Results:

There were 19 trials including 44,989 participants, in whom 2,496 major CV events were recorded during a mean 3.8 years of follow-up (range 1.0–8.4 years). After randomization, patients in the more intensive BP-lowering treatment group had mean BP levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive BP-lowering treatment achieved RR reductions (95% confidence interval [CI]) for major CV events (14% [4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI, –11 to 34]), CV death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major CV events was consistent across patient groups, and additional BP lowering had a clear benefit even in patients with systolic BP <140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with BP lowering were only reported by six trials and had an event rate of 1.2% per year in intensive BP-lowering group participants, compared with 0.9% in the less intensive treatment group (RR, 1.35; 95% CI, 0.93–1.97). Severe hypotension was more frequent in the more intensive treatment regimen (RR, 2.68; 95% CI, 1.21–5.89; p = 0.015), but the absolute excess was small (0.3% vs. 0.1% per person-year for the duration of follow-up).