Optimal Blood Pressure Targets: RCTs vs Real-World Data

New hypertension practice guidelines from the American Heart Association / American College of Cardiology (AHA/ACC) and Hypertension Canada are summarized in the October 2026 issue of American Family Physician (AFP). In contrast to a previous guideline from the American Academy of Family Physicians, both guidelines recommend treating to a systolic blood pressure (BP) target of less than 130 mm Hg.

A recent systematic review and meta-analysis compared intensive BP lowering to standard BP targets (less than 140/90 mm Hg) in 27 randomized trials (N = 88,830) that followed patients for at least one year. Overall, an intensive treatment strategy reduced the relative risk of major cardiovascular events by 15% for each 10 mm Hg decrease in systolic BP. Individuals with and without chronic kidney disease experienced 4.3 and 2.7 fewer events per 1000 person-years, translating to numbers needed to treat of 46 and 74 to prevent one cardiovascular event over 5 years. On the harms side, intensive BP lowering increased the risk of sustained declines in estimated glomerular filtration rate by 42% to 47% but did not affect the risk of kidney failure.

Since measurement and treatment protocols may differ substantially between the clinical trial environment and real-life primary care practice, researchers performed a retrospective cohort study​ in 2.3 million patients with hypertension seen at Veterans Health Administration outpatient practices in 2016 and 2017, with follow-up through March 2021. Dividing patients into groups based on 10 mm Hg increments of systolic BP, the study found that a systolic BP of 130 to 139 mm Hg was associated with the lowest all-cause mortality, followed by a systolic BP of 140 to 149 mm Hg, then a systolic BP of 120 to 129 mm Hg. This finding held regardless of cardiovascular disease history, though the mortality benefit was greater in persons with known cardiovascular disease.

The contradictory results of these studies suggest that despite the new guidelines, the optimal BP treatment target remains open to debate. In a 2025 editorial in AFP, Drs. Mark Ebell and David Slawson noted that specialist-authored guidelines generally recommend more intensive BP targets than primary care or multispecialty guidelines, and the BP measurement protocols used in the two largest randomized trials, SPRINT (Systolic Blood Pressure Intervention Trial) and BPROAD (Blood Pressure Control Target in Diabetes), are time-consuming and difficult to implement in routine practice. Treating to a systolic BP target of less than 130 mm Hg based on typical BP measurement protocols increases the risk of hypotension, adverse kidney events, and unnecessary polypharmacy. The authors concluded:

“The decision to pursue a more intensive BP target should not be routine and, at best, should be a shared decision balancing benefits and harms. To avoid overtreatment, it is of paramount importance that patients who choose a BP target of less than 130/80 mm Hg always have their BP measured using the time-consuming SPRINT or BPROAD protocol.”