Intensive blood pressure (BP) control is beneficial for high-risk hypertensive patients, regardless of their frailty status, according to a new post hoc analysis of the ESPRIT trial.¹ The findings suggest that even severely frail patients can safely achieve cardiovascular benefits from a lower systolic BP target.
Methodology
This analysis was conducted on data from the ESPRIT (Effects of intensive Systolic blood Pressure lowering treatment in reducing RIsk of vascular evenTs) trial, a multicentre, open-label, randomised controlled study in China.² The trial enrolled 11,255 hypertensive patients (average age 64.6 years) with high cardiovascular risk.
Participants were categorised by baseline frailty index (FI) into three groups: nonfrail (38.8%), moderately frail (46.7%), and severely frail (14.5%). They were randomised to either an intensive treatment strategy, targeting a systolic blood pressure (SBP) of <120 mm Hg, or a standard treatment strategy, targeting an SBP of <140 mm Hg.
The primary outcome for this analysis was major adverse cardiovascular events (MACE), a composite of myocardial infarction, hospitalisation for heart failure, stroke, or death from cardiovascular diseases. Secondary outcomes included all-cause death and safety events.
Results
The effects of intensive BP control on MACE did not significantly differ across the levels of frailty (P for interaction=0.67). The risk ratios (RR) for MACE in the intensive versus standard treatment groups were:
- Nonfrail: RR 0.84 (95% CI: 0.65–1.08)
- Moderately frail: RR 0.83 (95% CI: 0.70–0.99)
- Severely frail: RR 0.86 (95% CI: 0.69–1.08)
A similar pattern was observed for all-cause mortality, with no significant interaction by frailty status. While greater absolute risk reductions for MACE and death were seen with increasing frailty, the interactions were not statistically significant.
Regarding safety, the effects of intensive treatment on serious adverse events (SAEs), including hypotension, syncope, injurious falls, and acute kidney injury, did not differ by frailty status.
In Practice/Interpretation
These findings suggest that the presence of frailty, even when severe, should not preclude high-risk patients from receiving intensive BP-lowering therapy. The ESPRIT Investigators concluded, “Hypertensive patients with high cardiovascular risk benefit from the treatment strategy of targeting systolic BP <120 mm Hg, regardless of their frailty status.”¹ They also noted that the effects of intensive treatment on adverse events did not differ by frailty.
This study provides important hypothesis-generating data for a patient population often underrepresented in clinical trials, supporting a patient-centred approach that includes cautious titration of therapy and close monitoring.
This study was funded by the China Academy of Chinese Medical Sciences Innovation Fund for Medical Science, the National Key Research and Development Program from the Ministry of Science and Technology of China, and the Independent Project of National Cardiovascular Disease Clinical Research Center, Fuwai Hospital.
References
1. Li S, Peng Y, Li Y, et al. Effects of Intensive Blood Pressure Control in Patients With Frailty: A Post Hoc Analysis From ESPRIT. JACC. 2026 Jan, 87 (1) 4–16. https://doi.org/10.1016/j.jacc.2025.08.092
2. Liu J, Li Y, Ge J, et al. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. Lancet. 2024;404:245-255. https://doi.org/10.1016/S0140-6736(24)01028-6
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