Systolic Blood Pressure Targets in Patients With Hypertension With and Without Cardiovascular Disease: A Pooled Analysis of 4 Randomized Clinical Trials

BACKGROUND: – Inconsistent selection of reference groups may contribute to inconclusive blood pressure control targets for patients with hypertension. This study aims to identify optimal systolic blood pressure (SBP) targets for individuals with and without cardiovascular disease (CVD) by employing a novel metric combining blood pressure magnitude and duration. METHODS: – We conducted a secondary analysis of individual-level data from 4 clinical trials. Participants aged >80 years, with prevalent heart failure, or with missing follow-up SBP measurements or CVD history were excluded. The proportion of time-in-target range (TTR) was estimated using linear interpolation to quantify longitudinal SBP changes across predefined SBP ranges. Associations between TTR and major adverse cardiovascular events were assessed using stratified Cox proportional hazards models, analyzed separately by CVD history, and stratified by study trials, with hazard ratios (HRs) estimated per 10% increase in TTR. Lower TTR within the same target served as the implicit reference. RESULTS: – Among 59 727 participants included in the analysis, the mean age was 65.8 (SD, 6.9) years, 52.3% were men, and 24 524 (41.1%) had a history of CVD. Higher TTR within SBP ranges of 110 to 140 mm Hg was consistently associated with a lower risk of major adverse cardiovascular events in participants with and without CVD. For SBP of 110 to 120 mm Hg, HRs were 0.89 (95% CI, 0.86–0.92) in participants without CVD and 0.93 (95% CI, 0.90–0.95) among those with CVD; corresponding HRs were 0.86 (95% CI, 0.83–0.88) and 0.90 (95% CI, 0.88–0.92) for 120 to 130 mm Hg, and 0.94 (95% CI, 0.92–0.96) and 0.93 (95% CI, 0.91–0.95) for 130 to 140 mm Hg. SBP ≥150 mm Hg was associated with increased major adverse cardiovascular event risk in both groups, whereas SBP <110 mm Hg was associated with reduced risk only in participants without CVD (HR, 0.91 [95% CI, 0.86–0.97]) and not among those with CVD (HR, 1.02 [95% CI, 0.98–1.06]). CONCLUSIONS: – Restricted cubic spline analyses demonstrated a J-shaped association between achieved SBP and major adverse cardiovascular event irrespective of CVD history. Maintaining SBP within 110 to 140 mm Hg was similarly associated with lower cardiovascular risk in patients with and without CVD. Risk appeared lowest when SBP was between 120 and 130 mm Hg, while an SBP target <110 mm Hg may offer additional benefit among patients without CVD.