT evidence could improve BP control and reduce cardiovascular burden globally. (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing RIsk of Vascular events Study [ESPRIT]; NCT04030234).