Intensive Blood Pressure Targets in Geriatrics: Individualized Decision‐Making and Unresolved Risks

We read with great interest the article by Jamshidian et al., “Individualized Net Benefit of Intensive Blood Pressure Lowering Among Community-Dwelling Older Adults in SPRINT,” recently published in the Journal of the American Geriatrics Society [1]. The authors applied a novel decision-analytic framework to estimate net benefit from intensive systolic blood pressure (SBP) lowering (< 120 mmHg) compared with a standard target (< 140 mmHg). Their findings that nearly all older adults derived net benefit—even those aged ≥ 75 years, frail, or with polypharmacy—are provocative and have significant implications for geriatric hypertension management. While the study makes a valuable methodological contribution, several important considerations warrant further discussion. First, the generalizability of these findings is limited. As the authors acknowledge, SPRINT excluded individuals with diabetes, prior stroke, advanced chronic kidney disease, dementia, institutional residence, and life expectancy < 3 years [1]. Notably, in the dedicated ≥ 75-year subgroup of SPRINT, intensive treatment reduced cardiovascular events and mortality, while overall rates of serious adverse events were similar [2]. These exclusion criteria and subgroup trade-offs highlight that many frailest and most clinically complex older adults, commonly encountered in practice, remain underrepresented. Observational evidence provides a contrasting perspective: in the Berlin Initiative Study, older adults with normalized blood pressure (< 140/90 mmHg) had higher mortality compared with those with higher pressures, particularly among patients aged ≥ 80 years and those with cardiovascular disease [3]. SPRINT-MIND showed potential cognitive benefits of intensive BP lowering [4], but in frail older adults with multiple comorbidities these may be paradoxically offset by dizziness, orthostatic hypotension, or cerebral hypoperfusion. This highlights the uncertainty of applying trial-based benefits to the most vulnerable geriatric patients. The net benefit analysis hinges critically on the weighting of harms relative to benefits. Even under the harm-averse scenario, most participants derived net benefit; however, this simulation still weighted disease outcomes substantially more than treatment-related harms. In geriatric practice, however, independence and fall prevention often outweigh marginal survival gains. Nursing home data demonstrate increased syncope, fractures, and hospitalizations after antihypertensive initiation [4]. These outcomes, although not directly captured in SPRINT, are highly relevant for geriatric decision-making. The frailty index used was retrospectively derived from SPRINT variables and may not capture the multidimensional aspects of geriatric vulnerability. Such an approach may overlook key aspects of vulnerability, including gait speed, functional capacity, and susceptibility to orthostatic intolerance. Validated instruments such as the Fried phenotype or Rockwood Clinical Frailty Scale provide a more comprehensive assessment and could enhance the clinical applicability of these findings [5]. Importantly, reliance on limited frailty measures risks underestimating heterogeneity in treatment tolerance among older adults, where small differences in functional reserve can critically shape benefit–harm profiles. The study did not assess long-term trajectories of adverse events. Recurrent acute kidney injury (AKI) or repeated hypotensive episodes may have cumulative consequences, leading to chronic kidney disease progression or disability. This limitation underscores the need for extended follow-up beyond the trial window, especially in very old or multimorbid populations. Finally, the interpretation of the results should be reconciled with evidence from other major trials and meta-analyses. The STEP trial in older Chinese adults demonstrated cardiovascular benefits of intensive control but at the expense of increased hypotension and renal events [6]. A 2021 individual-participant meta-analysis involving over 340,000 patients confirmed cardiovascular benefits across blood pressure strata but highlighted heterogeneity in older subgroups [7]. Likewise, a Cochrane review concluded that evidence for lower BP targets in older adults remains uncertain, underscoring the need for individualized targets [8]. Moreover, a recent mediation analysis of SPRINT data demonstrated that serious adverse events substantially offset potential cardiovascular benefits in some older adults, again highlighting the importance of tailoring therapy [9]. Taken together, these findings reinforce the principle that while intensive treatment is beneficial for many, careful patient selection remains crucial. In conclusion, Jamshidian et al. provide valuable evidence that intensive SBP lowering can yield net benefit in community-dwelling, SPRINT-eligible older adults, even in the presence of frailty and polypharmacy. However, the exclusion of the most vulnerable geriatric populations, the limited assessment of functional outcomes, and the assumptions regarding harm weighting constrain broader applicability. These limitations highlight the need for careful consideration before applying intensive SBP targets broadly to the oldest and frailest patients. Ultimately, treatment of hypertension in older adults should not rely solely on trial-derived averages but must incorporate individualized, shared decision-making that balances cardiovascular and cognitive benefits against risks, while respecting patients' functional priorities and personal goals. A practical treatment decision algorithm that integrates frailty status, comorbidities, and patient-centered priorities is illustrated in Figure 1. We believe that future research should incorporate real-world frail elders, long-term functional outcomes, and patient-centered priorities such as independence and quality of life. Concept, design, writing – O.F.A. The author has nothing to report. The author has nothing to report. The author declares no conflicts of interest. This publication is linked to a related letter by Jamshidian et al. To view this article, visit https://doi.org/10.1111/jgs.70259.