A Tighter Blood Pressure Target Cut Heart Events and Deaths

CATEGORY: HEART & CIRCULATION

Blood pressure treatment has long aimed at getting the top number under 140. A randomized trial of 11,255 adults tested a target of under 120 instead, and over 3.4 years the lower target produced 12% fewer major heart and blood-vessel events.¹ Deaths from cardiovascular causes were 39% lower and deaths from any cause 21% lower, at the cost of a small rise in fainting episodes. Everyone enrolled had high blood pressure and a high risk of heart disease. The results appeared in The Lancet.

Why Going Under 120 Was Worth Testing Again

Systolic pressure is the top number in a reading. It measures the push against your artery walls each time the heart beats. A landmark American trial in 2015 suggested that driving it under 120 prevented more heart attacks, strokes and deaths than the usual goal of 140. That trial left out people with diabetes or a previous stroke, which limited how far its answer reached. ESPRIT was built to test the lower target in a broader group.¹

116 Chinese Sites, With the Outcome Judges Kept in the Dark

Researchers at 116 hospitals and clinics across China enrolled adults aged 50 and older who had 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; roughly a quarter had already had a stroke. Which target a person’s medication was adjusted toward came down to a random allocation rather than a doctor’s judgment. Over the follow-up, the intensive group averaged about 119 and the standard group about 135. Patients and their doctors could see which target they were chasing, but the committee judging each outcome could not. That outcome combined heart attack, stroke, hospitalization for heart failure, an artery-clearing procedure, and cardiovascular death, tracked over a median of 3.4 years.¹

9.7% Versus 11.1%, and One Event Avoided per 75 People

The primary outcome struck 9.7% of the intensive group and 11.1% of the standard group. That is a 12% lower relative risk. In counts, 547 people in the intensive group had such an event, against 623 in the standard group.¹ Cardiovascular death came out 39% lower and death from any cause 21% lower with intensive treatment, and the benefit held whether or not a person had diabetes or a prior stroke. Serious fainting was the clear downside, at 0.4% against 0.1%. Dangerously low blood pressure, electrolyte problems, injurious falls and acute kidney injury showed no significant difference.¹

What the Lower Reading Costs

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 turn prone to leaks and blockages. Getting a reading down usually takes an extra medication or a higher dose, which is where light-headedness comes in. That trade-off is what the trial measured. Randomization makes ESPRIT weightier evidence than any observational study, though it ran in one country over a few years, leaving longer-term effects and results elsewhere open.¹

Larger pools of data agree. 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

• Treating to a systolic reading below 120 rather than below 140 produced 12% fewer major cardiovascular events over 3.4 years among 11,255 adults at high risk.
• Cardiovascular deaths were 39% lower and deaths from any cause 21% lower in the intensive-target group.
• Serious fainting was more common with the lower target, 0.4% against 0.1%, while low blood pressure, falls and kidney injury did not differ significantly.
• The benefit appeared 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.