Hypertension Guidelines disagree on the definition of the more appropriate blood pressure (BP) target to achieve. A shared feature of Guidelines was the definition of precise, albeit differing across Guidelines, BP targets in different patient categories (i.e., 140 mmHg, 130 mmHg, etc.). The definition of rigid and precise BP targets overall and in different risk categories is not fully supported by evidence.

Observational studies: A direct relation between BP and risk of cardiovascular disease emerged from observational studies, including a large meta-analysis (Lancet 2002:1903). The majority of the studies showed that after correction for several confounders (cancer, heart failure, etc.), the lowest cardiovascular risk occurred at low values of achieved BP (<120/80 mmHg, or even <100/60 mmHg).

Intervention studies: Meta-analyses of randomized studies between different drugs or BP targets showed two main findings:

(a) the larger the BP difference between randomized groups in the achieved BP, the greater the benefit (particularly on stroke and heart failure) in the group with the lower achieved BP;

(b) when comparing a more intensive with a less intensive BP target (i.e., 120 vs 140 mmHg), the risk of major cardiovascular disease was lower in association with the more intensive strategy. In a meta-analysis, a more intensive strategy reduced stroke by 20%, myocardial infarction by 15%, heart failure by 25%, cardiovascular death by 18% and all-cause death by 11% (Hypertension 2016:642) when compared to a less intensive strategy. Notably, BP targets considerably differed across the studies.

Evidence regarding tolerability of treatment: According to Guidelines, a more intensive BP target may be allowed at condition that the treatment is well tolerated. However, the concept of ‘good tolerability of treatment’ holds at any level of achieved BP, irrespective of the BP target. No evidence supports the concept of ‘safety thresholds’ in patients who tolerate treatment very well.

Conclusion: The ‘lowest well tolerated BP’ looks like a simple, evidence-based and reasonable BP target regardless of the cardiovascular risk status of the patient.