Outcome specific optimal systolic blood pressure targets in high risk patients, balancing cardiovascular benefits, renal risks, and cancer prevention: meta-analysis of randomised controlled trials.

Objective: To directly compare the efficacy and safety of different intensive systolic blood pressure targets (<120 or <130 mm Hg) versus usual care on cardiovascular and renal outcomes. Design: Meta-analysis of randomised controlled trials. Data sources: Web of Science and Medline, from inception to 20 May 2025. Eligibility criteria for selecting studies: Randomised controlled trials comparing intensive versus usual systolic blood pressure targets. Studies reported cardiovascular disease or kidney outcomes, or both. Results: The study included 18 randomised controlled trials of 60 629 participants. Intensive control of systolic blood pressure significantly reduced the risk of major adverse cardiovascular events (relative risk 0.82, 95% confidence interval (CI) 0.78 to 0.87, P<0.001), including myocardial infarction, stroke, heart failure, and death from cardiovascular disease. Systolic blood pressure targets of <120 mm Hg and <130 mm Hg provided comparable cardiovascular protection. Intensive control of systolic blood pressure increased the risk of the composite chronic kidney disease outcome (relative risk 1.40, 95% CI 1.01 to 1.94, P=0.046), but with a likely higher risk for the target of <120 mm Hg. A systolic blood pressure target of <120 mm Hg also reduced the risk of albuminuria, but increased the risk of bradycardia and hypotension. Conclusions: Intensive control of systolic blood pressure provided substantial cardiovascular benefits but increased the risk of renal adverse events. A systolic blood pressure target of <130 mm Hg had a similar degree of cardiovascular protection as <120 mm Hg with a more favourable renal safety profile, supporting a personalised risk based approach to treatment intensification. Trial registration: PROSPERO CRD42025629962.