What is the initial blood pressure (BP) reduction goal in patients with hypertension?

Initial Blood Pressure Reduction Goal in Hypertension

The initial blood pressure reduction goal for patients with hypertension should be to achieve a target of less than 140/90 mmHg for most patients, with more intensive targets of less than 130/80 mmHg for those with diabetes, chronic kidney disease, or high cardiovascular risk. 1

General Blood Pressure Targets

• For most adults with hypertension, the primary goal is to reduce blood pressure to less than 140/90 mmHg, which is associated with a decrease in cardiovascular disease complications 1
• According to the most recent guidelines, a target of 120-129/70-79 mmHg is recommended if well tolerated 1
• The magnitude of BP reduction with standard doses of first-line antihypertensive medications (ACE inhibitors, ARBs, CCBs, diuretics, beta-blockers) is approximately 9/5 mmHg with office BP measurements 1
• Initial BP reduction should be gradual, especially in older adults, to avoid adverse effects from too rapid lowering 1

Special Populations Requiring More Intensive Targets

• For patients with diabetes or chronic kidney disease, a more aggressive target of less than 130/80 mmHg is recommended 1, 2
• For patients with proteinuria, maintaining blood pressure even below 125/75 mmHg may be beneficial for reducing progression of renal disease 1, 2
• Patients with high cardiovascular risk (10-year ASCVD risk ≥10%) should aim for a BP target of less than 130/80 mmHg 1

Initial Approach Based on Hypertension Severity

Stage 1 Hypertension (140-159/90-99 mmHg)

• Begin with a single antihypertensive agent, typically a thiazide-type diuretic, and titrate dosage before adding additional agents 1
• Follow up monthly until blood pressure control is achieved 1
• Consider lifestyle modifications alongside pharmacological therapy 1

Stage 2 Hypertension (≥160/100 mmHg)

• Initiate treatment with a two-drug combination for most patients, usually including a thiazide-type diuretic plus an ACE inhibitor, ARB, beta-blocker, or CCB 1
• If blood pressure is more than 20/10 mmHg above goal, initiation with two agents is strongly recommended 1
• More intensive monitoring may be required during initial treatment phase 1

Monitoring and Follow-up

• After initiating antihypertensive therapy, follow-up should occur at monthly intervals until control is achieved 1
• Assess both adherence and response to treatment at each follow-up visit 1
• For patients with diabetes, blood pressure should be measured at every routine visit 2
• In patients treated with ACE inhibitors, ARBs, or diuretics, monitor renal function and potassium levels within the first 3 months of treatment 2

Cautions and Pitfalls

• Avoid excessive rapid lowering of blood pressure, which may lead to orthostatic hypotension, especially in older adults 1
• Be cautious with initial combined therapy in patients at risk for orthostatic hypotension 1
• Monitor for adverse effects that may affect adherence, as withdrawals due to adverse effects may be more common with more aggressive blood pressure targets 3
• Remember that most patients with hypertension will require two or more medications to achieve their blood pressure goal 1, 2

The evidence clearly supports a stepped approach to blood pressure reduction with specific targets based on patient characteristics, with the ultimate goal of reducing cardiovascular and renal morbidity and mortality through appropriate blood pressure control.