What is the optimal blood pressure target for individuals to minimize cardiovascular risk?

Blood Pressure Targets in Hypertension

The correct answer is D: individuals should have their BP treated as close to optimal levels as tolerated. This reflects the current evidence-based approach where treatment targets vary based on individual risk factors and comorbidities, with the goal of achieving the lowest well-tolerated blood pressure rather than applying a single universal target to all patients.

Why the Other Options Are Incorrect

Option A is False: Not ALL individuals need BP <130/80

• The WHO 2022 guidelines recommend <140/90 mmHg as the target for all patients with hypertension without comorbidities (strong recommendation) 1
• More intensive targets of <130/80 mmHg are reserved for specific high-risk populations: those with known cardiovascular disease (strong recommendation) or high-risk patients with diabetes, chronic kidney disease, or elevated cardiovascular risk (conditional recommendation) 1
• The 2024 ESC guidelines similarly recommend the first objective should be lowering BP to <140/90 mmHg in all patients, with further intensification to 130/80 mmHg or lower only if well tolerated 1

Option B is False: Hypertension alone does not automatically confer "high risk" on ASCVD calculator

• The ASCVD risk calculator incorporates multiple variables including age, sex, race, cholesterol levels, smoking status, and diabetes—not just the presence of hypertension 1
• The 2019 American Diabetes Association guidelines specifically distinguished between higher cardiovascular risk (existing ASCVD or 10-year ASCVD risk ≥15%) warranting <130/80 mmHg targets versus lower risk (<15%) warranting <140/90 mmHg 1
• Having hypertension is one component of cardiovascular risk assessment, not an automatic designation of "high risk" 2

Option C is False: Not ALL individuals should have BP <140/90

• While <140/90 mmHg is the minimum initial target for most patients, evidence supports more intensive targets for higher-risk populations 1
• The 2024 ESC guidelines recommend targeting systolic BP to 120-129 mmHg in most adults to reduce cardiovascular risk, provided treatment is well tolerated 1
• Meta-analyses demonstrate that achieving BP <130/80 mmHg reduces major cardiovascular events by 14% compared to 140/81 mmHg, with greatest benefit in diabetic patients 1

The Evidence Supporting Option D: Individualized, Risk-Stratified Approach

Risk-Based Targeting Strategy

General population with hypertension:

• Initial target: <140/90 mmHg for all patients (strong recommendation) 1
• If well tolerated, intensify to 130/80 mmHg or lower in most patients 1
• Optimal systolic target: 120-129 mmHg if treatment is well tolerated 1

High-risk populations requiring more intensive targets:

• Patients with established cardiovascular disease: Target systolic BP <130 mmHg (strong recommendation) 1
• Diabetic patients: Target <130/80 mmHg (strong recommendation from American Diabetes Association 2024-2025) 1
• High cardiovascular risk patients (diabetes, chronic kidney disease, 10-year ASCVD risk ≥15%): Target systolic BP <130 mmHg (conditional recommendation) 1, 2
• Chronic kidney disease with eGFR >30 mL/min/1.73 m²: Target systolic BP 120-129 mmHg if tolerated 1

Populations requiring more lenient targets:

• Elderly patients ≥65 years: Target systolic BP 130-139 mmHg 1
• Patients ≥85 years: Consider more lenient targets (e.g., <140 mmHg) 1
• Frail patients at any age: Consider targets <140/90 mmHg 1
• Limited life expectancy (<3 years): Consider more lenient targets 1
• Symptomatic orthostatic hypotension: Consider targets <140 mmHg 1

Supporting Evidence from Major Trials

SPRINT trial (excluded diabetics):

• Intensive treatment (target <120 mmHg, achieved 121 mmHg) versus standard treatment (target <140 mmHg, achieved 136 mmHg) reduced major cardiovascular events by 25% 1
• However, adverse events including hypotension, syncope, electrolyte abnormalities, and acute kidney injury were more common with intensive treatment 1

ACCORD BP trial (diabetic patients):

• Intensive treatment (target <120 mmHg, achieved 119 mmHg) versus standard treatment (target <140 mmHg, achieved 133 mmHg) did not significantly reduce the primary composite cardiovascular endpoint 1
• Stroke risk was reduced by 41% with intensive treatment 1
• Adverse events were more frequent in the intensive arm 1

Meta-analyses findings:

• Targeting BP <130/80 mmHg significantly reduces major cardiovascular disease (HR 0.78) and all-cause mortality (HR 0.89) compared to ≥130 mmHg 3
• Benefits are most pronounced in patients with higher baseline cardiovascular risk 4, 5

Critical Safety Considerations

Lower Limits of Blood Pressure

• Do not target BP <120/70 mmHg as this may cause harm rather than benefit 6, 7
• Diastolic BP <60 mmHg is associated with increased cardiovascular events in patients with treated systolic BP <130 mmHg 1
• Treatment should be de-intensified if BP falls to <90/60 mmHg 1
• Optimal diastolic BP appears to be 70-79 mmHg when systolic BP is at target 1

Common Adverse Events with Intensive Treatment

• Hypotension and syncope 1
• Electrolyte abnormalities (hyperkalemia) 1
• Acute kidney injury and elevated serum creatinine 1
• Falls (particularly in elderly patients) 2
• Orthostatic symptoms 1

Practical Implementation Algorithm

Step 1: Establish initial target of <140/90 mmHg for all hypertensive patients 1

Step 2: Risk stratify the patient:

• High cardiovascular risk (established CVD, diabetes, CKD, ASCVD risk ≥15%): Consider intensifying to <130/80 mmHg 1, 2
• Elderly (≥65 years): Target 130-139 mmHg systolic 1
• Frail or limited life expectancy: Consider maintaining <140/90 mmHg 1

Step 3: Assess tolerability during intensification:

• Monitor for orthostatic symptoms, dizziness, weakness 7
• Check electrolytes and renal function 1
• Avoid lowering diastolic BP below 70 mmHg 1
• Do not push systolic BP below 120 mmHg 1, 6, 7

Step 4: Individualize based on response:

• If patient tolerates intensive treatment without adverse effects and has high cardiovascular risk, target systolic BP 120-129 mmHg 1
• If adverse effects occur, maintain less intensive target 1
• Monthly follow-up after medication changes until target achieved, then every 3-5 months 1

This risk-stratified, individualized approach—treating BP as close to optimal levels as tolerated—represents the consensus of current international guidelines and explains why Option D is the correct answer.