Lower achieved diastolic blood pressure during intensive SBP lowering did not increase stroke risk, showing a positive linear relationship (per 5 mmHg: HR 1.37; 95% CI 1.26-1.49).
RCT (n=11,250)
randomly assigned
Does low achieved diastolic blood pressure, pulse pressure, and mean arterial pressure during intensive systolic blood pressure lowering increase the risk of stroke in high-risk hypertensive patients?
Low achieved diastolic blood pressure, pulse pressure, and mean arterial pressure during intensive systolic blood pressure lowering do not increase the risk of stroke in high-risk hypertensive patients.
Hazard Ratio: 1.37 (95% CI 1.26–1.49)
Abstract Background Intensive systolic blood pressure (SBP) lowering treatment targeting below 120 mm Hg has been shown to reduce cardiovascular events. However, whether low blood pressure indicating cerebral hypoperfusion increasing risk of stroke remains inconclusive. Purpose To investigate the associations of achieved diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) during follow-up with risk of stroke. Methods We conducted a post-hoc analysis using data from the ESPRIT trial. Participants were randomly assigned to intensive treatment targeting attended office SBP 120 mm Hg or standard treatment targeting 140 mm Hg and followed up for three years. The minimal MAP, mean DBP, and mean PP values were calculated for each participant during the follow-up period prior to stroke occurrence or censoring. We used Cox proportional hazards regression models to examine the associations of the mean DBP, mean PP, and minimal MAP during follow-up with risk of stroke. We also examined the non-linear associations by plotting restricted cubic splines with the first deciles as reference. Results We randomized 11250 participants with high cardiovascular risk (3022 with prior stroke). Their mean age was 64.6 ± 7.1 years, and 4650 participants (41.3%) were female. Over the median follow-up period of 3.4 (3.0-3.4) years, mean DBP, mean PP and minimal MAP were 70.3 ± 6.3 mmHg, 51.1 ± 8.1 mmHg, 76.7 ± 5.9 mmHg in the intensive group, and 76.4 ± 7.4 mmHg, 58.6 ± 8.6 mmHg, 84.8 ± 7.0 mmHg in the standard group, respectively. We found a positive linear relationship for the associations of the mean DBP, mean PP, and minimal MAP with stroke (per 5 mmHg: DBP: HR 1.37, 95% CI 1.26, 1.49; PP: HR 1.11, 95% CI 1.04, 1.18; MAP: HR 1.76, 95% CI 1.64, 1.90). We also observed a positive linear relationship for ischemic stroke. However, for hemorrhagic stroke, there was a nonlinear positive relationship between the mean DBP (P for nonlinear = 0.113) and minimal MAP (P for nonlinear = 0.699). The mean PP was not associated with the risk of hemorrhagic stroke. Conclusions Low achieved DBP, PP, and MAP values by SBP lowering treatment does not increase the risk of stroke in hypertensive patients.
Lei et al. (2025) conducted an RCT in Hypertension with high cardiovascular risk (n=11,250). Intensive systolic blood pressure lowering treatment vs. Standard treatment targeting <140 mm Hg was evaluated on stroke (HR 1.37, 95% CI 1.26-1.49). Lower achieved diastolic blood pressure during intensive SBP lowering did not increase stroke risk, showing a positive linear relationship (per 5 mmHg: HR 1.37; 95% CI 1.26-1.49).