By Lucy Piper, medwireNews Reporter
medwireNews: Intensive blood pressure control provides a net benefit between cardiovascular disease and adverse events, including kidney-related events, suggests a study published in The Lancet.
The researchers conducted a pooled analysis of six key randomized trials comparing intensive and standard hypertension control in 80,220 people. By quantifying both the “cardiovascular benefits and the potential harms”, they say that the findings provide “deeper insight into treatment effects across diverse populations, supporting more precise and evidence-based clinical decision making.”
Yingxian Sun (First Hospital of China Medical University, Shenyang) and colleagues comment: “These insights offer important implications for refining blood pressure guidelines and underscore the importance of individualised strategies to optimise outcomes while avoiding both overtreatment and undertreatment.”
The six trials included were ACCORD BP, SPRINT, ESPIRIT, BPROAD, STEP and CRHCP. Across the trials, the participants were randomly assigned to receive intensive blood pressure treatment to achieve a target systolic blood pressure below 120 mmHg or 130 mmHg, or standard treatment aiming for a systolic blood pressure of below 140 mmHg or below 150 mmHg in older adults, or usual care.
The participants, 51.3% of whom were women, were aged a median of 64 years and the majority were Asian (82.6%) or White (10.1%).
Over a median follow-up of 3.2 years, the composite cardiovascular disease outcome of myocardial infarction, stroke, heart failure or cardiovascular death occurred in 5.3% of 40,503 patients receiving intensive blood pressure control, compared with 7.1% of 39,717 patients receiving standard blood pressure control.
This translated to a significant 1.73 percentage point absolute risk reduction, primarily driven by a decrease in stroke, with the intensive strategy and a number needed to treat to prevent one cardiovascular disease event of 58.
Significant risk reductions in the intensive treatment group were observed for each of the individual components as well as for all-cause death (hazard ratio [HR]=0.87), and they were consistent in those older and younger than 65 years of age.
However, intensive blood pressure lowering was also associated with an increase in adverse events of special interest, such as hypotension and syncope, and renal-related events, of which there were a total of 5056 and 2607 events, respectively. The absolute risk increase in such events with intensive versus standard blood pressure lowering was a significant 1.82 percentage points, with a number needed to harm of 55.
Nevertheless, “intensive blood pressure control showed a favourable benefit–harm profile compared with standard blood pressure control,” say Sun and colleagues.
Using adjudicated weighting in which one cardiovascular disease benefit was considered equivalent to 3.1 harmful events, they found that intensive blood pressure lowering resulted in a significant net benefit of 1.14, and 1.13 when comparing renal-related events specifically.
The study authors point out that cognitive outcomes were not evaluated and nor were patient-reported outcomes such as quality of life, limiting their ability to determine patient-centred benefits.
Even so, they conclude that their research “addresses substantial gaps in hypertension guidelines and offers robust, actionable evidence to inform clinical practice.”
In a related commentary, John McEvoy (University of Galway, Ireland) agrees that the evidence is “clear and consistent”. He points out that as “[w]e have effective treatments and know how to cure hypertension in most individuals”, it makes sense “that early and intensive treatment of hypertension be at least attempted in all adults where possible.”
News stories are provided by medwireNews, which is an independent medical news service provided by Springer Healthcare Ltd. © 2025 Springer Healthcare Ltd, part of Springer Nature
Lancet 2025; 406: 1009–1019
https://pubmed.ncbi.nlm.nih.gov/40902616/
Lancet 2025; 406: 980–982
https://pubmed.ncbi.nlm.nih.gov/40902615/
Keywords: hypertension, intensive blood pressure control, cardiovascular events, harm