What is the target blood pressure (BP) level we should aim for, according to National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS)?

NICE CKS Blood Pressure Targets

The recommended blood pressure target according to NICE CKS is below 140/90 mmHg for most adults with hypertension, with a target of below 150/90 mmHg for adults aged 80 years and older. 1

General Blood Pressure Targets

• For the general adult population with hypertension, NICE recommends a target blood pressure below 140/90 mmHg 1
• For adults aged 80 years and older, the target is less stringent at below 150/90 mmHg 1
• These targets align with several international guidelines that recommend similar thresholds for older adults 1

Special Populations and Considerations

Elderly Patients

• For patients aged 60-79 years, the target remains below 140/90 mmHg 1
• For those aged 80 years and above, the higher target of below 150/90 mmHg is recommended based largely on data from the HYVET study 1
• This higher target for elderly patients acknowledges the potential risks of aggressive blood pressure lowering in this population 1

Patients with Comorbidities

• For patients with diabetes or chronic kidney disease (CKD), NICE maintains the same target of below 140/90 mmHg as for the general hypertensive population 1, 2
• This differs from some other guidelines that recommend lower targets for these populations 3
• The evidence for lower targets (≤130/80 mmHg) in these populations has been inconsistent 2

Comparison with Other Guidelines

• The European Society of Cardiology (ESC) has recently recommended more aggressive targets, suggesting 120-129 mmHg systolic for most adults if well tolerated 3
• The American College of Cardiology/American Heart Association (ACC/AHA) recommends a target of <130/80 mmHg for all adults with hypertension 1
• The International Society of Hypertension (ISH) recommends a target of <130/80 mmHg 1
• NICE has maintained more conservative targets compared to these newer guidelines 1

Clinical Implementation

• Blood pressure should be measured accurately using validated devices with appropriate cuff sizes 1
• For diagnosis and monitoring, consider using ambulatory or home blood pressure monitoring to confirm office readings 1
• The target should be achieved within 3 months of initiating therapy 1
• Regular follow-up is essential to ensure blood pressure remains controlled 3

Common Pitfalls to Avoid

• Treating to excessively low targets in elderly patients, which may increase risk of falls and adverse events 1
• Ignoring orthostatic hypotension, especially in older adults 3
• Failing to consider the J-curve phenomenon, where excessively low diastolic pressure (below 70 mmHg) may increase cardiovascular risk 4
• Not accounting for white coat hypertension or masked hypertension when making treatment decisions 1

Treatment Approach

• Initial therapy should include lifestyle modifications for all patients 1
• For pharmacological therapy, NICE recommends starting with ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics depending on patient characteristics 1
• For patients not at target with a three-drug combination, consider adding spironolactone as a fourth agent 1

While newer guidelines are trending toward lower blood pressure targets, NICE CKS maintains its recommendation of <140/90 mmHg for most adults and <150/90 mmHg for those aged 80 years and older, prioritizing a balance between cardiovascular risk reduction and treatment-related adverse effects 1.