Efficacy and safety of intensive vs. standard blood pressure control: a systematic review and meta-analysis

Objective The study aimed to compare the efficacy and safety of intensive systolic blood pressure (SBP) control (target SBP < 120 mmHg) vs. standard blood pressure control (target SBP < 140 mmHg) in reducing cardiovascular risk. Methods We conducted a systematic search of the Cochrane Library, Embase, and PubMed databases, covering the period from the inception of each database to February 11, 2025, to identify randomized controlled trials comparing these two blood pressure control targets. Efficacy outcomes included major adverse cardiovascular events, heart failure, stroke, myocardial infarction, cardiovascular mortality, and all-cause mortality. Safety outcomes included hypotension, syncope, falls, and renal dysfunction. Results Five randomized controlled trials involving 39,433 patients were included. Compared to standard blood pressure control, intensive blood pressure control was associated with a significant reduction in the risk of major adverse cardiovascular events (RR, 0.80; 95% CI, 0.75–0.86; P < 0.001), heart failure (RR, 0.74; 95% CI, 0.62–0.90; P = 0.002), stroke (RR, 0.81; 95% CI, 0.73–0.90; P < 0.001), cardiovascular mortality (RR, 0.73; 95% CI, 0.56–0.94; P = 0.01), and all-cause mortality (RR, 0.86; 95% CI, 0.75–0.99; P = 0.03). Intensive blood pressure control was associated with a borderline statistically significant reduction in the risk of myocardial infarction (RR, 0.87, 95% CI 0.76–1.00; P = 0.04). Intensive blood pressure control increased the risks of hypotension (RR, 3.63; 95% CI, 1.41–9.35; P = 0.008) and syncope (RR, 1.50; 95% CI, 1.22–1.85; P < 0.001). Conclusion Based on currently available evidence, intensive blood pressure control may reduce the risk of cardiovascular events and mortality compared to standard blood pressure control, but it may increase the risk of hypotension and syncope.