Vancouver IM LMR

Nancy Duan (GIM PGY4) reviewed the recently published ESPRIT Trial at GIM Journal Club. See her slide deck here. Journal article can be accessed here.

Abstract:

• Background: in patients with high CV risk, is lowering SBP to < 120mmHg superior compared to < 140mmHg in preventing cardiovascular events, including in patients with diabetes or previous stroke? 
  • Recall that the SPRINT trial (2015) found that SBP target < 120 was superior than < 140 but excluded patients with diabetes or previous stroke.
• Methods: multi-centre, open-label, blinded outcome RCT that enrolled patients with CV disease or at least 2 CV risk factors to intensive treatment group (office SBP < 120) or standard treatment group (office SBP < 140). Primary outcome: composite of MI, revascularization, hospitalization for HF, stroke, or death from CV cause. Intention-to-treat.
  • Overall inclusion and exclusion criteria similar to SPRINT, except:
    • Inclusion: included participants with diabetes and history of stroke
    • Exclusion: excluded participants with eGFR < 45
• Results: 11 255 participants (4359 with diabetes and 3022 with previous stroke). Mean SBP throughout follow up was 119.1 mmHg in the intensive group and 134.8 mmHg in the standard group. Follow up was 3.4 years. The primary outcome occurred in 547 (9.7%) of participants in the intensive group and 623 (11.1%) in the standard group (hazard ratio [HR] 0.88, 95% CI 0.78–0.99; p=0.028). Syncope occurred infrequently but more often in the intensive group (0.4% vs 0.1% of participants). 
  • However, in the supplemental materials, subgroup analysis showed that for the subgroups of participants with diabetes and history of stroke, the primary outcome trended in favour of SBP < 120 but was NOT statistically significant.
• Conclusion: In patients with high CV risk, targeting SBP < 120 mmHg compared to < 140 mm Hg was superior in preventing major vascular events. 
  • What conclusions do you draw from this study? Can you apply it to the patients in your practice with diabetes and/ or history of stroke?