A Tighter Blood Pressure Target Cut Heart Events and Deaths

CATEGORY: HEART & CIRCULATION

Adults with high blood pressure and a high risk of heart disease who were treated to a systolic blood pressure target below 120 had 12% fewer major heart and blood-vessel events over 3.4 years than those treated to the standard target below 140, in a randomized trial of 11,255 people published in The Lancet.¹ Deaths from cardiovascular causes were 39% lower and deaths from any cause 21% lower in the more intensively treated group, at the cost of a small rise in fainting episodes.

The 2015 Trial Excluded Diabetes and Prior Stroke

Systolic pressure is the top number in a blood pressure reading—the pressure in your arteries each time the heart beats. The usual treatment goal has long been to bring it under 140. A landmark U.S. trial in 2015 suggested that pushing it under 120 prevented more heart attacks, strokes and deaths, but it excluded people with diabetes or a previous stroke. The ESPRIT trial was designed to test the lower target in a broader group.¹

116 Chinese Sites, Averages of 119 and 135

Researchers at 116 hospitals and clinics across China enrolled adults aged 50 and older with high blood pressure and high cardiovascular risk, meaning existing heart or blood-vessel disease or at least two major risk factors. About four in ten had diabetes and about a quarter had previously had a stroke. Participants were randomly assigned to have their medication adjusted toward a systolic reading below 120 or below 140. Over the follow-up, the intensive group averaged about 119 and the standard group about 135. Participants and doctors knew the target, but the committee judging each outcome did not. The primary outcome combined heart attack, a procedure to reopen a blocked artery, hospitalization for heart failure, stroke, or cardiovascular death, tracked over a median of 3.4 years.¹

Events in 9.7% Versus 11.1% of Participants

The primary outcome occurred in 9.7% of the intensive group and 11.1% of the standard group—a 12% lower relative risk, or roughly one event avoided for every 75 people treated to the lower target over that period. In counts, 547 people in the intensive group had a primary outcome event, compared with 623 in the standard group.¹ Cardiovascular death was 39% lower and death from any cause 21% lower with intensive treatment, and the benefit was similar with or without diabetes or a prior stroke. Serious fainting was more common in the intensive group (0.4% versus 0.1%), with no significant difference in dangerously low blood pressure, electrolyte problems, injurious falls or acute kidney injury.¹

Artery Walls Stiffen Under Higher, Longer Pressure

Blood pressure works on artery walls the way water pressure works on a garden hose: the higher and longer the pressure, the more the walls stiffen, thicken and become prone to leaks and blockages. Reaching a lower reading usually means an extra medication or a higher dose, which is where side effects such as light-headedness come in—the trade-off the trial was built to measure. Because ESPRIT was randomized, its results carry more weight than an observational study, though it ran in a single country for a few years, so longer-term effects and results elsewhere remain to be seen.¹

Six Trials in 80,220 People Found 24% Lower Risk

A pooled analysis of six randomized trials covering 80,220 people found major cardiovascular events in 5.3% of those treated to the lower target versus 7.1% at the usual one, a 24% lower risk. It counted roughly one event avoided per 58 people treated and one extra episode of fainting or low blood pressure per 55.² A separate trial in 12,821 adults with type 2 diabetes found a 21% lower risk over 4.2 years.³

Key Takeaways

• In 11,255 adults with high blood pressure and high heart-disease risk, aiming for a systolic reading below 120 rather than below 140 was linked to 12% fewer major cardiovascular events over 3.4 years.
• Cardiovascular deaths were 39% lower and deaths from any cause 21% lower in the intensive-target group.
• Serious fainting was more common with intensive treatment (0.4% versus 0.1%), while low blood pressure, falls and kidney injury were not significantly different.
• The benefit held whether or not participants had diabetes or a previous stroke.

References

1. Liu J, Li Y, Ge J, et al.; ESPRIT Collaborative Group. 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):245–255. link
2. Guo X, Sun G, Xu Y, et al.; BPRULE Study Group. Benefit–harm trade-offs of intensive blood pressure control versus standard blood pressure control on cardiovascular and renal outcomes: an individual participant data analysis of randomised controlled trials. The Lancet. 2025;406(10507):1009–1019. link.
3. Bi Y, Li M, Liu Y, et al.; BPROAD Research Group. Intensive blood-pressure control in patients with type 2 diabetes. New England Journal of Medicine. 2025;392(12):1155–1167. link.