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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e147

enrolled patients aged ≥50 years with high cardio­ vascular risk and an SBP >130 mm Hg, included 17% of participants with baseline CVD. In the sub­ group with CVD, intensive SBP lowering to <120 mm Hg versus standard treatment targeting <140 mm Hg reduced the incidence of the primary out­ come to a similar extent of those without CVD. In the STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) trial, which randomized adults aged 60 to 80 years to an SBP target of 110 to 130 mm Hg compared with 130 to 150 mm Hg, 6% of participants had a history of CVD, with similar findings. In the ESPRIT (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events) study of 11 255 patients (including 4359 with dia­ betes and 3022 with a history of stroke), random­ ization to intensive treatment targeting office SBP <120 mm Hg was associated with better CVD outcomes compared with standard treatment (haz­ ard ratio [HR]: 0.88 [95% CI: 0.78-0.99]) with no heterogeneity of treatment effect by comorbid dia­ betes or stroke history.5 In aggregate, these data indicate that the benefit of treatment clearly out­ weighs the potential harm at a threshold of ≥130 mm Hg for SBP for secondary prevention of CVD. 4.	 In adults with hypertension and clinical CVD (coro­

nary heart disease, stroke, HF), initiation of medica­ tions to lower BP is recommended when average DBP is ≥80 mm Hg to reduce the risk of cardiovas­ cular events and total mortality. Although elevated diastolic BP ≥80 mm Hg was included as an entry criterion in the ABCD trial that enrolled adults with diabetes and hypertension (with or without CVD), clinical trials have not exclusively enrolled individu­ als with elevated DBP ≥80 mm Hg. A meta-analysis

Figure 6. Use of Risk-Based Thresholds for Initiation of BP Treatment in Adults. *In older adults who may be frail or have a limited life expectancy, a clinician-patient assessment of potential benefits and harms of BP lowering should be pursued to align care with patient goals. †Increased short-term or 10-year risk is defined as a 10-year predicted risk for CVD events of ≥7.5% using PREVENT. BP indicates blood pressure; CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; HF, heart failure; PREVENT, Predicting Risk of cardiovascular EVENTs; and SBP, systolic blood pressure.

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