When “Intensive” Becomes Standard

Changing our mindset about hypertension

There are several headlines in this week’s issue of JACC I want to share.

First, the global picture. A new pooled analysis of 287 population-based studies, covering more than 6 million adults across 119 countries, finds that only one in five adults with hypertension worldwide has their blood pressure controlled to below 140/90 — the old target, the one almost every major guideline considered the bare minimum. 1.71 billion people now live with hypertension according to the old definition (the new definition is 130/80).

The gap between high-income and low-and middle-income countries is widening, not closing: 83% of the world’s uncontrolled cases are now in low and middle-income countries, up from 70% in 2000. Even high-income countries, after decades of progress, have plateaued. We are failing at the bar we already set.

Two trials in the same issue strengthen the case for going lower, and both focus on older adults, the population clinicians most often hesitate to treat to these levels. A new analysis of the STEP trial, which enrolled patients aged 60 to 80 and tested a systolic target of under 130 mm Hg, finds that patients who achieved rapid and stable control had the lowest cardiovascular event rates, and that each additional month of delay in reaching the target was associated with a measurable increase in risk.

The ESPRIT trial, conducted across 116 sites in China, including community medical centers, enrolled more than 11,000 high-risk patients — over 40% with longstanding uncontrolled blood pressure — and tested a systolic target under 120 mm Hg. Sustained intensive control was achievable, with a median time to target of 62 days and roughly one additional medication and one additional clinic visit per year. The two trials say something similar in different ways: in older adults, lower targets reduce cardiovascular risk, and the work of getting there is more feasible than many practices assume.

My Editor’s Page in this issue takes up the question of why practice continues to lag. Part of the answer, I argue, is language. When the major trials of lower blood pressure targets were first designed, the lower arm was referred to as “intensive treatment.” It was a fair label at the time; those targets really were more aggressive than standard practice. But study after study has now shown that treating to these levels meaningfully reduces cardiovascular risk, and we never updated the word. We still call it intensive. The word makes it sound exceptional, reserved for the unusually motivated patient or the unusually aggressive clinician. It increasingly isn’t. For many otherwise healthy older adults, what we still call intensive treatment is becoming the standard of good care.

This does not mean treating every patient the same way. Orthostatic symptoms, polypharmacy, and patient goals all matter. But it does mean we should be more careful before accepting “stable but suboptimal” as good enough. For lower risk, lower blood pressure targets are better. It’s a best buy in prevention. Let’s stop calling it intensive treatment and just call it good care.