Intensive blood pressure (BP) lowering may improve systemic microcirculation and mitigate hypertension-mediated organ damage, according to a secondary analysis of the ESPRIT trial. The study found that targeting a systolic BP of <120 mm Hg led to favourable changes in retinal microvasculature compared to a standard target of <140 mm Hg.¹

This analysis was a prespecified secondary outcome of the Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing RIsk of Vascular evenTs (ESPRIT; NCT04030234) trial. ESPRIT was a multicentre, open-label, randomised controlled trial conducted across 116 sites in China. The trial enrolled adults aged 50 years or older with high cardiovascular risk and a systolic blood pressure (SBP) between 130 and 180 mm Hg.

Participants were randomised 1:1 to either intensive treatment (SBP target <120 mm Hg) or standard treatment (SBP target <140 mm Hg). For this analysis, a subgroup of 1,081 participants from 17 sites underwent colour fundus photography at a 3-year follow-up. The main outcome was the arteriole-venule ratio (AVR), a measure of retinal arteriolar calibre. Other exploratory outcomes included measures of vessel complexity, density, and tortuosity.²

After a median follow-up of 3.5 years, the intensive treatment arm demonstrated a significant improvement in retinal microcirculation. After adjusting for age and sex, the intensive arm showed an increased arteriolar calibre, as evidenced by a higher AVR compared with the standard arm (β = 0.16; 95% CI: 0.05–0.28; p=0.005). This was consistent with an increase in the central retinal arteriolar equivalent (CRAE) (β = 0.14; 95% CI: 0.02–0.25; p=0.02).

No significant effects were observed for venular calibre. The intensive treatment arm also showed significantly increased arteriolar complexity and density, as well as reduced vessel tortuosity, compared with the standard treatment arm. These effects on AVR were consistent across all analysed subgroups, including age, sex, and presence of diabetes.

The findings suggest that a more aggressive BP-lowering strategy can have a positive impact on the microvasculature, which is a key target for hypertension-mediated organ damage. The study authors concluded, “Among hypertensive patients with high cardiovascular risk, lowering systolic blood pressure with a target of <120 mm Hg compared with <140 mm Hg has a favorable impact on retinal microvasculature, providing the first evidence that such intervention may improve systemic microcirculation and mitigate hypertension-mediated organ damage.”¹

Further investigation is warranted to determine whether intensive BP-lowering treatment can prevent or reverse other hypertension-related ocular diseases, such as diabetic retinopathy, glaucoma, and optic neuropathy.

This study was funded by the National High Level Hospital Clinical Research Funding, Fuwai Hospital, the China Academy of Chinese Medical Sciences Innovation Fund for Medical Science, the National Natural Science Foundation of China, the National Key Research and Development Program from the Ministry of Science and Technology of China, and the Internal Project of National Cardiovascular Disease Clinical Research Center, Fuwai Hospital.

References

1. Wang B, Shi D, Zhang Z, et al. Effect of Intensive Blood Pressure Lowering Treatment on Retinal Microvasculature: Secondary Analysis From ESPRIT. JACC. 2025;86(17):1377-1388. https://doi.org/10.1016/j.jacc.2025.05.020

2. Cheung CY, Ikram MK, Sabanayagam C, Wong TY. Retinal microvasculature as a model to study the manifestations of hypertension. Hypertension. 2012;60:1094-1103. https://doi.org/10.1161/hypertensionaha.111.189142

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