What is the target blood pressure (BP) goal for patients with hypertension (HTN)?

Blood Pressure Targets in Hypertension Management

For most patients with hypertension, the target blood pressure goal should be <140/90 mmHg initially, and if well tolerated, further reduction to <130/80 mmHg to maximize reduction in cardiovascular morbidity and mortality. 1

General Population Blood Pressure Targets

Standard Initial Target

• Target BP <140/90 mmHg for all hypertensive patients 1
• This initial target is associated with decreased complications of cardiovascular disease 1

Optimal Target (if well-tolerated)

• Further reduction to <130/80 mmHg for most patients 1, 2
• For systolic BP specifically, target 120-129 mmHg in most adults 1
• For diastolic BP, target 70-79 mmHg 1

Special Population Considerations

Elderly Patients (≥65 years)

• Target systolic BP range of 130-139 mmHg 1
• More conservative approach needed due to risk of orthostatic hypotension 1

High-Risk Patients

Target BP <130/80 mmHg for patients with:

• Diabetes mellitus 1
• Chronic kidney disease 1
• Known cardiovascular disease 1
• Proteinuria 1, 2

Implementation Strategy

1. Initial Approach:

   • Begin with lifestyle modifications for all patients 1, 2
   • Start pharmacotherapy based on BP level and cardiovascular risk 1, 3

2. Medication Strategy:

   • First-line options: ACE inhibitors/ARBs, thiazide diuretics, calcium channel blockers 1, 2
   • Consider combination therapy when BP is >20/10 mmHg above goal 1
   • Add spironolactone for resistant hypertension 1, 2

3. Monitoring and Titration:

   • Regularly monitor BP, renal function, and electrolytes 2
   • Titrate medications gradually to avoid organ hypoperfusion 2, 4
   • Assess for orthostatic hypotension, especially in elderly patients 1, 2

Clinical Considerations and Caveats

• J-curve phenomenon: Excessive BP lowering (below 120/70 mmHg) may increase cardiovascular risk in some patients 4
• Frailty assessment: Consider more lenient targets (e.g., <140/90 mmHg) in patients with significant frailty or limited life expectancy 1
• Orthostatic hypotension: Use caution with aggressive BP lowering in patients with symptomatic orthostatic hypotension 1
• Medication burden: Balance the benefit of BP control against the potential harms of polypharmacy 5

Evidence Quality Considerations

The most recent guidelines from the European Society of Cardiology (2024) provide the strongest evidence for a stepped approach to BP targets 1. While the 2017 ACC/AHA guidelines recommended a universal target of <130/80 mmHg 1, the European approach of achieving <140/90 mmHg first and then targeting lower values if tolerated provides a more balanced strategy that minimizes potential harms while maximizing cardiovascular protection 1.

Several meta-analyses have shown that while intensive BP lowering may reduce specific cardiovascular outcomes like myocardial infarction and heart failure, it does not significantly reduce total mortality or serious adverse events compared to standard targets 6, 7, supporting a cautious approach to aggressive BP lowering.