Intensive Treatment Leads to Lower CV Events In Older Patients with Hypertension

Weili Zhang, MD, PhD

Although the aging of the population has led to research into treatment target for systolic blood pressure in older patients with hypertension, there are inconsistencies in current guideline recommendations for the blood-pressure targets.

As a result, a recent study investigated the appropriate target for systolic blood pressure to reduce cardiovascular risk in older patients with hypertension.

Investigators, led by Weili Zhang, MD, PhD, Hypertension Center, FuWai Hospital, observed older patients with hypertension showed lower incidence of CV events following intensive treatment with a systolic blood pressure target of 110 to <130 mm Hg.

The study was presented online at the European Society of Cardiology (ESC) 2021 Congress.

Methods

The STEP trial was a randomized controlled trial that took place at 42 clinical centers throughout China. From January - December 2017, patients 60 - 80 years of age with hypertension and a systolic blood-pressure of 140 - 190 mm Hg were eligible for the study.

Eligible patients were then randomized on a 1:1 ratio to a systolic blood-pressure target of 110 to <130 mm Hg (intensive treatment) or a target of 130 to <150 mm Hg (standard treatment).

Patients were followed-up with a 1, 2, and 3 months, followed by every 3 months after until 48 months. They were provided with an automated, home blood-pressure monitor with an app used to upload readings to a data-recording center.

The primary outcome in the study 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.

In addition, secondary outcomes were specified, including individual components of the primary outcome, death from any cause, major adverse cardiac events, and renal outcomes.

Results

A total of 9624 patients were screened for eligibility, with 8511 patients enrolled in the trial. After randomization, a total of 4243 patients were randomized to the intensive-treatment group and 4268 patients randomized to the standard treatment group. Investigators noted 234 patients (2.7%) were lost to follow-up before trial end.

During 1 year of follow-up, data show 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.

Further, over a median follow-up of 3.34 years, primary-outcome events happened in 147 patients in the intensive-treatment group. In comparison, the standard-treatment group saw primary outcome events in 196 patients (HR 0.74; 95% CI, 0.60 - 0.92, P = .007).

In addition, most individual components of the primary outcome favored intensive treatment. Data show the HR for stroke at 0.67 (95% CI, 0.47 - 0.97), acute coronary syndrome at 0.67 (95% CI, 0.47 - 0.94), and acute decompensated heart failure at 0.27 (95% CI, 0.08 - 0.98).

Further, they found the HR for coronary revascularization at 0.69 (95% CI, 0.40 - 1.18), atrial fibrillation at 0.96 (95% CI, 0.55 - 1.68, and death from cardiovascular causes at 0.72 (95% CI, 0.39 - 1.32).

The team noted safety and renal outcome results did not have significant differences between the 2 groups, except for incidence of hypotension showing higher rates in the intensive-treatment group.

Conclusion

The team concluded intensive treatment with systolic blood-pressure targets of 110 to <130mm Hg in older patients with hypertension resulted in a lower incidence of CV events in standard treatment with a target of 130 to <150 mm Hg.

“However, caution is advised when generalizing the results to populations that were not included in the trial, including patients with a history of stroke,” investigators wrote.

The study, “Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension,” was published online in the New England Journal of Medicine.