Intensive systolic blood pressure control (<120-130 mmHg) significantly reduces cardiovascular events and mortality in high-risk phenotypes, but increases risks of hypotension and acute kidney injury.
Does intensive systolic blood pressure control (<120-130 mmHg) reduce cardiovascular events and mortality in patients with systemic arterial hypertension?
While intensive blood pressure control benefits high-risk cohorts, the associated risks and varying efficacy across populations highlight the need for personalized, precision-medicine approaches rather than a universal 'lower is better' mandate.
Systemic arterial hypertension remains the leading modifiable risk factor for cardiovascular mortality, yet the optimal blood pressure target remains a subject of intense global debate. While recent American guidelines advocate for a lower diagnostic threshold (≥130/80 mmHg), European and Asian guidelines largely maintain a conservative threshold (≥140/90 mmHg). This narrative review addresses the central clinical question: "Is lower always better?" We synthesize evidence from landmark trials, including SPRINT and STEP, which demonstrate that intensive systolic blood pressure control (<120-130 mmHg) significantly reduces cardiovascular events and mortality, particularly in high-risk phenotypes such as resistant hypertension. However, this benefit is not without cost. We discuss the physiological "J-curve," the increased risk of adverse events such as hypotension and acute kidney injury, and emerging concerns regarding the long-term durability of stroke prevention observed in the ESPRIT trial. Furthermore, the dominant narrative of "intensification" is challenged by the recent STOP-Trial, which validated a framework for safe de-prescribing in low-risk hypertensive patients using home-based monitoring. Crucially, the divergent findings of the CREOLE and TOPSPIN trials reveal that therapeutic efficacy varies profoundly by ethnicity and geography, rendering a "one-size-fits-all" approach obsolete. We conclude that while intensive control is a life-saving opportunity for high-risk cohorts, it is not a universal mandate. The future of hypertension management lies in the transition from a single numerical target toward precision medicine - utilizing pharmacogenomics and population-specific strategies to maximize protection while minimizing harm, mandating development of "population-based guidelines" aiming for personalized blood pressure targets.
Ahmed B Shamsulddin (Mon,) conducted a review in Systemic arterial hypertension. Intensive systolic blood pressure control vs. Conservative threshold (≥140/90 mmHg) was evaluated. Intensive systolic blood pressure control (<120-130 mmHg) significantly reduces cardiovascular events and mortality in high-risk phenotypes, but increases risks of hypotension and acute kidney injury.