Intensive versus standard blood pressure control in older persons with or without diabetes: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVES: To assess and compare the benefits and harms of intensive versus standard blood pressure (BP) control in older people with or without diabetes mellitus (DM). DESIGN: Systematic review and meta-analysis SETTING: Randomised controlled trials comparing intensive versus standard BP control, identified from MEDLINE, Embase, The Cochrane library, Web of Science and a search of bibliographies from inception till August 2022. PARTICIPANTS: Older people (≥65 years) with or without DM. MAIN OUTCOME MEASURES: Study-specific risk ratios (RRs) with 95% confidence intervals (CIs) were pooled for adverse vascular and safety outcomes. RESULTS: We included six randomised controlled trials (RCTs) comprising 20,985 patients (intensive BP = 10,474 and standard BP = 10,511) with a weighted mean follow-up of 3.1 years. In the general population, the RRs (95% CIs) of intensive versus standard BP control for composite cardiovascular events or major adverse cardiovascular events (CVD/MACE), CVD mortality, coronary heart disease, stroke and heart failure were 0.71 (0.62–0.82), 0.65 (0.49–0.86), 0.75 (0.60–0.95), 0.75 (0.61–0.92) and 0.58 (0.41–0.82), respectively. Intensive BP control did not increase the risk of renal failure or serious adverse events in the general population. Two RCTs reported results for composite CVD/MACE in patients with DM with a pooled estimate of 0.85 (0.67–1.07). CONCLUSIONS: Aggregate trial evidence shows that intensive BP control (<120 to <140 mmHg) reduces the risk of adverse cardiovascular outcomes in older hypertensive patients in the general population with no increase in adverse events. Intensive BP control may confer similar benefits for older patients with DM with no evidence for harm, but this is based on limited data. PROSPERO Registration: CRD42022349791