Background

• History tells us that the association of adverse health effects with elevated blood pressure was an actuarial observational discovery made by insurance companies and was initially railed against by the medical profession, although it was later enthusiastically appropriated once effective therapies became available

• Blood pressure status as a continuous-variable risk factor, instead of treating it as a dichotomous disease. After all, the origin of the word “disease” is “the absence of ease ... discomfort” and is therefore inappropriate for an asymptomatic condition.

• Such “disease” is evident only when major organ damage ensues. Preventive strategies must maximize avoidance of these events. Perhaps “hypertension” should henceforth be used only in its adjectival form to describe target organ damage (e.g., hypertensive nephropathy) and not as a noun to indicate a disease model. Moreover, the term can be confusing to our patients, which is another argument for its abandonment

• The approach of focusing on the absolute risk of adverse cardiovascular events, rather than on BP alone, has been promoted for decades from the Antipodes. Perhaps the STEP trial is another impetus for broader adoption of this approach.

SPRINT trial

• persons with a systolic BP of ≥130 and an increased cardiovascular risk, but without diabetes

• Systolic BP target of <120 (intensive treatment) vs. <140 (standard treatment).

• Primary composite outcome: myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes.

• 1 year, the mean systolic BP:

  • 121.4 in the intensive- treatment group

  • 136.2 in the standard-treatment group.

• Median follow-up of 3.26 years: significantly lower rate of the primary composite outcome in the intensive-treatment group (1.65% per year) vs. standard-treatment group (2.19% per year); HR 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001).

• All-cause mortality was also significantly lower in the intensive- treatment group

• Serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group

STEP trial

• Chinese patients 60 to 80 years of age with hypertension

• Systolic BP target of 110 to <130 (intensive treatment) vs. 130 to <150 (standard treatment).

• Primary outcome: composite of stroke, acute coronary syndrome (acute MI and hospitalization for unstable angina), acute decompensated heart failure, coronary revascularization, AF, or death from cardiovascular causes

• 1 year of follow-up, mean systolic BP:

  • 127.5 in the intensive-treatment group

  • 135.3 in the standard-treatment group

• Median follow-up period of 3.34 years, primary-outcome events:

  • 147 patients (3.5%) in the intensive-treatment group vs. 196 patients (4.6%) in the standard-treatment group (hazard ratio, 0.74; 95% confidence interval [CI], 0.60 to 0.92; P=0.007)

  • The results for most of the individual components of the primary outcome also favored intensive treatment

References

• A Randomized Trial of Intensive versus Standard Blood-Pressure Control (NEJM, 2015)

• Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension (STEP trial, NEJM, 2021)

• Moving the Goalposts for Blood Pressure — Time to Act (NEJM, 2021)