What is the target blood pressure in primary care?

Target Blood Pressure in Primary Care

The target blood pressure in primary care should be <130/80 mmHg for most patients, with individualized targets based on cardiovascular risk, age, and comorbidities. 1

General Blood Pressure Targets

• General population: <130/80 mmHg 1
• Patients aged 60-79 years: <140/90 mmHg 1, 2
• Patients aged ≥80 years: <140-150/90 mmHg (if tolerated) 2

Risk-Stratified Targets

High Cardiovascular Risk Patients

• Target: <130/80 mmHg 1
• Applies to:
  • Patients with diabetes and clinically diagnosed cardiovascular disease
  • Patients with 10-year ASCVD risk ≥15%
  • Patients with chronic kidney disease (especially with albuminuria)

Lower Cardiovascular Risk Patients

• Target: <140/90 mmHg 1
• Applies to:
  • Patients with 10-year ASCVD risk <15%
  • Patients with history of adverse effects from intensive BP control
  • Patients at high risk for adverse effects

Special Populations

Diabetes

• Target: <140/90 mmHg 1
• The ACCORD BP trial showed no significant benefit in the primary composite endpoint with more intensive control, though stroke risk was reduced by 41% 1

Chronic Kidney Disease

• Target: <120-130/80 mmHg 3
• With significant proteinuria: Consider lower target of <130/80 mmHg 3

Pregnancy with Hypertension

• Target: 120-160/80-105 mmHg 1
• This range optimizes maternal health while minimizing impaired fetal growth

Evidence Supporting Lower Targets

The SPRINT trial demonstrated that intensive BP control (target <120 mmHg systolic) compared to standard control (<140 mmHg) resulted in:

• 25% reduction in primary composite outcome (MI, ACS, stroke, heart failure, CVD death)
• 27% reduction in risk of death 1

However, intensive therapy increased risks of:

• Electrolyte abnormalities
• Acute kidney injury
• Hypotension 1

Implementation Strategy

1. Accurate measurement:

   • Use validated automated devices with appropriate cuff size
   • Take multiple readings and average them
   • Consider home or ambulatory BP monitoring to identify white-coat or masked hypertension 1

2. Initial approach:

   • For BP >120/80 mmHg: Begin with lifestyle modifications (DASH diet, sodium reduction, physical activity, weight loss) 1
   • For BP ≥140/90 mmHg: Consider pharmacotherapy along with lifestyle modifications 1

3. Medication selection:

   • First-line options: ACE inhibitors/ARBs, calcium channel blockers, thiazide diuretics 4, 5
   • For Black patients: Consider calcium channel blockers or thiazide diuretics as initial therapy 1
   • Avoid ACE inhibitor + ARB combinations due to increased adverse effects 1

Monitoring and Follow-up

• Assess BP control within 3 months of initiating therapy 1
• Monitor for adverse effects: hypotension, syncope, electrolyte abnormalities, acute kidney injury 1
• Pay special attention to diastolic pressure, which generally should not be <70 mmHg, especially in patients with coronary artery disease 3

Common Pitfalls and Caveats

• Overly aggressive treatment in elderly: May lead to falls, cognitive impairment, and reduced quality of life
• White-coat hypertension: Consider home or ambulatory BP monitoring to avoid overtreatment 1
• Orthostatic hypotension: Check for postural drops in BP, especially in elderly patients 1
• J-curve phenomenon: Excessive lowering of diastolic BP (<60 mmHg) may increase cardiovascular risk, especially in patients with coronary artery disease 6

The evidence strongly supports that achieving appropriate BP targets reduces cardiovascular morbidity and mortality. While the trend has moved toward lower targets based on recent evidence, the specific target should be determined by the patient's overall cardiovascular risk profile, age, and ability to tolerate treatment.