Intensive BP-lowering effective for high CVD risk patients regardless of frailty

ACC.25 – A post-hoc analysis of ESPRIT among hypertensive patients at high CVD risk showed their frailty status did not modify the effect of BP-lowering treatment targeting SBP <120 mmHg versus <140 mmHg.

This summary is based on the presentation of Shitian Li, MD (Beijing, China) at the ACC.25 Scientific Session - Homogeneous Effects Of Intensive Blood Pressure Control In Patients With Various Frailty Status: A Post-hoc Analysis Of The Esprit Trial.

Introduction and methods

Recently, the ESPRIT (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing RIsk of Vascular evenTs) trial showed a treatment strategy targeting systolic blood pressure (SBP) <120 mmHg reduced the risk of MACE compared with targeting SBP <140 mmHg, with minor excess risk. However, the risk–benefit profile of intensive BP-lowering treatment in frail patients with hypertension is uncertain.

This was a post-hoc analysis of the ESPRIT trial, a multicenter, open-label, blinded-outcome RCT conducted in China. In this trial, 11,255 patients with hypertension and high CVD risk were randomized to intensive BP-lowering treatment (target SBP <120 mmHg) or standard treatment (target SBP <140 mmHg). Median follow-up time was 3.4 years.

The primary endpoint was the incidence of MACE, a composite outcome of MI, revascularization, HF hospitalization or urgent HF visit, stroke, or CV death. Secondary endpoints included all-cause mortality and a composite kidney outcome (end-stage kidney disease, sustained eGFR decline to <10 mL/min/1.73 m², kidney death, or sustained eGFR decline ≥40%). Safety endpoints included hypotension, electrolyte abnormalities, injurious falls, and acute kidney injury.

In this post-hoc analysis, participants were categorized using a frailty index (FI) based on the Rockwood cumulative deficit approach: 2134 patients (19.0%) were non-frail (FI ≤0.210), 5771 (51.3%) were moderately frail (FI 0.211–0.310), and 3350 (29.8%) were severely frail (FI ≥0.311).

Main results

• During follow-up, similar proportions of patients in the standard-treatment group reached the BP target regardless of frailty status, whereas frail patients in the intensive-treatment group achieved the BP target more slowly than non-frail patients.
• However, the achieved SBP and diastolic BP at the end of the follow-up were comparable across frailty subgroups in the 2 study arms.
• Frailty did not modify the effect of intensive versus standard treatment on the risks of MACE, all-cause mortality, and the composite kidney outcome (all P for interaction>0.05).
• Stratified analysis by age (<70 vs. ≥70 years) showed similar results.
• The incidence of serious adverse events was low and did not differ across frailty subgroups, except for the frequency of injurious falls (P for interaction=0.007).

Conclusion

This post-hoc analysis of the ESPRIT trial among hypertensive patients at high CVD risk demonstrated their frailty status did not modify the effect of intensive BP-lowering treatment targeting SBP <120 mmHg versus standard treatment targeting SBP <140 mmHg. Dr. Li summarized the results as follows: “Treating 1000 participants in the severely-frail group with intensive BP control for 3.4 years will prevent 30 MACE, 21 all-cause deaths but induce 16 composite kidney outcomes and 7 injurious falls. Our findings support adopting the intensive BP control strategy targeting SBP <120 mmHg in hypertensive patients with high CVD risk regardless of frailty status.”

- Our reporting is based on the information provided at the ACC.25 Scientific Session -