Intensive blood pressure (BP) lowering to improve cardiovascular (CV) outcomes in patients with hypertension is supported by evidence, according to a systematic review published in the Annals of Internal Medicine.

A US Department of Veterans Affairs/US Department of Defense clinical practice guideline working group convened to identify systolic and diastolic BP (SBP and DBP, respectively) goals associated with improved outcomes in adult patients with hypertension. The working group examined English language comprehensive systematic reviews of randomized controlled trials published between December 2013 and March 2019.

A total of 8 systematic reviews were included. One review examined the effects of, of a standardized SBP target of -10 mm Hg, and the other 7, a BP lowering below a target threshold.

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The review’s primary outcome was the reduction in composite CV outcomes. High-strength evidence was found supporting a benefit of a 10-mmHg reduction in SBP on CV outcomes in patients with hypertension, chronic kidney disease or heart failure.

There was mixed evidence supporting the benefits of a reduction of SBP for improving CV outcomes in patients with a history of CV disease (moderate strength), diabetes mellitus (high-strength evidence), or stroke (low-strength).

The investigators were unable to determine whether intensive BP lowering is associated with an increased risk for dementia. In some studies, treatment of older adults with normal cognitive function at baseline with antihypertensive agents for ≥5 years to achieve moderate BP control was not associated with worsened cognitive outcomes compared with less strict control. Other safety results were either mixed or inconclusive.

This review was limited to systematic reviews of trials which reported a strict BP target, which may reduce the generalizability of the findings across different facets of patients care.

“Although our [systematic review] did not focus on how different classes of antihypertensive treatment compared with one another, large-scale observational databases suggest that thiazide or thiazide-like diuretics may be favored for effectiveness over angiotensin-converting enzyme inhibitors,” noted the review authors.


D’Anci KE, Tipton K, Hedden-Gross A, Rouse B, Hermanson L, Fontanarosa J. Effect of intensive blood pressure lowering on cardiovascular outcomes: A systematic review prepared for the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Guidelines. Published online September 1, 2020. Ann Intern Med. doi:10.7326/M20-2037