Target Blood Pressure Numbers to Reduce Mortality Risk in Hypertension
For most hypertensive patients, blood pressure should be reduced to at least below 140/90 mmHg, and to lower values of 130/80 mmHg for high-risk patients including those with diabetes, chronic kidney disease, or established cardiovascular disease. 1, 2
General Population Targets
Blood pressure targets should be stratified based on patient characteristics:
- Standard target for most hypertensive patients: <140/90 mmHg 1
- High-risk patients (diabetes, CKD, cardiovascular disease): <130/80 mmHg 1, 2
- Elderly patients (≥65 years): <130 mmHg if tolerated 2
- Very elderly patients (>80 years): 140-145 mmHg if well tolerated 2
Evidence Supporting These Targets
The European Society of Cardiology and European Society of Hypertension guidelines emphasize that achieving blood pressure values <140/90 mmHg is associated with significantly lower cardiovascular morbidity and mortality rates 1. The FEVER study demonstrated that patients who achieved blood pressure values of 138/82 mmHg had a 28% reduction in stroke recurrence and 26% reduction in major cardiovascular events compared to placebo 1.
For high-risk patients, more intensive blood pressure control is beneficial:
- Diabetic patients show reduced macro and microvascular complications with more intensive blood pressure control, as demonstrated in the HOT and UKPDS trials 1
- Patients with chronic kidney disease benefit from lower targets, particularly those with albuminuria 2
Recent Evidence Supporting Lower Targets
A 2024 systematic review and meta-analysis found that targeting systolic blood pressure <130 mmHg significantly reduced major cardiovascular disease events (HR 0.78) and all-cause mortality (HR 0.89) compared to targets ≥130 mmHg 3. This study also suggested potential benefits of an even lower target of <120 mmHg for further cardiovascular risk reduction, though with marginally insignificant mortality benefit (HR 0.85) 3.
Risk Reduction Magnitude
The relationship between blood pressure and cardiovascular risk is continuous, with risk beginning at 115/75 mmHg and doubling with each increment of 20/10 mmHg 1, 4. A 5 mmHg decrease in systolic blood pressure through regular exercise can reduce:
- Coronary heart disease mortality by 9%
- Stroke mortality by 14%
- All-cause mortality by 7% 5
Implementation Considerations
When implementing blood pressure control strategies:
- First-line therapy: Lifestyle modifications including weight loss, sodium restriction (2.3 g/day or less), DASH diet, physical activity, and alcohol moderation 2, 6
- Medication selection: Thiazide diuretics are recommended as initial therapy for most patients, alone or in combination with other agents 1, 6
- Combination therapy: Most patients will require two or more medications to achieve target blood pressure 1, 6
- High-risk patients: ACE inhibitors or ARBs are particularly beneficial for patients with diabetes or albuminuria 1, 2, 7
Monitoring Considerations
- Monitor for orthostatic hypotension before further medication adjustments, particularly in elderly patients 2
- For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels regularly 2
Pitfalls to Avoid
- Overly aggressive treatment in elderly: May lead to falls, cognitive impairment, and reduced quality of life
- Inadequate treatment in high-risk patients: Missing opportunities for cardiovascular risk reduction
- Ignoring secondary causes: Consider screening for secondary hypertension, particularly in young patients with poor control 2
- Medication combinations to avoid: ACE inhibitor + ARB and ACE inhibitor or ARB + direct renin inhibitor 2
By following these evidence-based targets and implementation strategies, clinicians can effectively reduce mortality risk in patients with hypertension.