What is the risk difference for cardiovascular events between systolic blood pressures of 120 mmHg and 139 mmHg?

Cardiovascular Risk Difference Between Systolic Blood Pressure of 120 mmHg vs 139 mmHg

A systolic blood pressure (SBP) of 120 mmHg is associated with significantly lower cardiovascular risk compared to 139 mmHg, with approximately 29% reduction in cardiovascular events and mortality. 1

Risk Stratification by Blood Pressure Category

• SBP of 120-129 mmHg is classified as the optimal target range according to the 2024 ESC guidelines, while 130-139 mmHg falls into the elevated blood pressure range 2
• The risk of cardiovascular events increases progressively and linearly from SBP levels as low as 115 mmHg, with each 20 mmHg increase in SBP associated with a doubling of mortality from both ischemic heart disease and stroke 2
• Individuals with SBP in the 130-139 mmHg range (high-normal BP) have a risk-factor-adjusted hazard ratio for cardiovascular disease of 2.5 (95% CI: 1.6-4.1) in women and 1.6 (95% CI: 1.1-2.2) in men compared to those with optimal blood pressure 3

Quantified Risk Difference

• Network meta-analysis shows that achieving SBP of 120-124 mmHg is associated with a 29% lower risk of major cardiovascular disease (HR 0.71; 95% CI: 0.60-0.83) compared to SBP of 130-134 mmHg 1
• The same analysis demonstrates a 27% reduction in all-cause mortality (HR 0.73; 95% CI: 0.58-0.93) when comparing SBP of 120-124 mmHg versus 130-134 mmHg 1
• The 10-year cumulative incidence of cardiovascular disease for individuals with high-normal blood pressure (130-139/85-89 mmHg) is significantly higher than those with optimal blood pressure:
  • For ages 35-64: 4% in women and 8% in men
  • For ages 65-90: 18% in women and 25% in men 3

Current Treatment Targets

• The 2024 ESC guidelines recommend targeting SBP to 120-129 mmHg in most adults to reduce cardiovascular disease risk, provided treatment is well tolerated 2
• This target represents a shift from previous guidelines that recommended SBP <140 mmHg as the initial objective, with a subsequent target of <130 mmHg if tolerated 2
• The target range of 120-129 mmHg reflects the most current evidence from contemporary RCTs and meta-analyses showing optimal cardiovascular outcomes in this range 2

Important Considerations and Caveats

• Excessive BP lowering to SBP ≤130 mmHg may be associated with increased risk in certain populations:
  • A study of hypertensive patients with ECG left ventricular hypertrophy found that SBP ≤130 mmHg was associated with no significant reduction in MI or stroke risk compared to 131-141 mmHg, and showed a 37% increased risk of all-cause mortality 4
  • For older patients (≥65 years), the recommended SBP target range is 130-139 mmHg rather than 120-129 mmHg 2
• More lenient BP targets (e.g., <140 mmHg) should be considered for patients with:
  • Pre-treatment symptomatic orthostatic hypotension
  • Age ≥85 years
  • Moderate to severe frailty
  • Limited predicted lifespan (<3 years) 2

Clinical Implications

• For most adults, targeting SBP to 120-129 mmHg provides optimal cardiovascular protection compared to higher values like 139 mmHg 2
• The risk difference is particularly significant for individuals with additional cardiovascular risk factors 3
• Lifestyle modifications should be the first approach for individuals with SBP in the 120-139 mmHg range, which can reduce cardiovascular risk by approximately 70% 5
• For diastolic BP, a target of <80 mmHg should be considered for all hypertensive patients, regardless of risk level and comorbidities 2