Regarding: Systolic blood pressure targets below 120 mm Hg are associated with reduced mortality: A meta-analysis

Abstract

Dear Editor,

The meta-analysis by Bergmann et al. [1] published in Journal of Internal Medicine provides a significant synthesis, concluding that intensive systolic blood pressure (SBP) control (<120 mm Hg) reduces mortality and MACE in high-risk individuals. This finding could reinforce a dominant narrative that “lower is always better” for SBP, universally applicable. However, the “insight” arises when considering the study's own highlighted limitations and the geographical concentration of the included RCTs (primarily North America and East Asia). This prompts a reconsideration of how these important findings are translated into global clinical practice.

Why is this reconsideration needed now? The increasing recognition of global health disparities and the influence of diverse socio-environmental and genetic factors on disease presentation and treatment response means that a one-size-fits-all approach, even for well-established interventions, may fall short. Extant therapeutic guidelines often strive for universality, but the gap in current understanding is how to effectively adapt evidence from specific trial populations to the vast heterogeneity of real-world patients globally. Simply stating a pooled benefit without robustly addressing generalizability overlooks this critical translational step.

This analysis by Bergmann et al., therefore, offers a new framing for future research: Instead of solely focusing on whether intensive SBP control works, the emphasis should shift to for whom, under what conditions, and with what regional adaptations. The generalizability point is not just a caveat; it is a call to extend the literature through trials specifically designed to assess intensive SBP strategies in underrepresented regions (e.g., Middle East, Africa, and South America), potentially incorporating cross-disciplinary thinking from public health and implementation science to understand contextual barriers and facilitators.

Furthermore, the consistent signal of increased adverse events (hypotension, syncope, AKI) [1] is not merely a secondary concern but a primary driver for the practical implication of individualized therapy. The challenge now is to move beyond simply acknowledging this trade-off. Indeed, if the profound cardiovascular benefits demonstrated by Bergmann et al. could be consistently replicated across all global regions and achieved without the burden of these significant adverse effects, it would undoubtedly represent a paradigm shift in cardiovascular prevention. Therefore, the future direction must be proactive: To discover and validate targeted strategies—perhaps guided by pharmacogenomics, precision risk stratification for adverse events, or novel co-therapies—that can uncouple the desired cardiovascular benefits from the concerning harms.

To convince a potentially skeptical audience that this nuance is paramount, I argue that the true advancement lies not just in demonstrating efficacy in pooled analyses but in ensuring that such efficacy can be safely and equitably realized across diverse global populations. Bergmann et al.’s work is a vital foundation, but the next chapter requires a dedicated focus on generalizability and harm mitigation.

The author declares no conflicts of interest.