How low should blood pressure go? New research may finally have the answer

A new study from researchers at Mass General Brigham is challenging long-standing assumptions about how aggressively blood pressure should be treated, suggesting that pushing levels lower than commonly recommended could prevent significantly more heart attacks and strokes.

The research indicates that aiming for a systolic blood pressure below 120 mm Hg, lower than the widely used target of under 130 mm Hg, may offer stronger protection against major cardiovascular events, including heart attacks, strokes, and heart failure. The findings were published in Annals of Internal Medicine and are based on large-scale data analysis combined with simulation modelling.

WHAT THE RESEARCHERS DID

Instead of running a single clinical trial, scientists pulled together evidence from multiple major sources, including the SPRINT trial and the US National Health and Nutrition Examination Survey. They then built models to estimate long-term health outcomes for patients managed under different blood pressure targets: under 140, under 130, and under 120 mm Hg.

The goal was to simulate what would happen over a lifetime – not just in the short term – if doctors pursued more or less intensive treatment strategies.

Importantly, the researchers also accounted for real-world issues that affect everyday medical care, such as inaccuracies in blood pressure readings taken in clinics. These variations can influence how patients are diagnosed and treated.

CLEAR HEALTH GAINS – BUT NOT WITHOUT TRADE-OFFS

Across the models, the most aggressive target (<120 mm Hg) consistently performed best in reducing cardiovascular disease. It was associated with fewer heart attacks, fewer strokes, and a lower risk of heart failure compared with higher targets.

However, the benefits came with clear downsides. More intensive treatment increased the risk of medication-related complications such as low blood pressure episodes, falls, kidney injury, and slow heart rate. It also required more frequent use of antihypertensive drugs and additional medical monitoring, which pushed up overall healthcare costs.

Even so, the study found the stricter target remained cost-effective by standard healthcare measures, estimating around $42,000 per quality-adjusted life year gained – a commonly used benchmark in health economics.

WHAT IT MEANS FOR PATIENTS

Researchers stressed that while the results are compelling at a population level, they do not suggest a one-size-fits-all approach. Some patients – especially those at high risk of cardiovascular disease – may benefit more from intensive treatment, while others may face greater harm from side effects.

As one of the lead researchers noted, treatment decisions should ultimately be individualised, balancing the potential heart health benefits with the risks and a patient’s personal preferences.

The takeaway is not that everyone should aim lower immediately, but that current targets may be more flexible than once thought – and that, for many patients, “lower” could indeed mean better protection for the heart.