Intensive Blood Pressure Lowering Improves Left Ventricular Geometry in Older Hypertensive Patients: The STEP Trial

Background The effect of intensive systolic blood pressure (SBP) lowering on left ventricular (LV) geometry remains unclear. Methods Patients with hypertension aged 60–80 years without prior stroke were enrolled from 42 centers across China from January 2017. Eligible patients were randomly assigned to intensive (target: 110 to <130 mmHg) or standard (target: 130 to < 150 mmHg) SBP-lowering treatment. LV mass (LVM) was assessed by two-dimensional, M-mode, color flow Doppler echocardiography. LV hypertrophy (LVH) was diagnosed according to LVM index (LVMI) to height 1.7 using sex-specific thresholds. Results Baseline demographic and LV parameters were comparable between the groups (n = 5709). During the median follow-up of 2.63 years, intensive treatment was associated with a lower risk of new LVH (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.69–1.00, P = 0.051) and greater regression of mean LVMI by 0.38 g/m 1.7 per year (95% CI 0.05–0.71, P = 0.024). The rate of baseline LVH regression did not differ between the groups. Male patients achieved a significantly greater benefit from intensive treatment than female patients in terms of new LVH prevention and baseline LVH regression (both P for interaction <0.10). The favorable effect of intensive treatment on the cardiovascular outcome (HR 0.73, 95% CI 0.54–1.00) was slightly attenuated after adjusting for LVMI as a time-varying covariate (HR 0.75, 95% CI 0.55–1.03). Conclusions In older patients with hypertension, intensive SBP lowering offers additional cardiovascular benefits in terms of LV geometry. This favorable effect partially explains the reduction in cardiovascular events. Trial registration Clinicaltrials.gov (Identifier: NCT03015311 ) Condensed Abstract This is the first randomized controlled trial with a sufficient sample size to compare the effect of intensive systolic blood pressure (SBP) lowering (<130 mmHg) on echocardiographic left ventricular (LV) geometry with that of standard SBP lowering (< 150 mmHg) in older patients with hypertension. A lower risk of new LV hypertrophy development and greater regression of LV mass index were observed in patients with intensive treatment than in those with standard treatment. This favorable effect partially explains the reduction in cardiovascular events associated with intensive SBP lowering.