Reference: N Engl J Med. 2021 Aug 30
Recommendations regarding systolic blood pressure goals vary considerably by organization. Ranging from 120 to 150 mm Hg, no matter what target is picked, there is likely a prominent guideline supporting this number. Lower blood pressure targets were supported by the influential SPRINT trial, despite some threats to validity and the lack of generalizability of that study. Still, among older individuals in particular, clinicians need to carefully balance the risk of hypotension and subsequent sequelae with the benefits of reduced cardiovascular events.
Investigators in China conducted a multicenter, unblinded randomized trial (the STEP trial) comparing a systolic goal of 110-129 versus 130-149 mm Hg. Participants included 8,511 adults between 60-80 years old of Han ethnicity with a mean systolic blood pressure of 146 mm Hg at baseline. About one-fifth had type 2 diabetes (18.9% in intensive control and 19.4% in standard control group) and about one-third had hyperlipidemia (37.5% vs. 36.1% respectively). Patients with a history of stroke, diastolic blood pressure <60 mm Hg, or HbA1C >8.0% were excluded. After 5 minutes of rest, three blood pressure measurements were obtained by trained staff over three minutes and results were averaged. Patients were followed for a mean of 3.34 years; the trial was stopped early due to evidence of benefit in the intensive control group.
The mean systolic blood pressure was 128 mm Hg in the intensive control arm and 135 mm Hg in the standard control group. Fewer patients in the intensive control group experienced the primary composite outcome of stroke, acute coronary syndrome, atrial fibrillation, coronary revascularization, decompensated heart failure, and cardiovascular death compared with standard treatment (3.5% vs. 4.6, respectively, hazard ratio [HR] 0.74; 95% CI 0.60-0.92). Individual outcomes that were significantly reduced included stroke, acute coronary syndrome, and acute decompensated heart failure. There was no difference in death from any cardiovascular cause (0.4% vs. 0.6%, respectively, HR 0.72; 95% CI 0.39-1.32) or death from any cause (1.6% v. 1.5%, respectively, HR 1.11; 95% CI 0.78-1.16). There were more episodes of hypotension in the intensive control group (3.4% vs. 2.6%, HR 1.31; 95% 1.02-1.68), while rates of dizziness, syncope, and fracture were similar in both groups.
Based upon these data, it appears lowering blood pressure for older adults to a systolic pressure goal of 110-129 mm Hg reduces the risk of some cardiovascular events without imposing excess harm. Compared to SPRINT, strengths of this trial include more realistic blood pressure measurements and broader inclusion criteria. However, including only individuals of Han descent and excluding patients with diabetes who had elevated HbA1C measurements limits generalizability. Stay tuned for more changes in the guidelines as lower might just be better—-even for older adults.
For more information, see the topic Hypertension Medication Selection and Management in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency; Edited by, Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Dan Randall, MD, Deputy Editor at DynaMed; Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed; Nicole Jensen, MD, family physician at WholeHealth Medical; Vincent Lemaitre, PhD, Medical Writer at DynaMed and Christine Fessenden, Editorial Operations Assistant at DynaMed.