Before lowering blood pressure to prevent ARIA, we need evidence of net benefit

Amyloid-related imaging abnormalities (ARIA) occur in 20-40% of patients treated with the amyloid-targeting drugs lecanemab and donanemab. While most cases of ARIA are asymptomatic, serious and fatal cases occur. Therefore, ARIA prevention remains vital as these drugs are increasingly offered. Intensive blood pressure management (i.e., target systolic blood pressure of <120-130 mmHg) has been proposed to prevent ARIA. Though blood pressure control is key for neurovascular risk optimization and dementia prevention, the evidence supporting intensive blood pressure management for ARIA prevention is not yet robust enough to inform clinical practice. Extant observational studies do not demonstrate a consistent association between blood pressure and ARIA, are often unadjusted or inappropriately adjusted, and none directly evaluate intensive blood pressure treatment initiation. Meanwhile, the harms of intensive blood pressure treatment in older adults are immediate and well documented. Thus, we argue that current guideline-concordant management of hypertension should continue in older adults.