Intensive Versus Standard Systolic Blood Pressure Targets: Evidence, Benefits and Harms – A Literature Review

Introduction: Hypertension affects over one billion people worldwide and is the leading modifiable risk factor for stroke, myocardial infarction, heart failure, and chronic kidney disease. Although lowering blood pressure clearly reduces risk, the optimal systolic target, especially below 130 mmHg, has been debated for years, with conflicting results across populations. Methods: Literature review of randomized trials and guidelines on intensive versus standard blood pressure control, focusing on SPRINT and ACCORD-BP, and on the 2017 ACC/AHA and 2020 Brazilian guidelines. Results: SPRINT randomized 9,361 adults aged 50 or older with systolic BP of 130-180 mmHg and elevated cardiovascular risk, excluding diabetes and prior stroke, to a target of <120 or <140 mmHg. The trial was stopped early, at a median follow-up of 3.26 years. Mean achieved systolic BP was 121.5 versus 134.6 mmHg. The intensive arm had fewer major cardiovascular events (HR 0.75; 95% CI 0.64-0.89) and lower all-cause mortality (HR 0.73; 95% CI 0.60-0.90). Serious adverse events (hypotension, syncope, electrolyte abnormalities, and acute kidney injury) were more frequent with intensive treatment. In ACCORD-BP (4,733 patients with type 2 diabetes), the <120 mmHg target did not significantly reduce the primary composite outcome (HR 0.88; 95% CI 0.73-1.06), although stroke was reduced. Discussion: The divergent results may reflect differences in population, statistical power, and event rates. SPRINT used unattended automated office measurements, which tend to give lower values than routine office readings, so its target cannot be transposed directly to usual practice. Frail patients, those with orthostatic hypotension, and those with advanced kidney disease were underrepresented, which limits generalization. Benefit must be weighed against drug burden, adherence, and adverse events. Conclusion: Intensive control benefits selected high-risk patients without diabetes when measurements are accurate and monitoring is close. In patients with diabetes, frailty, or orthostatic hypotension, targets should be individualized.