Key result
Intensive SBP lowering below 120 mmHg cuts MACE ~19% compared to standard targets.
Why the study?
Optimal systolic blood pressure targets in hypertensive patients at increased cardiovascular risk, especially with type 2 diabetes, remain uncertain, with no trials directly comparing <120 mmHg versus <130 mmHg targets.
Does intensive systolic blood pressure lowering (< 120 mmHg) reduce major adverse cardiovascular events in hypertensive patients at increased cardiovascular risk compared to standard lowering (< 140 mmHg)?
Meta-Analysis
Does intensive systolic blood pressure lowering (< 120 mmHg) reduce major adverse cardiovascular events in hypertensive patients at increased cardiovascular risk compared to standard lowering (< 140 mmHg)?
Hazard Ratio: 0.81 (95% CI 0.75–0.87)
Intensive SBP lowering to <120 mmHg reduces MACE risk compared to <140 mmHg, but its superiority over the guideline-recommended <130 mmHg target remains uncertain.
Recent studies have renewed the debate over optimal systolic blood pressure (SBP) targets in hypertensive patients, particularly those at increased cardiovascular (CV) risk and with type 2 diabetes mellitus (T2DM). The Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events (ESPRIT) and Blood Pressure Control Target in Diabetes (BPROAD) randomized controlled trials, both conducted in Chinese populations, offer new insights into intensive versus standard SBP-lowering strategies. ESPRIT enrolled 11,255 patients with high CV risk (including 38.7% with T2DM), while BPROAD included 12,821 hypertensive patients with T2DM and elevated CV risk. Both trials compared intensive SBP lowering (< 120 mmHg) with standard treatment (< 140 mmHg). Results from both studies showed that intensive treatment significantly reduced the incidence of major adverse cardiovascular events (MACE). ESPRIT reported a hazard ratio (HR) of 0.88 for MACE, along with notable reductions in CV and all-cause mortality. BPROAD similarly found a HR of 0.79 for MACE, although it did not demonstrate a statistically significant benefit in all-cause mortality. However, intensive treatment in both trials was associated with higher-though relatively low-absolute rates of adverse events, including hypotension, syncope, and renal impairment. When considered alongside previous trials, our meta-analysis suggests a consistent reduction in MACE risk with intensive SBP control. Nevertheless, concerns remain regarding the safety profile and generalizability of these findings, particularly given that both ESPRIT and BPROAD were limited to ethnically Chinese cohorts and reported unusually low adverse event rates compared to Western studies. In summary, the cumulative evidence suggests that an SBP target < 140 mmHg may be suboptimal. However, whether a target < 120 mmHg is superior to the current guideline-recommended range of 120-129 mmHg remains uncertain. No trials have directly compared < 120 mmHg with < 130 mmHg. Therefore, future research should determine whether the additional benefits of more aggressive SBP lowering outweigh potential risks, especially in diverse populations with and without diabetes.
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Kreutz et al. (2025) conducted a meta-analysis in Hypertension at increased cardiovascular risk. Intensive systolic blood pressure lowering (< 120 mmHg) vs. Standard systolic blood pressure lowering (< 140 mmHg) was evaluated on Major adverse cardiovascular events (MACE) (19% risk reduction, 95% CI 13-25). Intensive systolic blood pressure lowering to a target below 120 mmHg significantly reduced the risk of major adverse cardiovascular events by 19% compared to a target below 140 mmHg.
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