What is the ideal blood pressure (BP) target for a 72-year-old female with a history of stroke?

Blood Pressure Target for a 72-Year-Old Female with History of Stroke

For a 72-year-old female with history of stroke, the recommended blood pressure target is 120-130 mmHg systolic blood pressure (SBP). 1

Evidence-Based Recommendations

Primary Target Recommendation

• For patients with ischemic stroke or TIA, a systolic blood pressure target range of 120-130 mmHg is recommended to reduce cardiovascular disease outcomes, provided treatment is tolerated 1
• This recommendation is specifically supported by the 2024 ESC guidelines which state that "in all hypertensive patients with ischaemic stroke or TIA, an SBP target range of 120–130 mmHg should be considered" 1
• For older patients (≥65 years) with history of stroke, this target is still appropriate but requires careful monitoring for tolerability 1

Age-Specific Considerations

• While the 2024 ESC guidelines recommend a systolic BP range of 130-139 mmHg for general older people (≥65 years), the specific recommendation for those with stroke history is more aggressive at 120-130 mmHg 1
• The AHA/ASA guidelines support a BP goal of less than 130/80 mmHg for adults who experience a stroke or TIA 1
• For elderly patients, careful titration is important to avoid adverse effects while still achieving cardiovascular protection 1, 2

Medication Selection

First-Line Agents

• For patients with history of stroke, treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is recommended 1
• Diuretics alone and in combination with ACEIs have shown the most benefit for recurrent stroke prevention 1
• The choice of specific drugs should be individualized based on comorbidities and agent pharmacological class 1

Treatment Algorithm

1. Start with a thiazide diuretic, ACE inhibitor, or ARB 1
2. If BP target not achieved, consider combination therapy with thiazide diuretic plus ACE inhibitor 1
3. If further BP control needed, add a calcium channel blocker 1
4. For resistant hypertension, consider adding spironolactone or other agents 1

Evidence Quality and Considerations

Strength of Evidence

• The recommendation for a target of 120-130 mmHg in stroke patients is supported by high-quality evidence from the 2024 ESC guidelines 1
• The PROGRESS trial demonstrated that lower BP targets (median 112/72 mmHg in the lowest quartile) were associated with the lowest risk of stroke recurrence without evidence of a J-curve relationship 3
• Multiple guidelines consistently support more aggressive BP targets for secondary stroke prevention than for general hypertension management 1

Special Considerations

• Avoid rapid or excessive BP reduction, as this may compromise cerebral perfusion 1, 4
• Monitor for orthostatic hypotension, especially in elderly patients 1
• Regular BP monitoring is essential to ensure target achievement while avoiding excessive lowering 4

Common Pitfalls to Avoid

• Pitfall #1: Setting too high a target (>140 mmHg) based on age alone, which may increase risk of recurrent stroke 1, 2
• Pitfall #2: Lowering BP too rapidly, which can compromise cerebral perfusion and cause neurological deterioration 1, 4
• Pitfall #3: Not considering medication interactions and side effects in elderly patients who may be on multiple medications 1
• Pitfall #4: Failing to monitor for orthostatic hypotension, which is more common in elderly patients and can increase fall risk 1

In conclusion, while general recommendations for elderly patients might suggest higher BP targets, the evidence specifically for patients with prior stroke supports a more aggressive target of 120-130 mmHg systolic to reduce the risk of recurrent stroke and other cardiovascular events 1, 3.