PAST-BP
PAtient Self-management of blood pressure in Stroke and TIA
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 | HR / OR / RR | 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.
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