Blood Pressure Trajectories and Cardiovascular Outcomes in Older Patients

BACKGROUND: Intensive blood pressure (BP) control is fundamental to cardiovascular disease prevention. However, the heterogeneity of individual responses-specifically the velocity, stability, and control quality-remains unclear. OBJECTIVES: We aim to identify the diversity in BP response, to characterize distinct systolic blood pressure (SBP) control trajectories during intensive treatment, and to evaluate their prognostic value for cardiovascular outcomes. METHODS: We analyzed 7,296 patients with hypertension receiving intensive BP treatment from the STEP (Strategy of Blood Pressure Intervention in Elderly Hypertensive Patients) trial, comprising both the original intensive-treatment arm and the standard-treatment arm that transitioned to intensive therapy during the extension period. Based on BP data from the first 12 months, patients were classified by control velocity (time to target) and stability (visit-to-visit average real variability). Four continuous metrics-time to target, average real variability, time in target range, and cumulative SBP Load-were also calculated for each patient. The primary outcome was a composite of cardiovascular events. HRs were estimated using Fine-Gray subdistribution hazard models after sequential adjustment for potential confounders. RESULTS: Profound heterogeneity was detected among patients receiving intensive therapy, and 7 trajectories were identified. The ideal Rapid-Stable group exhibited the lowest incidence of the primary outcome and a favorable safety profile. Compared with the Rapid-Stable group, all other trajectories were associated with a significantly and progressively increasing cardiovascular risk. Specifically, the risks were highest in Uncontrolled trajectories (HRs: ≥2.0), and significantly elevated in Labile (HR: 1.83), Delayed (HRs: 1.81-1.89), and Rapid-Unstable (HR: 1.50) groups. Furthermore, continuous dynamic metrics served as independent determinants of cardiovascular outcomes. Each 1-month delay in target achievement increased cardiovascular risk by 3% (HR: 1.03; 95% CI: 1.01-1.04). Higher variability (HR: 1.13 per SD increase), higher SBP Load (HR: 1.21 per SD increase), and lower time in target range (HR: 0.95 per 10% increase) were significantly associated with worse outcomes. CONCLUSIONS: BP control trajectories served as effective predictors of cardiovascular risk. The Rapid-Stable pattern yielded optimal benefits, whereas any deviations-characterized by delayed, unstable, or failed control-significantly elevated risk. The velocity, stability, and quality of control were found to be independent predictors of cardiovascular outcomes. Hypertension management should prioritize achieving rapid, stable, and sustained BP control.