More Blood Pressure Control is Better than Less Blood Pressure Control

The epidemiological evidence of recent years shows that a greater control of blood pressure is beneficial, reducing mortality and incidence of age-related conditions. Hypertension, raised blood pressure, is characteristic of age and very damaging to fragile tissues throughout the body. That damage adds up over time, and is a major contribution to age-related degeneration. A sizable component of age-related hypertension is lifestyle related, rather than an inexorable consequence of the mechanisms of aging, and thus avoidable. Further, a range of comparatively safe drugs can force a lowering of blood pressure, overriding dysfunction in blood pressure regulation. Even without addressing underlying causes related to the mechanisms of aging, this can produce a meaningful reduction in mortality and cardiovascular disease.

Aggressive blood pressure treatment in older hypertensive patients lowers the incidence of cardiovascular events compared to standard therapy, without increasing adverse outcomes. More than one billion people have hypertension worldwide. The overall prevalence in adults is around 30-45%, rising to more than 60% of people over 60 years of age. As populations age, adopt more sedentary lifestyles, and increase their body weight, the prevalence of hypertension worldwide will continue to rise. Elevated blood pressure was the leading global contributor to premature death in 2015, accounting for almost 10 million deaths.

The STEP study was conducted to provide new evidence on the benefits of blood pressure lowering in older patients with hypertension. Specifically, it examined whether intensive treatment targeting a systolic blood pressure (SBP) below 130 mmHg could reduce the risk of cardiovascular disease compared with a SBP target below 150 mmHg. The study enrolled 8,511 older essential hypertensive patients from 42 clinical sites in China. All participants were aged 60-80 years, with a SBP of 140-190 mmHg during three screening visits or taking antihypertensive medication. Patients with prior stroke were excluded.

Participants were randomly assigned to 1) intensive treatment (SBP target below 130 mmHg but no lower than 110 mmHg); or 2) standard treatment (SBP target 130-150 mmHg). uring a median 3.34-year follow-up period, the average decrease in SBP from baseline was 19.4 mmHg in the intensive treatment group and 10.1 mmHg in the standard treatment group. Average SBP reached 126.7 mmHg and 135.9 mmHg in the intensive and standard groups, respectively, with an average between-group difference of 9.2 mmHg.

The primary outcome was a composite of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularisation, atrial fibrillation, or death from cardiovascular causes. A total of 196 primary outcome events were documented in the standard treatment group (4.6%) compared to 147 events in the intensive treatment group (3.5%), with a relative risk reduction of 26%.