New long-term data from the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial suggests that sustained, intensive blood pressure (BP) control provides greater cardiovascular benefits compared to a delayed approach in older patients with hypertension.¹ The findings also indicate that the earlier intensive treatment is initiated, the greater the reduction in cardiovascular risk.
The STEP trial was a multicentre, randomised controlled trial involving 8,511 Chinese patients aged 60–80 years with hypertension.² Initially, participants were assigned to either an intensive treatment group, with a systolic blood pressure (SBP) target of 110 to <130 mmHg, or a standard treatment group, with an SBP target of 130 to <150 mmHg.
Following the original trial period, all surviving patients entered an extended follow-up phase where they received intensive BP control. The original intensive treatment group was designated the 'sustained intensive treatment' group, while the standard treatment group became the 'delayed intensive treatment' group. The primary outcome was a composite of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularisation, atrial fibrillation, or death from cardiovascular causes.
After a median follow-up of 6.11 years, the sustained intensive treatment group had a significantly lower incidence rate of the primary composite outcome compared to the delayed intensive treatment group (1.12% per year vs 1.33% per year; HR: 0.82; 95% CI: 0.71–0.96).¹
Among secondary outcomes, the risk of stroke was notably lower in the sustained intensive treatment group (HR: 0.72; 95% CI: 0.55–0.94). There were no significant differences between the groups for other secondary outcomes, including death from any cause.
Regarding safety, the incidence of most adverse events was similar between the two groups. However, hypotension occurred more frequently in the sustained intensive treatment group than in the delayed group (3.82% vs 2.81%; p=0.011).
These 6-year results reinforce the long-term cardiovascular benefits of a sustained intensive BP-lowering strategy in older adults with hypertension. The data strongly suggest that delaying the implementation of intensive control may result in less favourable outcomes. According to the study investigators, “The earlier intensive treatment is initiated after the hypertension diagnosis, the greater the cardiovascular benefits will be.”¹ The findings support the prompt initiation of intensive therapy to maximise cardiovascular protection in this patient population.
This study was funded by the Noncommunicable Chronic Diseases-National Science and Technology Major Project, the National Natural Science Foundation of China, the Beijing Municipal Science & Technology Commission, and the Beijing Research Ward Excellence Program.
References
1. Song Q, Peng X, Bai J, et al. Intensive Blood Pressure Control in Older Patients With Hypertension: 6-Year Results of the STEP Trial. J Am Coll Cardiol. 2025;86(17):1421–1433. https://doi.org/10.1016/j.jacc.2025.06.045
2. Zhang W, Zhang S, Deng Y, et al. Trial of intensive blood-pressure control in older patients with hypertension. N Engl J Med. 2021;385(14):1268–1279. https://doi.org/10.1056/NEJMoa2111437
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