2024 Top Story in Cardiology: The ESPRIT Trial

Hypertension remains a common and undertreated cardiovascular risk factor throughout the world. The recommended target for the treatment of high blood pressure (BP) has long been a systolic BP of less than 140 mm Hg. The SPRINT trial¹ did show that targeting a systolic BP of less than 120 mm Hg was better than 140 mm Hg in patients at high cardiovascular risk but without diabetes or stroke. The ESPRIT trial² has now validated and extended the SPRINT findings to include patients with diabetes or stroke.

ESPRIT was an open-label, blinded-outcome, randomized trial conducted in Chinese patients. A total of 11,255 patients were randomized, of whom 4359 had diabetes and 3022 had a prior stroke. The average age was 65 years, with 25% aged 70 years or older. The average systolic BP was 119 mm Hg in the intensive group and 135 mm Hg in the standard group — both reflecting better control than seen in many real-world settings. During a median follow-up period of 3.4 years, the primary endpoint of myocardial infarction, revascularization, hospitalization for heart failure, stroke, and cardiovascular death occurred in 9.7% of the intensive group versus 11.1% of the standard group (HR, 0.88; P = .028). Syncope was more frequent in the intensive group (0.4% vs 0.1%); however, the rates of serious hypotension, electrolyte abnormalities, falls, and acute kidney injury were comparable.

Therefore, given the global implications, ESPRIT is the top story in cardiology for 2024. Furthermore, based on the totality of data, for patients with hypertension at high cardiovascular risk, the appropriate BP target should now be less than 120 mm Hg, provided it can be achieved without adverse effects and with caution in frail, older populations.