The following are key points to remember from this systematic review prepared for the 2020 US Department of Veterans Affairs/US Department of Defense guidelines on the effect of intensive blood pressure (BP) lowering on cardiovascular (CV) outcomes:

1. According to the 2017 American College of Cardiology/American Heart Association guidelines, hypertension is defined as a BP of >130/80 mm Hg for most patients. This new threshold is based largely on the findings of the SPRINT trial and results in an additional 14% of the US adult population qualifying as “hypertensive.”
2. A 10 mm Hg reduction in systolic BP (SBP) is associated with a significant reduction in major CV disease (CVD) events (relative risk [RR], 0.80; 95% confidence interval [CI], 0.77-0.83) based on a meta-analysis of 55 randomized controlled trials and 265,578 patients. Similar results were seen across all baseline BPs.
3. Among older patients (age ≥60 years) with normal baseline cognitive function, receipt of antihypertensive agents for 5+ years to achieve moderate BP control did not worsen cognitive outcomes compared to less strict BP control.
4. Among older patients (age ≥60 years), intensive BP control (SBP <120 mm Hg) did not increase the risk of falls compared to less intensive BP control. However, achieved SBP of 121.5-143.0 mm Hg was associated with an increased risk of syncope as compared to an achieved SBP of 134.6-155.0 mm Hg (RR, 1.52; 95% CI, 1.22-2.07).
5. Among older patients (age ≥60 years), achieving a diastolic BP (DBP) <70 mm Hg was associated with an increased risk of symptomatic hypotension and/or syncope as compared to less strict DBP control. There was no increased risk of falls, fractures, or cognitive impairment in these patients.
6. Among patients with a history of chronic kidney disease (CKD) stage 3-5, high-quality evidence demonstrated that a 10 mm Hg reduction in SBP results in a decreased risk of CV outcomes compared to control patients with a history of CKD (RR, 0.84; 95% CI, 0.73-0.96).
7. Among patients with a history of heart failure, high-quality evidence found that a 10 mm Hg reduction in SBP reduced major CVD events compared to control patients with heart failure (RR, 0.75; 95% CI, 0.68-0.83).

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Heart Failure, Hypertension, Hypotension, Metabolic Syndrome, Primary Prevention, Renal Insufficiency, Chronic, Risk, Syncope, Vascular Diseases, Veterans

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