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2024 ESC guidelines: To reduce CVD risk, it is recommended that treated systolic BP values in most adults be targeted to 120-129mmHg, provided the treatment is well tolerated (Class I, Level A). In cases where on-treatment systolic BP is at or below target (120-129mmHg) but diastolic BP is not at target (≥80mmHg), intensifying BP-lowering treatment to achieve an on-treatment diastolic BP of 70-79mmHg may be considered to reduce CVD risk (Class IIb, Level C). Because CVD benefit of an on-treatment systolic BP target of 120-129mmHg may not generalise to the following specific settings, personalised and more lenient systolic BP targets (eg, <140mmHg): should be considered among patients meeting the following criteria: pre-treatment, symptomatic, orthostatic hypotension; and/or age ≥85 years (Class IIa, Level C). Because the CVD benefit of an on-treatment systolic BP target of 120-129mmHg may not generalise to the following specific settings, personalised and more lenient BP targets (eg, <140/90mmHg) may be considered among patients meeting the following criteria: clinically significant, moderate to severe frailty at any age; and/or limited predicted lifespan (<3 years) (Class IIb, Level C). 2023 ESH guidelines: For patients 18-64 years, the goal is to lower office BP to <130/80mmHg (Class I, Level A). For patients 65-79 years, the primary goal of treatment is to lower BP to <140/80mmHg (Class I, Level A). However, lowering BP to ≤130/80mmHg may be considered if treatment is well tolerated (Class II, Level B). For patients 65-79 with ISH, the primary goal of treatment is to lower systolic BP in the 140-150mmHg range (Class I, Level A). However, a reduction of office systolic BP in the 130-139mmHg range should be considered if well tolerated, albeit cautiously if diastolic BP is already below 70 mmHg (Class I, Level B). For patients aged ≥80 years, office systolic BP should be lowered to a systolic BP in the 140-150mmHg range (Class I, Level A). However, reduction of office systolic BP between 130 to 139mmHg may be considered if well tolerated, albeit cautiously if diastolic BP is already below 70mmHg (Class II, Level B). 2025 ACC/AHA guidelines: For adults with confirmed hypertension who are at increased risk for CVD (defined as a 10-year predicted risk for CVD events of ≥7.5% using PREVENT), an SBP goal of at least <130mmHg, with encouragement to achieve SBP <120mmHg, is recommended to reduce the risk of cardiovascular events and total mortality (Class I, Level A). In adults with confirmed hypertension who are not at increased risk for CVD, an SBP goal of <130mmHg, with encouragement to achieve SBP <120mmHg, may be reasonable to reduce risk of further elevation of BP (Class 2b, Level B-NR).

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Retrospective cohort study of ~2.4 million adults (from January 2006 to December 2010; n=470,386 with rHTN or non-rHTN. rHTN was subcategorized into 2 groups: individuals with controlled rHTN (defined as BP <140/90mmHg on ≥4 medications; n=23,104) and uncontrolled rHTN (defined as BP ≥140/90mmHg on ≥3 medications; n=37,223). All other individuals with HTN were categorized as non-rHTN (n=410,059). Average BP was 154/79mmHg in the uncontrolled rHTN group, 123/67mmHg in the controlled rHTN group, and 132/75mmHg in the non-rHTN group. The primary outcomes evaluated were IHE, CHF, CVA, incident ESKD, and all-cause mortality as
separate competing outcomes. The rHTN population had greater proportions of those who reached any of the outcomes (31.0% vs 16.7%) compared with the non-rHTN population (p<0.001). Multivariable adjusted outcomes data comparing the rHTN (controlled and uncontrolled) population with the non-rHTN population presented as HR and 95% CI: IHE (HR 1.24; 95% CI: 1.20–1.28); CHF (HR 1.46; 95% CI: 1.40–1.52); CVA (HR 1.14; 95% CI: 1.10–1.19); ESKD (HR 1.32; 95% CI: 1.27–1.37); all-cause mortality (HR 1.06; 95% CI: 1.03–1.08). CHF defined as HF and cardiomyopathy; ESKD defined as treatment with dialysis or kidney transplantation; IHE defined as MI, angina, coronary occlusion, myocardial necrosis, and any procedure for PCI or CABG; CVA defined as stroke, central nervous system bleed, or cerebrovascular disease/accident not otherwise specified. 

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Systematic review and meta-analysis of 123 randomised trials (published between 1966 and 2015) evaluated the effects of BP lowering on CV disease and mortality across various baseline BP levels and comorbidities in 613,815 participants. Data were also extracted for major CV disease events (defined as fatal and nonfatal MI, sudden cardiac death, revascularization, fatal and nonfatal stroke, and fatal and nonfatal heart failure), CHD (fatal and nonfatal MI and sudden cardiac death, excluding silent MI), stroke (fatal and nonfatal, excluding TIA), HF (new diagnosis of HF, hospital admission, or death), and renal failure (ESKD resulting in dialysis, transplantation, or death) and all-cause mortality. The relative risks for events per 10mmHg reduction in systolic BP were as follows: major CV events: 20% (RR=0.80; 95% CI: 0.77–0.83); CHD: 17% (RR=0.83; 95% CI: 0.78–0.88); stroke: 27% (RR=0.73; 95% CI: 0.68–0.77); HF: 28% (RR=0.72; 95% CI: 0.67–0.78); all-cause mortality: 13% (RR=0.87; 95% CI: 0.84–0.91); renal failure: 5% (RR=0.95; 95% CI (0.84–1.07). The effect on renal failure was not significant.