Reevaluating Blood Pressure Treatment Goals: Is it Time to Change?

<h2 id="Background">Background:</h2><ul><li>Hypertension remains a leading modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD).</li><li>In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) redefined hypertension as 130/80 mm Hg, while the 2023 European Society of Hypertension (ESH) and 2024 European Society of Cardiology (ESC) guidelines retain a threshold of 140/90 mm Hg. Despite differences in definitions, both U.S. and European guidelines generally recommend a treatment goal of&lt; 130/80 mm Hg for most adults, particularly those at elevated cardiovascular risk.<br>The achieved SBPs in the most recent BPROAD (Blood Pressure Control Target in Diabetes) trial targeting lower SBPs were generally in the low 120s mm Hg range which led to 20-25% ASCVD risk reduction in high CV risk patients.</li><li>There remains ongoing debate regarding the optimal systolic blood pressure (SBP) target, particularly whether treatment goals should be lowered further to&lt; 120 mm Hg.</li><li>Emerging trial data over the past two decades have increasingly supported the cardiovascular benefits of intensive SBP lowering, particularly in individuals at high ASCVD risk, such as those with type 2 diabetes mellitus (T2DM), prior cardiovascular events, or elevated estimated 10-year risk.</li></ul><h2 id="Supporting">Supporting evidence:</h2><h3>1. The concept of intensive SBP control:</h3><ul><li>It was first investigated in the ACCORD trial (2008), which studied patients with T2DM and elevated CVD risk. A prespecified subgroup receiving standard glycemic control and intensive BP therapy experienced a significantASCVD risk reduction (HR, 0.71).</li><li>This finding was reinforced in the ACCORDION follow-up study, which showed a sustained 21% ASCVD risk reduction (HR, 0.79) in this subgroup over 9 years of follow-up.</li></ul><h3>2.Results of SPRINT trial:</h3><ul><li>This trial included patients with high CVD risk was stopped early due to significant benefits of intensive SBP lowering (&lt;120 mm Hg)</li><li>Study achieved 25% reduction in major adverse cardiovascular events (MACE; HR, 0.75) and a 27% reduction in all-cause mortality (HR, 0.73).</li><li>Mean achieved SBP was 120 mm Hg in the intensive group versus 134 mm Hg in standard care.</li><li>There was no significant difference in overall serious adverse events (SAE; p = 0.23).</li></ul><h3>3. Other trials have yielded varied but supportive results:</h3><ul><li>The RESPECT trial, targeting SBP &lt; 120 mm Hg for secondary stroke prevention, found risk reduction (HR, 0.73), and a modest 6.5 mm Hg SBP difference.</li><li>The ESPRIT trial in patients with high CVD risk reported a 12% MACE reduction (HR, 0.88), with no significant difference in SAE rates (p = 0.78).</li><li>The BPROAD trial evaluated intensive SBP control in patients with T2DM and elevated CVD risk. A mean SBP of 122 mm Hg was achieved in the intensive group vs. 133 mm Hg in standard care, resulting in a 21% reduction in MACE (HR, 0.79) and no significant increase in SAE (p = 0.96).</li></ul><p>Across trials (Table), the average SBP difference between treatment arms ranged from 10-15 mm Hg, and the intensive SBP targets were achieved with only one additional antihypertensive medication, most commonly thiazide-type diuretics, ACE inhibitors, ARBs, and calcium channel blockers.</p><p>Combination therapy, as endorsed by major guidelines, facilitates reaching lower targets without excessive pill burden.</p><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/Summary_Of_trial_treating_to_SBP.webp" alt="Summary of Trials Treating to SBP &lt;120 vs. &lt;140 mm Hg." width="976" height="660"></p><h2 id="Conclusion">Conclusion</h2><ul><li>Emerging evidence consistently shows that targeting a SBP below 120 mm Hg can significantly lower the risk of ASCVD in high-risk patients.</li><li>These lower SBP targets were associated with a 20-25% reduction in ASCVD risk across multiple trials without a significant increase in overall serious adverse events, reinforcing the safety of intensive blood pressure control in appropriately selected high-risk populations.</li><li>Given the magnitude of ASCVD risk reduction, and the manageable increase in treatment intensity, future hypertension guidelines should strongly consider recommending a lower SBP goal of &lt;120 mm Hg for patients at high cardiovascular risk.</li></ul>

Cardio Update   Issue 4   2025

<ul><li><a href="#Background">Background</a></li><li><a href="#Supporting">Supporting evidence</a></li><li><a href="#Conclusion">Conclusion</a></li></ul>

Reevaluating Blood Pressure Treatment Goals: Is it Time to Change?

Reference