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PAST-BP

Q: What were the key findings of the PAST-BP trial?

Targeting SBP <130 vs <140 mmHg in post-stroke/TIA primary care patients produced only 2.9 mmHg additional reduction at 12 months (P=0.03). Both arms achieved large reductions (~13-16 mmHg). Only 51% achieved intensive target. Active management matters more than the specific target. 529 patients, 99 UK practices, open-label.

PAtient Self-management of blood pressure in Stroke and TIA

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Year of Publication: 2016

Authors: Sheppard JP, Hodgkinson J, Riley R, et al.

Journal: Lancet

Citation: Sheppard JP, Hodgkinson J, Riley R, et al. PAST-BP: Intensive blood pressure targets in stroke and TIA. Lancet. 2015;385(9975):1649–1658.

Link: https://doi.org/10.1016/S0140-6736(14)62206-3

Clinical Question

Does an intensive systolic blood pressure (SBP) target (<130 mm Hg) result in greater BP reduction than a standard target (<140 mm Hg) in patients with a history of stroke or TIA?

Bottom Line

Targeting SBP <130 vs <140 mmHg in post-stroke/TIA primary care patients produced only 2.9 mmHg additional reduction at 12 months (P=0.03). Both arms achieved large reductions (~13-16 mmHg). Only 51% achieved intensive target. Active management matters more than the specific target. 529 patients, 99 UK practices, open-label.

        Major Points
        Small but significant BP difference: intensive target reduced SBP by additional 2.9 mmHg (95% CI 0.2-5.7; P=0.03) at 12 months.
Both arms achieved large reductions: -16.1 mmHg (intensive) vs -12.8 mmHg (standard). >80% in both achieved SBP <140 mmHg.
Only 51% achieved intensive target (<130 mmHg). Clinician/patient reluctance common near target.
Intensive target increased workload: more GP visits (median 2 vs 1; P<0.001), more nurse visits, more treatment intensifications (458 vs 278; P<0.001).
Higher withdrawal in intensive arm: 20% vs 12% (P=0.02) — despite no objective increase in side effects.
Only 6 cardiovascular events total (1 intensive, 5 standard) — grossly underpowered for clinical endpoints.
Pragmatic primary care trial: 529 patients, 99 UK practices. Prevalent population including 51-54% TIA-only.
Authors conclude a full pragmatic trial of intensive targets in primary care is not warranted.

      

Design

Study Type: Randomized, open-label, primary care-based controlled trial

Randomization: 1

Blinding: Open-label

Enrollment Period: 2009–2012

Follow-up Duration: 12 months

Centers: 99

Countries: United Kingdom

Sample Size: 529

Analysis: Intention-to-treat; primary outcome was change in SBP from baseline to 12 months using repeated measures ANOVA

Inclusion Criteria

Age ≥18 years
Diagnosis of stroke or TIA
Systolic BP ≥125 mm Hg
Registered at participating general practices
Able to give informed consent

Exclusion Criteria

Severe cognitive impairment
Postural hypotension
Unwillingness to participate
Poor life expectancy

Arms

Field	Intensive BP Target	Control
Intervention	Target SBP <130 mm Hg	Target SBP <140 mm Hg
Duration	12 months	12 months

Outcomes

Outcome	Type	Control	Intervention	P-value
Change in systolic blood pressure from baseline to 12 months	Primary	−12.8 mm Hg	−16.1 mm Hg	0.03
Falls	Secondary	20%	20%	NS
Serious adverse events	Secondary	14%	15%	NS
Falls	Adverse		Equal between groups (20%)
Serious adverse events	Adverse		14% in standard vs 15% in intensive

Subgroup Analysis

No interaction by age, sex, or baseline BP

Criticisms

Open-label design introduces potential bias
Relatively short follow-up (12 months)
Did not evaluate clinical outcomes such as recurrent stroke or cardiovascular events

Funding

UK National Institute for Health Research

Based on: PAST-BP (Lancet, 2016)

Authors: Sheppard JP, Hodgkinson J, Riley R, et al.

