Intensive blood-pressure lowering reduces mortality and cardiovascular disease in clinical trials, but real-world BP measurements often differ from standardised protocols. In this retrospective cohort of over 2.3 million US Veterans with hypertension (mean age 66; 36% diabetes, 22% cardiovascular disease, 19% kidney disease), systolic BP was treated as a time-dependent variable across seven categories. Lowest mortality was seen at a systolic BP of 130-139 mmHg. Compared with a year at BP ≥160 mmHg, adjusted hazard ratios included 1.29 at <110, 0.83 at 130-139 and 0.86 at 140-149 mmHg — a J-shaped relationship consistent across patients with and without cardiovascular or kidney disease. In routine practice, a somewhat higher BP target thus appears appropriate, especially for older patients with comorbidity.
Hypertension, Volume 83, Issue 6, Page e25787, June 1, 2026. BACKGROUND:Intensive blood pressure (BP) control reduces mortality and cardiovascular disease in clinical trials. However, real-world BP measurements often differ from standardized protocols. We evaluated the impact of real-world systolic BP on mortality among US Veterans.METHODS:We conducted a retrospective cohort study of Veterans with hypertension, defined by diagnostic codes, antihypertensive prescriptions, or ≥2 office BP readings ≥130/90 mm Hg in 2016 to 2017, with follow-up through March 2021. Systolic BP was treated as a time-dependent covariate and categorized into 7 groups: <110, 110−119, 120−129, 130−139, 140−149, 150−159, and ≥160 mm Hg. Discrete-time survival models assessed associations with all-cause mortality, adjusting for demographics, body mass index, and comorbidities. Stratified analyses were conducted based on cardiovascular disease and chronic kidney disease status.RESULTS:Among >2.3 million Veterans (mean age, 66 years; 36% with diabetes; 22% with cardiovascular disease; and 19% with chronic kidney disease), the lowest mortality risk was observed in those with systolic BP of 130 to 139 mm Hg. In this cohort, adjusted hazard ratios for all-cause mortality per year in each systolic BP category were 1.29 for BP <110; 1.03 for BP 110 to 119; 0.88 for BP 120 to 129; 0.83 for BP 130 to 139; 0.86 for BP 140 to 149; and 0.89 for BP 150 to 159 mm Hg, compared with a year with BP ≥160 mm Hg. These associations remained consistent across cardiovascular disease and chronic kidney disease subgroups.CONCLUSIONS:Veterans with routine systolic BP of 130 to 139 mm Hg had the lowest mortality. These findings suggest that a higher BP target may be appropriate in clinical practice, especially for older adults with comorbidities.
