Kreutz Reinhold, Brunström Mattias
Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.
Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
Clin Hypertens. 2025 May 1;31:e20. doi: 10.5646/ch.2025.31.e20. eCollection 2025.
Recent studies have renewed the debate over optimal systolic blood pressure (SBP) targets in hypertensive patients, particularly those at increased cardiovascular (CV) risk and with type 2 diabetes mellitus (T2DM). The Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events (ESPRIT) and Blood Pressure Control Target in Diabetes (BPROAD) randomized controlled trials, both conducted in Chinese populations, offer new insights into intensive versus standard SBP-lowering strategies. ESPRIT enrolled 11,255 patients with high CV risk (including 38.7% with T2DM), while BPROAD included 12,821 hypertensive patients with T2DM and elevated CV risk. Both trials compared intensive SBP lowering (< 120 mmHg) with standard treatment (< 140 mmHg). Results from both studies showed that intensive treatment significantly reduced the incidence of major adverse cardiovascular events (MACE). ESPRIT reported a hazard ratio (HR) of 0.88 for MACE, along with notable reductions in CV and all-cause mortality. BPROAD similarly found a HR of 0.79 for MACE, although it did not demonstrate a statistically significant benefit in all-cause mortality. However, intensive treatment in both trials was associated with higher-though relatively low-absolute rates of adverse events, including hypotension, syncope, and renal impairment. When considered alongside previous trials, our meta-analysis suggests a consistent reduction in MACE risk with intensive SBP control. Nevertheless, concerns remain regarding the safety profile and generalizability of these findings, particularly given that both ESPRIT and BPROAD were limited to ethnically Chinese cohorts and reported unusually low adverse event rates compared to Western studies. In summary, the cumulative evidence suggests that an SBP target < 140 mmHg may be suboptimal. However, whether a target < 120 mmHg is superior to the current guideline-recommended range of 120-129 mmHg remains uncertain. No trials have directly compared < 120 mmHg with < 130 mmHg. Therefore, future research should determine whether the additional benefits of more aggressive SBP lowering outweigh potential risks, especially in diverse populations with and without diabetes.
近期研究再次引发了关于高血压患者最佳收缩压（SBP）目标的争论，尤其是那些心血管（CV）风险增加且患有2型糖尿病（T2DM）的患者。在中国人群中进行的强化收缩压降低治疗降低血管事件风险（ESPRIT）和糖尿病血压控制目标（BPROAD）随机对照试验，为强化与标准SBP降低策略提供了新的见解。ESPRIT纳入了11255例高CV风险患者（包括38.7%的T2DM患者），而BPROAD纳入了12821例患有T2DM且CV风险升高的高血压患者。两项试验均比较了强化SBP降低（<120 mmHg）与标准治疗（<140 mmHg）。两项研究的结果均表明，强化治疗显著降低了主要不良心血管事件（MACE）的发生率。ESPRIT报告MACE的风险比（HR）为0.88，同时CV和全因死亡率显著降低。BPROAD同样发现MACE的HR为0.79，尽管在全因死亡率方面未显示出统计学上的显著益处。然而，两项试验中的强化治疗均与较高（尽管相对较低）的不良事件绝对发生率相关，包括低血压、晕厥和肾功能损害。与之前的试验一起考虑时，我们的荟萃分析表明强化SBP控制可一致降低MACE风险。然而，这些发现的安全性和普遍性仍存在担忧，特别是考虑到ESPRIT和BPROAD均限于中国人群队列，且与西方研究相比报告的不良事件发生率异常低。总之，累积证据表明SBP目标<140 mmHg可能不是最佳的。然而，目标<120 mmHg是否优于当前指南推荐的120 - 129 mmHg范围仍不确定。尚无试验直接比较<120 mmHg与<130 mmHg。因此，未来的研究应确定更积极降低SBP的额外益处是否超过潜在风险，特别是在有或没有糖尿病的不同人群中。
