To the Editor:

We appreciate the thoughtful editorial by Drs. Ebell and Slawson on blood pressure (BP) targets and the importance of shared decision-making.¹ However, additional context and more recent evidence are needed. Challenging a recommended systolic BP goal of less than 130 mm Hg risks adding confusion and hesitancy at a time when clarity and forward momentum are urgently needed.

The authors cited a 2020 Cochrane review in their editorial, but multiple randomized controlled trials have since been published.² A more recent 2025 meta-analysis incorporating data from four randomized controlled trials published after the 2020 Cochrane review further strengthens the evidence supporting lower systolic BP targets.³ Compared with standard BP control, intensive control is associated with statistically significant reductions in myocardial infarction, stroke, heart failure, and cardiovascular mortality. The 2025 meta-analysis showed a number needed to treat of 58 to prevent one major cardiovascular event.³ In time-to-benefit analyses, intensive BP control prevented one major cardiovascular event per 100 patients at 34 months.⁴

Adverse events were more common in the intensive BP control group in the 2025 meta-analysis, with a number needed to harm of 55, but they were generally mild and manageable with medication adjustments.³ Older adults who are frail, those with limited life expectancy, and those unable to tolerate lower systolic BPs remain appropriate candidates for individualized targets. However, for most patients, the benefits of a systolic BP goal less than 130 mm Hg outweigh the risks.

Concerns about BP measurement techniques in trials such as SPRINT (Systolic Blood Pressure Intervention Trial) are legitimate but should not eclipse the broader evidence.⁵ In the 2025 meta-analysis, most of the trials included protocols with staff-attended BP measurements, which is closer to routine practice. Newer guideline targets already incorporate a pragmatic buffer by recommending systolic BP less than 130 mm Hg instead of less than 120 mm Hg, which is used in most trials.^3,6

With increasing evidence, most national and international organizations have updated their recommendations to favor lower systolic BP targets. The 2025 American College of Cardiology/American Heart Association hypertension guideline is cosponsored by a broad coalition of 13 professional societies.⁶ In addition, guidelines from the US Veterans Affairs, Kidney Disease Improving Global Outcomes, American Diabetes Association, Hypertension Canada, Japanese Society of Hypertension, European Society of Cardiology, and International Society of Hypertension endorse systolic BP targets of less than 130 mm Hg for most adult patients.

Shared decision-making remains essential, but for most adults with hypertension and elevated cardiovascular risk, contemporary evidence supports systolic BP less than 130 mm Hg as a default treatment target.

In Reply:

Shared decision-making around BP targets is appropriate when relevant potential benefits and harms are present, especially when those harms and benefits may vary based on a patient's risk factors, age, personal values, and comorbidities. Although Drs. McDaniel and Jenkins dislike “confusion and hesitancy” and prefer “clarity and forward momentum,” caution is appropriate when we are helping patients make critical decisions about lifelong treatment.

They cite a 2025 individual patient data meta-analysis of two randomized trials from the United States and four randomized trials from China.¹ It is notable that 83% of the data comes from studies set in China, including 43% from a cluster randomized trial in rural Chinese villages.² In the latter study, the final systolic BP in the intensive care group was 126 mm Hg; in the usual care group, it was 156 mm Hg. In effect, the studies compared intensive therapy with inadequate therapy, inflating any apparent benefit. Reporting of harms also appears to have been inconsistent in the Chinese trials. For example, acute kidney injury occurred in 4.1% of intensively treated patients in the US SPRINT trial, compared with only 0.1% of patients in two large Chinese randomized controlled trials reporting this outcome.^3–5 The same pattern is seen for syncope and worsening kidney function.

Drs. McDaniel and Jenkins acknowledge that patients “…unable to tolerate lower systolic BPs remain appropriate candidates for individualized targets,” and we agree. They cite the Hypertension Canada guideline in support of broad use of the 130/80 mm Hg target; however, that guideline recommends the more intensive target primarily for patients with high cardiovascular risk who are able to tolerate more intensive therapy. In fact, the guideline states: “The committee recognizes that the benefit of pharmacotherapy initiation in people at lower risk (i.e., systolic BP 130–139 without any high-risk conditions) is uncertain.”⁶

In addition, six of the nine physicians on the Hypertension Canada panel were hypertension specialists.⁶ Studies have shown that the composition of a panel reflects the intellectual biases of its members, with subspecialists generally favoring more intensive treatment and, as we noted in our editorial, primary care physicians taking a broader perspective of the whole patient that more fully balances benefits, harms, and individual patient values.⁷

The American College of Cardiology/American Heart Association guidelines included 13 professional societies with an impressive alphabet soup of acronyms, but this panel was dominated by subspecialists and did not include representation from the two most important primary care groups: the American Academy of Family Physicians and American College of Physicians. Family physicians should not only be at the table, they should hold the leadership role when guidelines are developed to inform our practice.

Regarding measurement of BP, the SPRINT, ESPRIT (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events) trial, and BPROAD (Blood Pressure Control Target in Diabetes) study use intensive and time-consuming office protocols that do not reflect the real world of clinical practice, with SPRINT being most relevant to a US primary care setting. The notion of a buffer between the desired target of less than 120 mm Hg and the stated target of 130 mm Hg is a novel concept but does not change the fact that treatment decisions should be based on the actual BP experienced by patients during their daily life and is not likely to cause harm due to overtreatment.

In conclusion, we stand by our core assertions: a 130/80 mm Hg target is not appropriate for all patients, and if pursued after shared decision-making, it should be based on the BP measured at home or office BP measured with protocols used in the SPRINT and BPROAD studies.

Editor’s Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP.