Weekly Journal Scan: Exploring the balance of benefits and harms of intensive blood pressure control

This comment refers to ‘Benefit-harm trade-offs of intensive blood pressure control versus standard blood pressure control on cardiovascular and renal outcomes: an individual participant data analysis of randomised controlled trials’ which was published in The Lancet, https://doi.org/10.1016/S0140-6736(25)01391-1. Over the past decade, the management of arterial hypertension has evolved substantially, shifting from uniform systolic targets to a more individualized, risk-based approach.8 Landmark trials such as SPRINT3 and STEP6 reignited debate on the cardiovascular benefits of intensive BP lowering while also highlighting its potential trade-offs. The relationship between BP and cardiovascular risk appears more complex than a simple linear association; a so-called J-curve phenomenon has been described to indicate the increased risk associated with lower BP targets, which may vary based on patient characteristics and comorbidities.9 These observations underscore the need for a nuanced, patient-centred approach that balances potential benefits against the risk of adverse events. The debate is further complicated by geographic and ethnic variability in achieving BP levels and treatment responses, as most recent large-scale studies have predominantly involved Asian populations. Consequently, extrapolating the benefits of aggressive BP control to European or multi-ethnic cohorts remains unjustified. Reflecting these complexities, the 2024 European Society of Cardiology guidelines recommend a systolic BP target of 120–129 mmHg for most patients—provided that the treatment is well tolerated—while emphasizing caution and individualization in older, frail, or comorbid patients.8,10