What are the target blood pressures for managing permissive hypertension?

Target Blood Pressure Ranges for Permissive Hypertension Management

For permissive hypertension management, blood pressure should be maintained in the range of 130-139 mmHg systolic and <90 mmHg diastolic for most patients, with individualized targets based on specific clinical conditions. 1

General Target Blood Pressure Ranges by Condition

Standard Hypertension Management

• General population: SBP 130-139 mmHg, DBP <90 mmHg 1
• Minimum acceptable control (audit standard): <150/90 mmHg 1

Special Populations

Diabetes

• Target: SBP 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
• Older diabetic patients (≥65 years): SBP 130-139 mmHg 1
• Frail elderly with diabetes: <140-150/90 mmHg 2

Chronic Kidney Disease

• Moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²): SBP 120-129 mmHg 1
• General CKD: SBP 130-139 mmHg 1
• Lower eGFR or renal transplant: Individualized targets 1

Heart Failure

• Heart failure patients: Follow standard targets while using appropriate medications (ACE inhibitors/ARBs, beta-blockers, MRAs, SGLT2 inhibitors) 1

Stroke

• Post-ischemic stroke/TIA: SBP 120-130 mmHg 1

Day-by-Day Management Approach

Day 1-2: Initial Assessment and Stabilization

• Determine baseline BP and presence of target organ damage
• For most patients, aim for SBP <140 mmHg initially 1
• For patients with stroke history, aim for SBP 120-130 mmHg 1

Day 3-7: Titration Phase

• Adjust medications to achieve target range based on patient's condition
• Monitor for signs of organ hypoperfusion (orthostatic hypotension, dizziness, weakness) 3
• Avoid reducing DBP below 60 mmHg in patients with coronary artery disease 2

Day 7+: Maintenance Phase

• Continue monitoring and adjusting to maintain target BP range
• For most patients: SBP 130-139 mmHg, DBP <90 mmHg 1
• For high-risk patients (stroke, CKD, diabetes): SBP 120-130 mmHg 1

Important Considerations

Measurement Technique

• Use validated device with appropriate cuff size 1
• Patient should be seated with arm at heart level 1
• Take multiple readings and use the average 1
• Consider ambulatory or home BP monitoring (values typically 10/5 mmHg lower than office readings) 1

Cautions

• Avoid excessive BP lowering in elderly patients and those with coronary artery disease 2
• Monitor orthostatic changes in BP, particularly in elderly patients 2
• Diastolic BP should not fall below 60 mmHg in patients with isolated systolic hypertension 2
• Avoid rapid BP reduction which may lead to organ hypoperfusion 3

Clinical Pitfalls to Avoid

1. Overly aggressive BP reduction - Targeting SBP <120 mmHg may increase adverse events in many patients 4
2. Ignoring standing BP measurements - Orthostatic hypotension is common, especially in elderly patients 2
3. One-size-fits-all approach - Targets should be adjusted based on comorbidities and cardiovascular risk 1
4. Inadequate monitoring - Regular BP checks are needed during titration phase
5. Ignoring patient tolerance - Watch for symptoms of hypoperfusion when approaching lower BP targets 3

The most recent evidence from the 2024 ESC guidelines 1 provides the strongest recommendations for target BP ranges in permissive hypertension management, emphasizing the importance of balancing cardiovascular risk reduction with avoiding excessive BP lowering that could lead to adverse outcomes.