What is the ideal diastolic blood pressure target to aim for?

Optimal Diastolic Blood Pressure Target

For most hypertensive patients, a diastolic blood pressure target of <80 mmHg should be considered, independent of the level of risk and comorbidities, with an optimal range of 70-79 mmHg to reduce cardiovascular disease risk. 1

General Blood Pressure Targets

• The first objective of treatment should be to lower blood pressure to <140/90 mmHg in all patients, and if well tolerated, further reduce to 130/80 mmHg or lower 1
• For systolic blood pressure, the recommended target for most adults is 120-129 mmHg, provided treatment is well tolerated 1
• For diastolic blood pressure, a target of <80 mmHg is recommended for all hypertensive patients 1

Optimal Diastolic Range

• When systolic blood pressure is at or below target (120-129 mmHg) but diastolic blood pressure remains ≥80 mmHg, intensifying treatment to achieve a diastolic blood pressure of 70-79 mmHg may be considered to reduce cardiovascular disease risk 1
• Research suggests that a diastolic blood pressure between 70-80 mmHg represents the optimal range with the lowest cardiovascular risk 2, 3
• Caution should be exercised when lowering diastolic blood pressure below 60 mmHg, as this has been associated with increased risk of cardiovascular events 4, 2

Special Populations

• In older patients (aged ≥65 years), systolic blood pressure should be targeted to 130-139 mmHg, while maintaining the diastolic target of <80 mmHg 1
• For patients aged 80 years and older, a more lenient systolic blood pressure target (<140 mmHg) may be considered, particularly in those with:
  • Pre-treatment symptomatic orthostatic hypotension 1
  • Moderate to severe frailty 1
  • Limited predicted lifespan (<3 years) 1

The Diastolic J-Curve Phenomenon

• Evidence suggests that excessively low diastolic blood pressure (<60 mmHg) may increase cardiovascular risk, creating a J-shaped relationship between diastolic blood pressure and outcomes 4, 2
• In patients with treated systolic blood pressure <130 mmHg, a diastolic blood pressure <60 mmHg was associated with:
  • 46% increased risk of primary composite outcome (all-cause death, nonfatal MI, nonfatal stroke) 2
  • 74% increased risk of composite cardiovascular outcome 2
  • 73% increased risk of nonfatal myocardial infarction 2
  • 167% increased risk of nonfatal stroke 2

Clinical Implementation

• Blood pressure measurement should be performed using validated devices with appropriate cuff sizes 5
• For diagnosis and monitoring, consider ambulatory or home blood pressure monitoring to confirm office readings 5
• Target blood pressure should be achieved within 3 months of initiating therapy 5

Common Pitfalls to Avoid

• Treating to excessively low diastolic blood pressure (<60 mmHg), especially in patients with coronary artery disease, as this may compromise coronary perfusion 4, 2
• Ignoring orthostatic hypotension when aggressively lowering blood pressure in elderly patients 1, 5
• Not accounting for white coat hypertension or masked hypertension when making treatment decisions 5

Treatment Approach

• Initial therapy should include lifestyle modifications for all patients 1, 5
• For pharmacological therapy, ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics are recommended as first-line agents 1
• If blood pressure is not controlled with a three-drug combination, consider adding spironolactone as a fourth agent 1