Intensive blood pressure (BP) control targeting a systolic blood pressure (SBP) of <120 mm Hg significantly reduces the risk of haemorrhagic stroke compared to standard treatment, according to a secondary analysis of the ESPRIT trial.¹ While the overall risk of stroke was not significantly reduced over the entire follow-up, the preventive effect emerged after one year of intervention.

The ESPRIT (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events) trial was a multicentre, open-label, randomised controlled study conducted across 116 sites in China. The trial enrolled 11,255 hypertensive patients (mean age 64.6 years; 41.3% female) with high cardiovascular risk, including 3,022 with a history of previous stroke.²

Participants were randomly assigned on a 1:1 basis to either an intensive treatment group, with a target SBP of <120 mm Hg, or a standard treatment group, with a target SBP of <140 mm Hg. The prespecified secondary outcome for this analysis was the incidence of stroke, with post-hoc analyses conducted on stroke subtypes. The median follow-up was 3.4 years.

During the follow-up period, the mean SBP achieved was 119.1 mm Hg in the intensive arm and 134.8 mm Hg in the standard arm. Overall, stroke occurred in 4.7% of participants in the intensive group versus 5.4% in the standard group, a difference that was not statistically significant (HR: 0.86; 95% CI: 0.73–1.02; p=0.083).

However, analysis of stroke subtypes revealed a significant difference. The risk of haemorrhagic stroke was halved in the intensive treatment group compared to the standard group (0.4% vs 0.8%; HR: 0.51; 95% CI: 0.31–0.85; p=0.009). There was no significant difference in the risk of ischaemic stroke between the groups (4.3% vs 4.6%; HR: 0.93; 95% CI: 0.78–1.11; p=0.423).

A landmark analysis showed that the risk difference for overall stroke emerged after the first year of treatment. For the period beyond one year, intensive treatment was associated with a significantly lower risk of stroke (HR: 0.75; 95% CI: 0.60–0.94; p=0.011). The effects were consistent across all prespecified subgroups, including patients with a history of stroke or orthostatic hypotension.

This analysis of the ESPRIT trial suggests that while an intensive SBP target of <120 mm Hg does not significantly reduce the overall incidence of stroke over a 3.4-year period, it provides a substantial benefit in preventing haemorrhagic stroke without increasing the risk of ischaemic stroke. The ESPRIT Collaborative Group noted that, 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.”¹

The authors concluded that due to the explorative nature of the post-hoc analysis, further studies are needed to confirm these findings.

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, and Chinese Academy of Medical Sciences.

References

1. Li J, Lei L, Li Y, et al. Effect of Intensive Blood Pressure Control on Stroke: A Prespecified Secondary Analysis of the ESPRIT Trial. JACC. 2025;86(17):1405–17. https://doi.org/10.1016/j.jacc.2025.07.055

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(10449):245–55. https://doi.org/10.1016/s0140-6736(24)01028-6

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