Intensive control of blood pressure could safely reduce cardiovascular risk even in frail patients, according to a new study. Post hoc analysis of the Effects of intensive Systolic blood Pressure lowering treatment in reducing Risk of vascular events (ESPRIT) trial showed that across all frailty categories, intensive blood pressure control produced similar relative reductions in major adverse cardiovascular events and all-cause mortality. Notably, statistical analyses showed no significant interaction between frailty status and treatment effect, suggesting that frail patients also benefited from this approach. Frailty and treatment effect “Hypertensive patients with high cardiovascular risk benefit from the treatment strategy of targeting systolic BP <120 mm Hg, regardless of their frailty status,” wrote the authors of the paper, led by Shitian Li, MD, from the National Center for Cardiovascular Disease in Beijing. “In addition, the effects of intensive treatment on experiencing adverse events did not differ by frailty status.” The trial, which appears in the January 12 issue of the Journal of the American College of Cardiology, included 11,255 hypertensive patients at high cardiovascular risk. They were randomly assigned to intensive systolic blood pressure control targeting <120 mm Hg or standard treatment targeting <140 mm Hg. Participants were categorized as nonfrail, moderately frail or severely frail using a validated frailty index, with nearly 15% meeting criteria for severe frailty. The trial also found that frail participants did experience higher overall rates of serious adverse events, but these increases were attributed to frailty itself rather than to intensive blood pressure lowering. Rates of hypotension, syncope, electrolyte abnormalities, injurious falls, and acute kidney injury did not differ meaningfully between intensive and standard treatment across frailty groups. Clinical challenge “Most severely frail patients can achieve the target of SBP <120 mm Hg, although the process of reaching the target was slower with increasing frailty. This likely reflects the clinical challenge of managing polypharmacy and medication titration in severely frail patients,” the authors wrote. The research team also noted a higher risk of kidney function decline with intensive treatment, but this effect was consistent across frailty levels and did not translate into higher rates of severe renal events. They said that careful monitoring and individualized adjustment of therapy remained essential, particularly for patients with complex comorbidities. Discussing clinical approaches, the authors said that careful patient selection, gradual titration and close monitoring allowed many frail patients to achieve cardiovascular benefit without an excess risk of treatment-related harm. Source: Li S, Peng Y, Li Y, et al. Effects of Intensive Blood Pressure Control in Patients With Frailty: A Post Hoc Analysis From ESPRIT. J Am Coll Cardiol. 2026;87:4–16. Image Credit: may1985 – stock.adobe.com