Intensive blood pressure (BP) control compared with standard BP control offers a net benefit between the decrease in cardiovascular events and increase in adverse events, including kidney-related events, according to a meta-analysis published Sept. 6 in The Lancet.

Xiaofan Guo, MD, et al., conducted a post-hoc, pooled participant-level analysis of six landmark randomized controlled trials on intensive BP lowering (ACCORD BP, SPRINT, ESPRIT, BPROAD, STEP and CRHCP), which compared intensive systolic BP targets (<120 mm Hg or <130 mm Hg) with standard treatment (systolic BP target <140 mm Hg, <150 mm Hg in older adults, or usual care).

The analysis included 80,220 participants (40,503 received intensive treatment; 39,717 received standard treatment). The median age was 64 years, most patients were Asian (83%) or White (10%), and 51% were women.

Results revealed that the primary benefit cardiovascular disease outcome (a composite of myocardial infarction, stroke, heart failure and cardiovascular death) occurred in 5.3% of participants in the intensive treatment group and in 7.1% in the standard treatment group (hazard ratio [HR], 0.76; p<0.0001). During the median 3.2-year follow-up, 4,969 composite cardiovascular events occurred.

Regarding primary harm outcomes, 5,056 adverse events of interest (e.g., hypotension and syncope) occurred, including 2,607 kidney-related events. Additionally, all-cause mortality was lower with intensive BP control vs. standard BP control (HR, 0.87; p=0.0016).

Notably, intensive BP control was associated with a 1.73% absolute risk reduction in cardiovascular disease (number needed to treat = 58) and a 1.82% absolute risk increase for adverse events of interest (number needed to harm = 55) compared with standard BP control. Overall, intensive BP control showed a positive benefit-harm profile, with a net benefit of 1.14 using adjudicated weighting. When considering kidney-related adverse events, the net benefit remained favorable (1.13).

Guo, et al., write that their findings using the net benefit-harm approach to hypertension management "offer important implications for refining [BP] guidelines and underscore the importance of individualized strategies to optimize outcomes while avoiding both overtreatment and undertreatment."

In an accompanying editorial, John W. McEvoy, MBBCh, BAO, MHS, writes that with clear and consistent evidence such as that provided by Guo and colleagues, hypertension can no longer be tolerated where treatment is available and accessible, and that early and intensive treatment should be attempted in all adults where possible. "Indeed, I believe that hypertension should now be considered much more optional than essential."