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Background: Managing blood pressure reduces CVD risk, but optimal treatment thresholds remain unclear as it is a balancing act to avoid hypotension-related adverse events. Objectives: This systematic review, meta-analysis and meta-regression evaluated the benefits of intensive BP treatment in hypertensive older adults. Methods: We systematically searched PubMed, MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials until January 31, 2020. Studies comparing different BP treatments/targets and/or active BP against placebo treatment, with a minimum 12 months follow-up, were included. Risk ratios (RR) and 95% CIs were calculated using a random effects model. The primary outcome was RR of major cardiovascular events (MCEs); secondary outcomes included myocardial infarction (MI), stroke, heart failure (HF), cardiovascular (CV) mortality, and all-cause mortality. Results: We included 16 studies totaling 65,890 hypertensive participants (average age 69.4 years) with a follow-up period from 1.8 to 4.9 years. Intensive BP treatment significantly reduced the relative risk of MCEs by 26% (RR:0.74, 95%CI 0.64–0.86, p = 0.000; I2 = 79.71%). RR of MI significantly reduced by 13% (RR:0.87, 95%CI 0.76–1.00, p = 0.052; I2 = 0.00%), stroke by 28% (RR:0.72, 95%CI 0.64–0.82, p = 0.000; I2 = 32.45%), HF by 47% (RR:0.53, 95% CI 0.43–0.66, p = 0.000; I2 = 1.23%), and CV mortality by 24% (RR:0.76, 95%CI 0.66–0.89, p = 0.000; I2 = 39.74%). All-cause mortality reduced by 17% (RR:0.83, 95%CI 0.73–0.93, p = 0.001; I2 = 53.09%). Of the participants - 61% reached BP targets and 5% withdrew; with 1 hypotension-related event per 780 people treated. Conclusions: Lower BP treatment targets are optimal for CV protection, effective, well-tolerated and safe, and support the latest hypertension guidelines.