What is the ideal blood pressure goal?

Ideal Blood Pressure Goals

The ideal blood pressure goal for most adults is 120-129/70-79 mmHg, provided this target is well-tolerated by the patient. 1

General Blood Pressure Targets by Population

• For most adults with hypertension, the recommended target blood pressure is 120-129/70-79 mmHg, with 120 mmHg being the optimal point in this range if tolerated 1
• For adults with diabetes, the recommended blood pressure goal is <130/80 mmHg 1
• For older adults aged 65-84 years, the target remains 120-129/70-79 mmHg if well-tolerated 1
• For adults aged ≥85 years, a more lenient target with systolic blood pressure as low as reasonably achievable (preferably <140 mmHg) is recommended 1
• For pregnant individuals with diabetes and chronic hypertension, a blood pressure goal of 110-135/85 mmHg is suggested 1

Evolution of Blood Pressure Targets

Blood pressure targets have evolved significantly in recent years based on emerging evidence:

• The 2017 American College of Cardiology/American Heart Association guidelines lowered the definition of hypertension to ≥130/80 mmHg and recommended a treatment target of <130/80 mmHg 1
• The 2024 European Society of Cardiology guidelines recommend a more specific target range of 120-129/70-79 mmHg 1
• The 2025 American College of Cardiology/American Heart Association guideline recommends a goal of <130/80 mmHg, with encouragement to further reduce systolic blood pressure to <120 mmHg 2

Special Considerations for Different Populations

Older Adults

• For adults aged 65-84 years without significant frailty, the target of 120-129/70-79 mmHg is still recommended 1
• For adults aged ≥85 years or those with symptomatic orthostatic hypotension, the target should be as low as reasonably achievable, preferably <140 mmHg 1
• For older adults with significant frailty or limited life expectancy (<3 years), a more lenient target may be appropriate 1

Patients with Diabetes

• For people with diabetes, the blood pressure goal should be <130/80 mmHg 1
• This target is supported by evidence from the ADVANCE trial, which showed that treatment to an achieved systolic blood pressure of 135 mmHg significantly decreased cardiovascular event rates compared to 140 mmHg 1

Patients with Established Cardiovascular Disease

• For patients with established cardiovascular disease, the target remains 120-129/70-79 mmHg if tolerated 1
• However, a Cochrane review found insufficient evidence to justify lower blood pressure targets (≤135/85 mmHg) compared to standard targets in people with hypertension and established cardiovascular disease 3

Potential Pitfalls and Considerations

• Treating to excessively low targets in elderly patients may increase the risk of falls and adverse events 4
• More intensive blood pressure control is associated with increased risk of adverse effects such as hypotension, electrolyte abnormalities, and acute kidney injury 1
• The risk of serious adverse events may be 1.0% to 1.5% greater with intensive treatment compared to standard treatment 1
• Blood pressure measurement technique is critical - automated office blood pressure measurement in a quiet room provides more accurate readings than traditional office measurements 5

Implementation Strategy

1. Initial Assessment:

   • Measure blood pressure accurately using validated devices with appropriate cuff sizes 4
   • Consider ambulatory or home blood pressure monitoring to confirm office readings 4

2. Treatment Approach:

   • Begin with lifestyle modifications for all patients 4
   • For pharmacological therapy, start with ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics based on patient characteristics 1, 4
   • For Black patients, thiazide diuretics or calcium channel blockers are preferred over ACEIs or ARBs 1, 6

3. Monitoring and Follow-up:

   • Aim to achieve target blood pressure within 3 months of initiating therapy 4
   • Monitor for adverse effects, especially in older adults 1
   • Adjust therapy based on individual response 1

The evidence strongly supports that lower blood pressure targets, specifically 120-129/70-79 mmHg, provide optimal cardiovascular protection for most adults when tolerated. However, treatment should be carefully monitored, especially in older adults and those with comorbidities, to minimize adverse effects.