"Continuing SPRINT legacy", STEP trial shows aggressive BP lowering beneficial in elderly too

The appropriate target for systolic blood pressure to reduce cardiovascular risk in older patients with hypertension remains unclear. Zhang et al have conducted the STEP trial which investigated the veracity of the findings of the previous trial SPRINT in an older cohort. The results published in NEJM today showed that intensive treatment with a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than 150 mm Hg.

With aging of the population, determination of the treatment target for systolic blood pressure in older patients with hypertension has become a focus of research. Current guideline-based recommendations for the systolic blood-pressure target in older patients remain inconsistent.

The target is less than 150 mm Hg in the American College of Physicians–American Academy of Family Physicians guideline, 130 to 139 mm Hg in the European guideline, and less than 130 mm Hg in the American College of Cardiology–American Heart Association guideline.

Impressive cardiovascular benefits were observed with intensive blood-pressure control (systolic blood-pressure target, <120 mm Hg), as compared with standard blood-pressure control (target, <140 mm Hg), in the Systolic Blood Pressure Intervention Trial (SPRINT), even in patients 75 years of age or older.

Authors conducted the STEP trial to assess whether intensive treatment would reduce cardiovascular risk to a greater extent than standard treatment in 60 to 80 years of age with hypertension. Moreover, they used a smartphone-based application (app) to examine home blood pressure as an adjunct to office blood pressure during the follow-up period.

The primary outcome was a composite of stroke, acute coronary syndrome (acute myocardial infarction and hospitalization for unstable angina), acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes.

At 1 year of follow-up, the mean systolic blood pressure was 127.5 mm Hg in the intensive-treatment group and 135.3 mm Hg in the standard-treatment group.

During a median follow-up period of 3.34 years, primary-outcome events occurred in 147 patients (3.5%) in the intensive-treatment group, as compared with 196 patients (4.6%) in the standard-treatment group (P=0.007).

The results for most of the individual components of the primary outcome also favoured intensive treatment: the hazard ratio for stroke was 0.67, 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.

The results for safety and renal outcomes did not differ significantly between the two groups, except for the incidence of hypotension, which was higher in the intensive-treatment group.

Is it time to redefine hypertension??

"We continue to manage blood pressure as an isolated risk factor rather than as an integrated part of a patient's risk profile because we adhere to the rusted-on clinical concept of hypertension. According to this concept, there is an arbitrary number above which disease is present and below which it is absent. The STEP trial and SPRINT tell us that now is an opportune time to return elevated blood pressure to its status as a continuous-variable risk factor, instead of treating it as a dichotomous disease", notes Mark R. Nelson, M.B., B.S., M.F.M., Ph.D. in an accompanying editorial.

"Although SPRINT showed that a systolic blood-pressure target of less than 120 mm Hg was associated with cardiovascular benefits, practical issues have been raised with regard to this treatment strategy. Such a low systolic blood-pressure target is challenging to reach and can result in higher medication costs and more frequent clinic visits", caution authors in discussion.

Source: NEJM:

1. DOI: 10.1056/NEJMoa2111437

2. DOI: 10.1056/NEJMe2112992