IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older patients with hypertension remains uncertain. OBJECTIVE To evaluate the effects of intensive (<120mmHg) compared with standard (<140mmHg) SBP targets in persons aged 75 years or older with hypertension but without diabetes. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015. INTERVENTIONS Participants were randomized to an SBP target of less than 120mmHg (intensive treatment group, n = 1317) or an SBP target of less than 140mmHg (standard treatment group, n = 1319). MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcomewas a composite of nonfatalmyocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. All-cause mortality was a secondary outcome. RESULTS Among 2636 participants (mean age, 79.9 years; 37.9%women), 2510 (95.2%) provided complete follow-up data. At a median follow-up of 3.14 years, there was a significantly lower rate of the primary composite outcome (102 events in the intensive treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66 [95%CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67 [95%CI, 0.49-0.91]). The overall rate of serious adverse events was not different between treatment groups (48.4%in the intensive treatment group vs 48.3%in the standard treatment group; HR, 0.99 [95%CI, 0.89-1.11]). Absolute rates of hypotension were 2.4%in the intensive treatment group vs 1.4%in the standard treatment group (HR, 1.71 [95%CI, 0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95%CI, 0.76-2.00]), 4.0% vs 2.7%for electrolyte abnormalities (HR, 1.51 [95%CI, 0.99-2.33]), 5.5%vs 4.0% for acute kidney injury (HR, 1.41 [95%CI, 0.98-2.04]), and 4.9% vs 5.5%for injurious falls (HR, 0.91 [95%CI, 0.65-1.29]). CONCLUSIONS AND RELEVANCE Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120mmHg compared with an SBP target of less than 140mmHg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause.