A meta-analysis of 27 randomized clinical trials involving nearly 90,000 participants published in JAMA Cardiology shows that intensive blood pressure control reduces major cardiovascular events by 15% per 10 mmHg reduction in systolic pressure. The benefits apply equally to adults with and without chronic kidney disease, preventing 4.3 cardiovascular events per 1,000 person-years in CKD patients. While intensive targets increase mild or temporary filtration drops, they do not increase the risk of end-stage kidney failure.
Cardiovascular and mortality benefits
- ▪Intensive blood pressure lowering reduced major cardiovascular risk by 15% overall (11% with chronic kidney disease and 16% without chronic kidney disease) per 10 mmHg reduction in systolic blood pressure.
- ▪Intensive blood pressure treatment reduced all-cause mortality by 11% per 10 mmHg reduction in systolic blood pressure across participants with and without chronic kidney disease.
- ▪Intensive blood pressure lowering avoided an estimated 4.2 to 4.3 cardiovascular events per 1,000 person-years in people with chronic kidney disease compared with 2.7 in those without.
Scope of the meta-analysis
- ▪The JAMA Cardiology meta-analysis added three recent major trials—ESPRIT, BPROAD, and STEP—which contributed 32,587 participants, including 1,843 with chronic kidney disease.
- ▪A JAMA Cardiology meta-analysis of 27 randomized clinical trials (88,830 participants, search through January 16, 2026) evaluated intensive blood pressure targets (systolic blood pressure below 120 or 130 mmHg) versus standard targets (below 140 mmHg).
Chronic kidney disease research
- ▪Analysis of post-trial follow-up data totaling 1,331 outcomes showed intensive blood pressure lowering did not increase risk of kidney failure requiring dialysis or transplantation compared to standard treatment.
- ▪A Cochrane meta-analysis restricted to chronic kidney disease populations found no added cardiovascular benefit from intensive blood pressure targets.
eGFR declines and diuretic effects
- ▪Researchers suggested that eGFR declines during intensive blood pressure treatment reflect temporary blood flow changes caused by increased diuretic use rather than permanent kidney damage.
- ▪In the ESPRIT trial, 43% of participants in the intensive blood pressure lowering arm used diuretics at study end compared with 15% in the standard arm.
- ▪Intensive blood pressure lowering increased the relative risk of sustained eGFR declines of 30% or more by 42% and declines of 40% or more by 47%.
Intensive blood pressure targets and risks
- ▪Intensive blood pressure lowering aims for a systolic blood pressure goal below 120 mmHg or 130 mmHg, compared to standard targets below 140 mmHg.
- ▪Prior research has associated intensive blood pressure treatment with acute kidney injury and hypotension-related events, including syncope and falls.
Clinical guidelines and recommendations
- ▪The Kidney Disease: Improving Global Outcomes 2024 guideline suggests a target systolic blood pressure of less than 120 mmHg for people with chronic kidney disease.
- ▪The authors of the JAMA Cardiology meta-analysis concluded that clinical guidelines should recommend intensive blood pressure lowering in patients with and without chronic kidney disease alongside careful kidney function monitoring.
- ▪The 2023 European Society of Hypertension guideline advises against actively aiming for systolic blood pressure below 120 mmHg.
- ▪The 2025 American Heart Association/American College of Cardiology guideline targets systolic blood pressure below 130 mmHg and encourages targets below 120 mmHg.
Blood pressure levels and heart risk
- ▪Earlier observational studies indicated a J-shaped curve where very low blood pressure increases the risk of heart complications or death in people with underlying conditions.
- ▪A 20 mmHg increase in blood pressure doubles the risk of dying from heart disease, even in individuals without other pre-existing health conditions.
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