Arq. Bras. Cardiol. 2025; 122(3): e20240761

Systematic Review of the Effectiveness of Intensive Antihypertensive Treatment Goals: Brazilian Society of Cardiology (SBC) Recommendation

Andréa Araujo Brandão , Cibele Isaac Saad Rodrigues , Luiz Aparecido Bortolotto , Leonardo Castro Luna , Bruno Monteiro Barros , Mario Fritsch Toros Neves , Ana Flávia de Souza Moura , Frida Liane Plavnik , Luciano Ferreira Drager , Osni Moreira Filho, Weimar Kunz Sebba Barroso de Souza , Wilson Nadruz

DOI: 10.36660/abc.20240761i

This Original Article is referred by the Short Editorial "Ideal Blood Pressure Levels: So Long the J-Curve, Lower is Better".

Abstract

Background

Strict blood pressure control has been investigated as a strategy to reduce severe cardiovascular events in patients with hypertension. However, there are still doubts about the impact of intensive antihypertensive treatment goals (< 130/80 mmHg) compared to conventional goals (≥ 130/80 mmHg) in preventing myocardial infarction, stroke, mortality, and possible treatment-related adverse effects.

Objective

To evaluate the effectiveness of intensive antihypertensive treatment goals in reducing critical cardiovascular events compared to usual goals.

Methods

This systematic review included randomized controlled trials (RCTs) that compared intensive blood pressure control goals with conventional goals in adults aged 18 years or older. Studies with at least one of the following outcomes were included: mortality, myocardial infarction, stroke, progression to stage 4 or 5 chronic kidney disease, need for dialysis, or kidney transplantation. Medline, Embase, and Cochrane Library databases were searched up to May 2024. Risk of bias assessment was performed by two independent reviewers using the Cochrane Collaboration’s Risk of Bias 2 (RoB 2) tool. Synthesis of results was conducted through meta-analysis for the composite outcome of myocardial infarction, stroke, and all-cause mortality. The certainty of scientific evidence and strength of recommendation followed the methods proposed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Results

Nine RCTs with more than 34,000 participants were included. Intensive treatment was associated with a 13% reduction in cardiovascular events. In the studies with low risk of bias, the reduction was 17%, with high certainty of evidence. Separately, a significant reduction was observed in the outcomes of myocardial infarction and stroke, but not in all-cause mortality. Limited data were found on the progression of kidney disease and the need for dialysis or kidney transplantation.

Conclusion

High-quality evidence suggests that more intensive antihypertensive treatment goals significantly reduce cardiovascular events. However, the choice of treatment goals should be individualized, considering factors such as age, frailty, individual cardiovascular risk, and the possibility of adverse events. Adherence to treatment is essential to therapeutic success.