Effect of intensive blood pressure control in patients with resistant hypertension: insights from the STEP trial

Clinical Snapshot

Key Findings

• P Value: P = 0.035

• Effect Size: 64% relative risk reduction (HR 0.36)

• Primary Outcome: Composite cardiovascular events

• Nnt Or Sensitivity: NNT not calculable from available data; absolute risk reduction not provided

• Confidence Interval: 95% CI 0.14-0.93

Clinical Application

Requires intensive monitoring and medication titration; may increase healthcare utilisation and costs Aligns with current RACGP guidelines supporting lower BP targets; PBS coverage for multiple antihypertensive classes supports implementation Patients with resistant hypertension defined as uncontrolled BP despite ≥3 antihypertensive drugs or controlled BP requiring ≥4 drugs

Abstract

AIMS: Resistant hypertension is defined as uncontrolled blood pressure (BP) despite the use of ≥3 antihypertensive drugs or controlled BP with ≥4 antihypertensive drugs. Whether intensive BP control is beneficial for the management of resistant hypertension is unknown. METHODS AND RESULTS: Intensive (<130 mmHg) BP control in patients is compared with standard (130-150 mmHg) BP control in patients with resistant hypertension, using the Strategy of Blood Pressure Intervention in Older Hypertensive Patients (STEP) trial data. Patients were divided into those with and without resistant hypertension. The primary outcome was a composite of cardiovascular events. Hazard ratios (HRs) were calculated using the Fine-Gray sub-distribution hazard model for primary and secondary events and the Cox regression model for all-cause death. In patients with resistant hypertension, intensive BP control was associated with a lower risk of primary outcomes (HR, 0.36; 95% CI, 0.14-0.93; P = 0.035). Results were consistent across different BP thresholds used to define resistant hypertension and in patients with true resistant hypertension. The benefit of intensive BP control was consistent across resistant hypertension status. Intensive BP control was not associated with an increased risk of adverse events in patients with resistant hypertension. Patients with resistant hypertension had increased cardiovascular risk compared with those without (HR, 1.78; 95% CI, 1.13-2.81; P = 0.012). CONCLUSION: Intensive BP control is associated with reduced risk of cardiovascular events in patients with resistant hypertension without increased risk of adverse events. REGISTRATION: https://www.clinicaltrials.gov/ct2/show/NCT03015311. The present study is a secondary analysis of the effect of intensive blood pressure control in patients with resistant hypertension in the STEP trial. Resistant hypertension is characterized as elevated blood pressure (BP) despite three antihypertensive agents or controlled BP with four or more agents. Intensive BP control in patients with resistant hypertension may reduce the risk of cardiovascular events. Further research is needed to investigate multifaceted treatment approaches, including both pharmacological and non-pharmacological interventions.Intensive blood pressure (BP) control is associated with a reduced risk of cardiovascular events and death in patients with resistant hypertension, compared with standard BP control, without increasing the risk of adverse events.Patients with resistant hypertension remain at higher risk of cardiovascular events compared with patients without resistant hypertension. Intensive BP control in this population may lower the risk of cardiovascular events.

References

1. 1.Dong, X., Bai, J., Ling, Q., Zhao, X., & Cai, J. (2026). Effect of intensive blood pressure control in patients with resistant hypertension: insights from the STEP trial. European Journal of Preventive Cardiology. https://doi.org/10.1093/eurjpc/zwaf507