Abstract Body: Introduction
More intensive systolic blood pressure (BP) targets have been proposed to improve cardiovascular outcomes, but the balance of benefit and risk remains uncertain.

Hypothesis
Intensive lowering of systolic BP to <130 mmHg reduces the incidence of major cardiovascular events compared with less intensive BP targets.

Methods
A systematic review and meta-analysis of randomized controlled trials published from 2009 to 2024 was conducted. MEDLINE, Embase, and the Cochrane Central Register were searched for trials comparing intensive (systolic BP <130 mmHg) versus less intensive (>130 mmHg) targets. The primary outcome was a composite of major cardiovascular events (MACE). Secondary outcomes included cardiovascular death, all-cause mortality, stroke, myocardial infarction, and heart failure. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Heterogeneity was quantified by inconsistency index.

Results
Ten trials enrolling 83,580 participants met inclusion criteria. Intensive BP lowering reduced the risk of MACE compared with a less intensive strategy (RR 0.77; 95% CI, 0.70–0.85; p < 0.001; inconsistency index = 60%). Lower BP targets decreased the risk of cardiovascular death (RR 0.73; 95% CI, 0.65–0.82; p < 0.001; inconsistency index = 0%), all-cause mortality (RR 0.88; 95% CI, 0.82–0.95; p = 0.002; inconsistency index= 11%), stroke (RR 0.76; 95% CI, 0.69–0.84; p < 0.001; inconsistency index = 33%), myocardial infarction (RR 0.82; 95% CI, 0.73–0.92; p = 0.001; inconsistency index = 0%), and heart failure (RR 0.71; 95% CI, 0.60–0.84; p < 0.001; inconsistency index = 16%). There was no significant difference in acute coronary syndrome and revascularization (RR 0.89; 95% CI, 0.75–1.06; p = 0.18; inconsistency index= 40%). The results of the primary analysis remain consistent among the subgroups of diabetes and stroke. Intensive treatment increased hypotension and syncope but did not raise serious adverse event rates.

Conclusions
Targeting systolic BP to <130 mmHg significantly lowers major cardiovascular events and mortality compared with higher BP targets, with an acceptable safety profile. These findings support adopting lower systolic BP goals in high-risk populations.