Variability in systolic blood pressure (SBP) response during intensive treatment may influence cardiovascular risk, but patterns of control over time remain incompletely characterized. In a post hoc analysis of the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial published in the Journal of the American College of Cardiology, SBP trajectories were examined in relation to cardiovascular outcomes among 7,296 patients with hypertension receiving intensive treatment. 

The analysis included participants from both the original intensive-treatment arm and those transitioning from standard to intensive therapy during the extension phase. SBP data from the first 12 months were used to classify patients based on control velocity (time to target) and stability (visit-to-visit average real variability). Seven distinct trajectories were identified. 

The Rapid-Stable group had the lowest incidence of the composite cardiovascular outcome and a favorable safety profile. Compared with this group, higher risks were observed across other trajectories, including Uncontrolled (hazard ratios [HRs] ≥2.0), Labile (HR 1.83), Delayed (HRs 1.81–1.89), and Rapid-Unstable (HR 1.50).

Continuous metrics were independently associated with outcomes. Each 1-month delay in achieving target SBP was associated with a 3% increase in cardiovascular risk (HR 1.03; 95% confidence interval [CI] 1.01-1.04). Higher SBP variability, greater cumulative SBP load, and lower time in target range were also associated with adverse outcomes.

These findings indicate that SBP control trajectories are associated with cardiovascular outcomes during intensive treatment, with more rapid and stable control linked to lower risk.