The randomized controlled STEP trial revealed that lowering the systolic blood pressure (SBP) to below 130 mmHg in patients over 60 years led to a 26% reduction of adverse cardiovascular (CV) events [1]. A target SBP below 130 mmHg did not increase serious adverse events.

“This study is important because it addresses a very simple question: When treating BP in older people, how low should we go,” expressed the trial discussant Prof. Bryan Williams (University College London, UK) [2]. STEP (NCT03015311) investigated intensive blood pressure (BP) treatment from 110 mmHg to <130 mmHg as SBP target versus standard therapy with SBP between 130 mmHg and <150 mmHg. The study enrolled 8,511 patients between 60–80 years of age who had no history of a prior stroke. BP medications consisted of olmesartan, amlodipine, and hydrochlorothiazide. The measuring of BP was either performed by trained personnel in an office setting or at home with a smartphone app as a monitoring device. Furthermore, various examinations were executed at baseline and throughout the control visits including ECG, echocardiography, and cognitive function testing. The primary outcome was a composite of adverse CV events (i.e. stroke, acute coronary syndrome, revascularization, decompensation of heart failure, atrial fibrillation, CV mortality). Baseline findings of the study population included a mean age of 66.2 years, just over half of the participants were women, and about 19% had diabetes.

“After randomization, the 2 treatment strategies resulted in a rapid and sustained between-group difference in SBP,” Prof. Jun Cai (FuWai Hospital, China) pointed out. Over a median follow-up of 3.34 years, the event rate for the primary outcome was 3.5% on intensive treatment and 4.6% on standard therapy. Intensive treatment reduced the likelihood of primary outcome by 26% (HR 0.74; 95% CI 0.60–0.92; P=0.007). Prof Cai highlighted that the intensive BP lowering approach provided a significant 33% reduction in stroke and acute coronary syndrome, 28% in major adverse cardiac events, and 73%  reduction in heart failure. However, no significant decrease was seen in all-cause mortality, atrial fibrillation, or coronary revascularisation.

As for safety outcomes, there was a significant difference in the rate of hypotension events (3.4% intensive group vs 2.6% standard group; P=0.03), but none concerning dizziness, severe events such as syncopes or fractures nor deterioration of renal function. “The STEP results support that the SBP target in older patients should be set lower than 130 mmHg for better CV benefits without increasing serious adverse events as well as renal injuries”, concluded Prof Cai.

  1. Cai J. STEP Study: intensive vs. standard blood pressure control among older hypertensive patients. Hot Line Session, ESC Congress 2021, 27–30 August.
  2. Willams B. STEP Study – Discussant review. Hot Line Session, ESC Congress 2021, 27–30 August.

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