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Objective To directly compare the efficacy and safety of different intensive systolic blood pressure targets (<120 or <130 mm Hg) versus usual care on cardiovascular and renal outcomes.Design Meta-analysis of randomised controlled trials.Data sources Web of Science and Medline, from inception to 20 May 2025.Eligibility criteria for selecting studies Randomised controlled trials comparing intensive versus usual systolic blood pressure targets. Studies reported cardiovascular disease or kidney outcomes, or both.Results The study included 18 randomised controlled trials of 60 629 participants. Intensive control of systolic blood pressure significantly reduced the risk of major adverse cardiovascular events (relative risk 0.82, 95% confidence interval (CI) 0.78 to 0.87, P<0.001), including myocardial infarction, stroke, heart failure, and death from cardiovascular disease. Systolic blood pressure targets of <120 mm Hg and <130 mm Hg provided comparable cardiovascular protection. Intensive control of systolic blood pressure increased the risk of the composite chronic kidney disease outcome (relative risk 1.40, 95% CI 1.01 to 1.94, P=0.046), but with a likely higher risk for the target of <120 mm Hg. A systolic blood pressure target of <120 mm Hg also reduced the risk of albuminuria, but increased the risk of bradycardia and hypotension.Conclusions Intensive control of systolic blood pressure provided substantial cardiovascular benefits but increased the risk of renal adverse events. A systolic blood pressure target of <130 mm Hg had a similar degree of cardiovascular protection as <120 mm Hg with a more favourable renal safety profile, supporting a personalised risk based approach to treatment intensification.Trial registration PROSPERO CRD42025629962.