Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension (STEP)

The STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) trial randomized 8,511 older Chinese patients (ages 60–80) with hypertension to intensive SBP target (110 to <130 mmHg) versus standard target (130 to <150 mmHg), measuring a composite cardiovascular outcome including stroke, MI, acute coronary syndrome, heart failure, coronary revascularization, atrial fibrillation, and cardiovascular death.

Intensive blood pressure control significantly reduced the composite cardiovascular endpoint compared with standard control (HR 0.74, 95% CI 0.60–0.92, p=0.007). The SBP achieved was 127.5 mmHg versus 135.3 mmHg in the standard group. All-cause mortality was not significantly different. Serious adverse events — particularly hypotension and syncope — were numerically more common with intensive treatment.

STEP extends SPRINT’s intensive BP control evidence to older (age 60–80) patients and to a Chinese population — addressing concerns that SPRINT’s US population findings might not generalize. The consistent cardiovascular benefit at a lower SBP target (110–130 versus <120 in SPRINT) across two large independent trials in different populations substantially strengthens the evidence for intensive hypertension management in older adults.

Both SPRINT and STEP demonstrate cardiovascular benefit from intensive SBP control in high-risk older adults, with similar relative risk reductions (~25–26%) despite differences in target thresholds, patient populations, and cardiovascular outcome composites. This convergent evidence supports SBP targets below 130 mmHg as appropriate for most hypertensive adults tolerating intensive therapy.

We rate the evidence strong. The STEP trial establishing that intensive blood pressure control (SBP 110–130 mmHg) reduces cardiovascular events by 26% in older Chinese hypertensive patients — important cross-population replication of SPRINT’s findings for intensive hypertension management in older adults.