Blood pressure targets: are clinical guidelines wrong?

Hypertension clinical guidelines have recommended a universal target blood pressure of less than 140/90 mmHg, and lower if tolerated. Even lower targets have been set for patients considered at higher cardiovascular risk. Those targets are considered as the blood pressure values below which the greatest clinical benefit is achieved. Our objective is to briefly review new evidence from randomized controlled trials evaluating clinical events associated with different blood pressure targets in the treatment of hypertension.

A Cochrane systematic review has shown no clinical benefits in morbidity or mortality when comparing standard (<140/90 mmHg) vs. lower blood pressure targets in the general population of persons with elevated blood pressure. Those data refer mainly to diastolic blood pressure. The JATOS trial in elderly hypertensive patients, and the ACCORD trial in diabetic patients, showed no clinical benefit when targeting a lower systolic blood pressure (<140 instead of <160 mmHg, and <120 instead of <140 mmHg, respectively). By contrast, the Cardio-Sis trial reported a reduction in some clinical events associated with a lower systolic target (<130 mmHg instead of <140 mmHg). Finally, despite lower blood pressures achieved in several recent randomized trials, there were no significant reductions in clinical events.

In hypertension, evidence does not support the traditional premise 'the lower the better'. The optimal blood pressure targets have not been established, especially for systolic blood pressure in nondiabetic patients. Randomized clinical trials are urgently needed to address these important issues.