What are the target parameters and management strategies for systolic blood pressure (SBP)?

Systolic Blood Pressure Targets and Management Strategies

For most adults with hypertension, systolic blood pressure (SBP) should be targeted to 120-129 mmHg, provided the treatment is well tolerated. 1

General SBP Targets by Population

Standard Adult Population

• Initial goal: Lower BP to <140/90 mmHg in all patients 1
• Optimal target: SBP 120-129 mmHg for most adults, if tolerated 1
• Diastolic target: <80 mmHg for all hypertensive patients 1

Age-Specific Targets

• Adults ≥65 years: SBP range of 130-139 mmHg 1
• Adults ≥85 years: Consider more lenient target (<140 mmHg) 1
• Frail patients: Consider more lenient targets (<140/90 mmHg) regardless of age 1
• Limited life expectancy (<3 years): Consider more lenient targets (<140/90 mmHg) 1

Special Populations

1. Diabetes:

   • Target SBP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
   • For diabetic patients ≥65 years: SBP range of 130-139 mmHg 1

2. Chronic Kidney Disease (CKD):

   • Moderate-to-severe CKD with eGFR >30 mL/min/1.73m²: SBP 120-129 mmHg, if tolerated 1
   • All CKD patients: SBP range of 130-139 mmHg 1
   • Individualize treatment based on tolerability, renal function, and electrolytes 1

3. Stroke/TIA history:

   • SBP target range of 120-130 mmHg 1
   • For confirmed BP ≥130/80 mmHg with history of TIA or stroke: 120-129 mmHg 1

4. Heart Failure:

   • Treatment should include ACE inhibitor/ARB, beta-blocker, diuretic, and/or MRA as needed 1
   • For HFrEF/HFmrEF: Include SGLT2 inhibitors in regimen 1
   • For HFpEF: Consider SGLT2 inhibitors, ARBs, and/or MRAs 1

Management Strategies

First-Line Pharmacotherapy

1. Initial approach:

   • Start with combination therapy for most patients 1
   • Preferably single-pill combinations of:
     • ACE inhibitor/ARB + CCB or
     • ACE inhibitor/ARB + thiazide/thiazide-like diuretic 1, 2

2. Specific populations:

   • Black patients: Initial therapy should include CCB or thiazide diuretic, either alone or with RAS blocker 1
   • Black patients from Sub-Saharan Africa: CCB combined with either thiazide diuretic or RAS blocker 1

Resistant Hypertension Management

Defined as BP ≥130/80 mmHg despite 3+ medications or controlled BP requiring 4+ medications 2

1. Step 1: Reinforce lifestyle measures, especially sodium restriction 1
2. Step 2: Add low-dose spironolactone (25-50 mg daily) to existing treatment 1, 2
3. Step 3 (if spironolactone not tolerated):
   • Try eplerenone (50-100 mg daily) 1, 2
   • Or higher dose thiazide/thiazide-like diuretic 1
   • Or loop diuretic 1
   • Or add bisoprolol or doxazosin 1
4. Step 4: Consider centrally acting BP medications, alpha-blockers, or hydralazine 1
5. Step 5: Consider referral for renal denervation if performed at medium-to-high volume center 1

Lifestyle Modifications

• Sodium restriction to ≤2.3 g/day 2
• DASH diet (high in fruits, vegetables, low-fat dairy; low in red meat and fats) 2
• Alcohol moderation (≤14 units/week for men, ≤8 units/week for women) 1
• Regular physical activity 1
• Weight management (target BMI 20-25 kg/m²) 2

Monitoring and Follow-Up

• After initiating therapy: Follow-up within first 2 months 1
• After achieving target: Follow-up every few months for BP monitoring 1
• Reassess risk factors and organ damage every 2 years 1
• Monitor for orthostatic hypotension before and after initiating therapy 2
• For ACE inhibitor/ARB therapy: Check creatinine/eGFR and potassium 1-4 weeks after starting 2

Common Pitfalls and Caveats

1. Avoid excessive BP lowering:

   • Do not target SBP <120 mmHg in most patients 1
   • For diabetic patients, do not lower SBP <120 mmHg 1

2. Medication combinations to avoid:

   • Simultaneous use of ACE inhibitors and ARBs 1, 2
   • ACE inhibitor/ARB + direct renin inhibitor 2
   • Atenolol (less effective than other options) 2
   • Beta-blockers with intrinsic sympathomimetic activity 2

3. Special considerations:

   • NSAIDs can counteract BP-lowering effects of medications 2
   • Automated office BP readings are typically 10-15 mmHg lower than usual office readings 3
   • Consider more lenient targets for patients with symptomatic orthostatic hypotension 1

4. Renal denervation cautions:

   • Not recommended as first-line intervention 1
   • Not recommended for patients with eGFR <40 mL/min/1.73m² 1
   • Should only be considered after multidisciplinary assessment 1

The 2024 ESC guidelines represent the most current evidence-based approach to hypertension management, emphasizing lower SBP targets than previous guidelines while maintaining safety through careful patient selection and monitoring.