What are the target blood pressures after a Transient Ischemic Attack (TIA) and at what point do they become normal targets?

From the Guidelines

After a Transient Ischemic Attack (TIA), the target blood pressure should be a systolic BP of 120–129 mmHg, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This target is recommended to reduce cardiovascular disease (CVD) outcomes in patients with a history of TIA or stroke, provided treatment is tolerated. The following key points support this recommendation:

• The 2024 ESC guidelines recommend a systolic BP target of 120–129 mmHg for patients with a history of TIA or stroke 1.
• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines also recommend a blood pressure target of less than 130/80 mmHg for patients with a history of stroke or TIA 1.
• Lifestyle modifications, such as reduced sodium intake, regular exercise, limited alcohol consumption, and weight management, can help achieve blood pressure control.
• First-line medications for blood pressure control include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide diuretics. The aggressive blood pressure target after TIA is based on evidence that lower blood pressure significantly reduces the risk of recurrent stroke, with each 10 mmHg reduction in systolic blood pressure associated with approximately 20-30% reduction in stroke risk. Some key considerations for blood pressure management after TIA include:
• The importance of individualizing blood pressure targets based on patient characteristics and tolerance to treatment.
• The need for regular monitoring of blood pressure and adjustment of treatment as needed to achieve target blood pressure levels.
• The role of lifestyle modifications in achieving and maintaining blood pressure control.
• The selection of appropriate medications for blood pressure control, taking into account patient characteristics and comorbidities.

From the Research

Target Blood Pressures after a Transient Ischemic Attack (TIA)

• The target blood pressure after a TIA is generally considered to be less than 140/90 mmHg, as stated in the study 2.
• However, for high-risk patients, a target systolic blood pressure of less than 120 mmHg may be recommended, as measured by automated office blood pressure measurement 2.
• In patients with diabetes, the target systolic blood pressure should be less than 140 mmHg, according to the ACCORD trial 2, 3.
• For patients with protein-creatinine ratio >500 mg/g (albumin-creatinine ratio >300 mg/g), with or without diabetes, a lower systolic blood pressure target of less than 130 mmHg may be proposed for renal protection 2.

Normal Targets

• The normal target blood pressure is considered to be less than 140/90 mmHg, as stated in the study 2, 3, 4.
• However, some studies suggest that a target blood pressure of less than 130/80 mmHg may be beneficial for adults at increased risk for cardiovascular disease, including diabetics 3, 4.
• The decision to target a blood pressure of less than 120/80 mmHg in certain diabetics requires more research and is less clear 4.

Considerations

• When targeting blood pressure, it is essential to consider the risk of orthostatic hypotension, particularly in elderly patients 2.
• Diastolic blood pressure should also be considered, as a diastolic blood pressure of less than 70 mmHg may increase the risk of ischemic heart events 2.
• Renal function should be monitored, as acute renal failure is more frequently reported at low blood pressure targets 2.