The report calls for a move away from current guidelines which recommend pills only be prescribed if blood pressure is above a certain threshold.
But experts acknowledge lifestyle factors also have an important role to play in bringing blood pressures down.
The study appears in the Lancet.
High blood pressure has long been linked to a higher risk of heart disease and stroke.
Current guidelines – issued by England’s National Institute for Health and Care Excellence – suggest patients should only take medication when their blood pressure levels reach 140 mmHg.
Until this point even those at highest risk, for example people who have had previous heart attacks and strokes, are offered monitoring but not pills.
Now a global team of experts are calling for doctors to focus on an individual’s risks rather than rigid and “arbitrary” blood pressure thresholds.
Experts analysed the results of more than 100 large-scale trials involving some 600,000 people between 1966 and 2015.
They found those patients at highest risk – including smokers with high cholesterol levels and people over 65s with diabetes – would benefit most from treatment, lowering their chance of heart attacks and strokes.
In addition the report suggests once on treatment, blood pressure levels could be reduced even further than the targets currently used.
The study also adds to growing evidence that patients may benefit from lowering their blood pressure whatever their baseline levels – either through lifestyle changes or drugs.
But it shows the lower the person’s blood pressure to start with, the lower the benefit they gain from reducing it.
The authors do not go as far as to suggest everyone should be given pills and caution side-effects of medication must be weighed up.
Prof Liam Smeeth, of the London School of Hygiene and Tropical Medicine, agreed the findings were important for those at highest risk.
But he warned: “One important caveat is that not everyone will be able to tolerate having their blood pressure reduced to low levels, and there is a need to balance possible drug side effects and likely benefits.”
Heart specialist Dr Tim Chico, of the University of Sheffield, said medication need not be the only way to tackle the issue.
He added: “We can all reduce our blood pressure.
“We can do this safely, cheaply and as effectively as tablets by eating healthily, taking more physical activity, reducing alcohol intake, and maintaining a healthy weight.”