Targeting a systolic blood pressure of 110 mmHg but below 130mmHg with aggressive treatment of elderly patients with hypertension reduced the occurrence of cardiovascular events when compared to the standard treatment with systolic BP target ranging from 130 to 150 mm Hg. These findings from the STEP trial have been published in the New England Journal of Medicine and were also presented at the recently concluded European Society of Cardiology (ESC) Congress.

There were 8511 participants, aged 60 to 80 years, in this multicenter trial. At the time of recruitment, they had a SBP of 140–190 mmHg or were on antihypertensive treatment. Patients with a previous history of stroke were not included in the trial. The patients were randomized to the intensive-treatment group (n=4243) or to the standard-treatment group (n=4268). This study also took into consideration monthly home BP monitoring as adjunct to office BP measurements through an app linked to an automatic home blood pressure monitor via Bluetooth.

The average reduction in systolic BP during the 3.34-year follow-up period was 20.4 mmHg in the intensive treatment group versus 10.8 mmHg in the standard treatment group. The average systolic BP was lower in the intensive-treatment group in comparison to the standard-treatment group; 125.6mm Hg vs 135.2 mm Hg, respectively, with an average between-group difference of 9.6 mmHg

At 3.34 years, more patients (196;4.6%) in the standard treatment group suffered a cardiovascular event in the form of stroke, acute MI, atrial fibrillation, acute decompensated heart failure or underwent revascularization or died from cardiovascular causes compared to patients who were intensively treated (147;3.5%) with a relative risk reduction of 25%. 

The hazard ratio for cardiovascular events also favored intensive treatment: stroke and acute coronary syndrome 0.67, acute decompensated heart failure 0.27, coronary revascularization 0.69, atrial fibrillation 0.96 and death from cardiovascular causes 0.72. Measurement of brachial-ankle pulse velocity showed slower progression of arterial stiffness in the intensive treatment group

Except for hypotension, which was reported by a larger number of patients in the intensive treatment group (146 patients vs 113), patients in both treatment groups had similar rates of adverse events and renal outcomes. However, at this point of time, we do not have enough details to further characterise the hypotension in terms of how severe it was, did it necessitate discontinuation of treatment etc.

Based on their findings, the researchers concluded that actively treating older adults with hypertension to lower systolic BP below 130mmHg but not less than 110, prevented major cardiovascular events, with no adverse impact on kidney function. It is pertinent to emphasize here that since we do not know the number of participants in each age group, we cannot say exactly how each age group responded to the treatment that they were assigned to. The results herein talk of an overall reduction in systolic BP in the intensive treatment group vis-à-vis standard treatment group.

Source: Zhang W, et al. Trial of intensive blood-pressure control in older patients with hypertension. N Engl J Med. DOI: 10.1056/NEJMoa2111437: ESC News August 30, 2021