Reevaluating Antihypertensive Therapy: Discontinuation in Low-Risk Patients

Overview

The STOP trial demonstrated that 36% of low cardiovascular risk patients with Grade 1 hypertension maintained normal home blood pressure after discontinuing antihypertensive therapy. Baseline home BP below 120/80 mmHg and use of angiotensin-receptor blockers were associated with sustained normotension over one year.

Background

Current guidelines recommend early hypertension diagnosis and treatment based on risk stratification, including out-of-office BP measurements. However, in practice, hypertension diagnosis and treatment initiation may be premature and rarely reassessed, leading to indefinite therapy continuation. The STOP trial investigated whether patients with uncomplicated Grade 1 hypertension and low cardiovascular risk could safely discontinue antihypertensive treatment while maintaining normal BP.

Data Highlights

Key Findings

• 36% of patients with Grade 1 hypertension and low CV risk maintained normal home BP after stopping antihypertensive therapy for 1 year.
• Baseline home BP below 120/80 mmHg strongly predicted sustained normotension.
• Home SBP above 120 mmHg or DBP above 80 mmHg significantly decreased the likelihood of maintaining normotension.
• Use of angiotensin-receptor blockers prior to withdrawal was positively associated with normotension persistence.
• Only one ischemic stroke occurred during follow-up, suggesting safety in selected patients.
• Out-of-office and repeated BP measurements at diagnosis did not differ significantly between those who maintained normotension and those who did not, indicating possible phenotype variability.

Clinical Implications

In low cardiovascular risk patients with Grade 1 hypertension and low home BP (<120/80 mmHg), discontinuation of antihypertensive therapy may be feasible with close BP monitoring. This approach underscores the importance of repeated out-of-office BP measurements and individualized reassessment of hypertensive status to avoid unnecessary lifelong treatment. Additionally, ARB therapy may confer benefits in maintaining normotension after withdrawal.

Conclusion

The STOP trial supports reconsidering indefinite antihypertensive treatment in selected low-risk patients, highlighting the potential to safely discontinue therapy under careful monitoring. These findings advocate for personalized hypertension management and reinforce guideline recommendations for repeated BP assessments.

References

1. Boivin JM et al. 2023 -- Stopping antihypertensive Treatment amOng hypertensive patients in Primary care: the STOP trial
2. 2023 European Society of Hypertension Guidelines
3. 2024 European Society of Cardiology Guidelines