Lowering Systolic BP to <120 mm Hg vs <140 mm Hg in Patients at High Cardiovascular Risk With and Without Diabetes or Previous Stroke

High systolic blood pressure (BP), an important feature of hypertension, is the leading contributor to global death and disability from heart disease and stroke.¹ Among the estimated 1.3 billion adults with hypertension worldwide, only about 1 in 5 have their hypertension controlled to a systolic BP of less than 140 mm Hg. The reason for this poor hypertension control rate is complex and includes factors at multiple levels; among these factors is the lack of treatment intensification to achieve ideal BP targets. For many physicians, there remains substantial uncertainty about the benefits and risks of lowering systolic BP to less than 120 mm Hg, despite compelling evidence from the SPRINT study, which showed that an intensive BP target of less than 120 mm Hg significantly reduced the risks of cardiovascular events and mortality compared with a target of less than 140 mm Hg.²

To further address this uncertainty, the present study randomized 11,255 adults (mean age, 64.6 years) with high cardiovascular risk (4359 with diabetes and 3022 with previous stroke) to intensive treatment (target systolic BP, <120 mm Hg) or standard treatment (target systolic BP, <140 mm Hg). The primary outcome was a composite of myocardial infarction, revascularization, hospitalization for heart failure, stroke, and death from cardiovascular causes. During a median follow-up period of 3.4 years, the incidences of the primary outcome in the intensive and standard treatment groups were 9.7% and 11.1%, respectively. Syncope occurred more frequently in the intensive treatment group (0.4% vs 0.1%), with a hazard ratio of 3.00 (95% CI, 1.35–6.68); however, there were no significant between-group differences in other serious adverse events.

The major take-home message from this study is that, for patients with hypertension who are at high cardiovascular risk (with or without diabetes or a history of previous stroke), treatment to a systolic BP target of less than 120 mm Hg is superior to treatment to a target of less than 140 mm Hg for the prevention of major cardiovascular events. However, patients who do not tolerate a systolic BP of less than 120 mm Hg should be maintained at their lowest tolerable systolic BP level. The observed increase in the incidence of syncope during the intensive treatment strategy calls for increasing patient awareness of and education on strategies to mitigate symptoms of low systolic BP during intensive treatment of hypertension.

References

1. Mensah GA, Fuster V, Murray CJL, et al. Global Burden of Cardiovascular Diseases and Risks, 1990-2022. J Am Coll Cardiol. 2023;82(25):2350-2473. https://www.sciencedirect.com/science/article/pii/S0735109723080233?via%3Dihub
2. SPRINT Research Group. A Randomized Trial of Intensive Versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103-2116. https://www.nejm.org/doi/10.1056/NEJMoa1511939