Citation: Sheppard JP, Hodgkinson J, Riley R, et al. PAST-BP: Intensive blood pressure targets in stroke and TIA. Lancet. 2015;385(9975):1649–1658.

Content summarized and formatted by NeuroTrials.ai.

PAST-BP

(2016)

Objective

Assess whether an intensive systolic blood pressure (SBP) target (<130 mm Hg or ≥10 mm Hg reduction) reduces SBP more than a standard target (<140 mm Hg) in patients with prior stroke or TIA in primary care.

Study Summary

• In a primary care population with prior stroke or TIA, setting an intensive SBP target (<130 mm Hg or 10 mm Hg reduction) led to a small additional reduction in SBP (≈3 mm Hg) compared to a standard <140 mm Hg target. Both groups saw clinically meaningful reductions, suggesting that active BP management is more impactful than target selection.

Intervention

Open-label randomized controlled trial in 99 UK general practices. Patients were randomized to intensive SBP target (<130 mm Hg or ≥10 mm Hg drop if baseline <140) vs. standard SBP target (<140 mm Hg). Follow-up: 12 months.

Study Design

Arms: Array

Outcome

• Primary: SBP reduction — 16.1 mm Hg (intensive) vs. 12.8 mm Hg (standard); between-group difference: –2.9 mm Hg (95% CI –5.7 to –0.2); p=0.03
• Target BP <130 mm Hg achieved in 51% (intensive) vs. 54% (standard); p=0.36
• More consultations and treatment changes in the intensive group
• Clinical events: 1 vs. 5 major CV events (HR 0.19; p=0.16)
• Emergency admissions similar (HR 1.26; p=0.16)
• No significant difference in reported symptoms or side effects

Bottom Line

Major Points

Small but significant BP difference: intensive target reduced SBP by additional 2.9 mmHg (95% CI 0.2-5.7; P=0.03) at 12 months.
Both arms achieved large reductions: -16.1 mmHg (intensive) vs -12.8 mmHg (standard). >80% in both achieved SBP <140 mmHg.
Only 51% achieved intensive target (<130 mmHg). Clinician/patient reluctance common near target.
Intensive target increased workload: more GP visits (median 2 vs 1; P<0.001), more nurse visits, more treatment intensifications (458 vs 278; P<0.001).
Higher withdrawal in intensive arm: 20% vs 12% (P=0.02) — despite no objective increase in side effects.
Only 6 cardiovascular events total (1 intensive, 5 standard) — grossly underpowered for clinical endpoints.
Pragmatic primary care trial: 529 patients, 99 UK practices. Prevalent population including 51-54% TIA-only.
Authors conclude a full pragmatic trial of intensive targets in primary care is not warranted.

Study Design

Study Type: Randomized, open-label, primary care-based controlled trial
Randomization: Yes
Blinding: Open-label
Sample Size: 529
Follow-up: 12 months
Centers: 99
Countries: United Kingdom

Primary Outcome

Definition: Change in systolic blood pressure from baseline to 12 months

Control	Intervention	HR/OR	P-value
−12.8 mm Hg	−16.1 mm Hg	- (−5.8 to −0.4 mm Hg (between-group difference))	0.03

Limitations & Criticisms

Open-label design introduces potential bias
Relatively short follow-up (12 months)
Did not evaluate clinical outcomes such as recurrent stroke or cardiovascular events

Citation

Sheppard JP, Hodgkinson J, Riley R, et al. PAST-BP: Intensive blood pressure targets in stroke and TIA. Lancet. 2015;385(9975):1649–1658.

View Original Publication →

PAST-BP

PAtient Self-management of blood pressure in Stroke and TIA

Clinical Question

Bottom Line

Major Points

Design

Inclusion Criteria

Exclusion Criteria

Arms

Outcomes

Subgroup Analysis

Criticisms

Funding

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