What is the goal blood pressure (BP) for a patient with hypertension?

Goal Blood Pressure for Patients with Hypertension

For most adults with hypertension, the goal blood pressure is <130/80 mm Hg, with treatment initiation and targets determined by cardiovascular risk, age, and comorbidities. 1

Standard Blood Pressure Targets

General Adult Population (Age <65 years)

• Target BP is <130/80 mm Hg for adults with hypertension and high cardiovascular risk (10-year ASCVD risk ≥10%, known CVD, diabetes, or chronic kidney disease) 1
• For adults without high-risk features, initiate drug therapy when BP ≥140/90 mm Hg, with the same target of <130/80 mm Hg 1
• Stage 1 hypertension (130-139/80-89 mm Hg) without high-risk features can be managed initially with lifestyle modifications alone 1, 2

Older Adults (Age ≥65 years)

• Target systolic BP is <130 mm Hg for community-dwelling, ambulatory, noninstitutionalized adults aged 65 years or older 1
• The ACC/AHA guideline does not specify a diastolic target for this age group 1
• Adults ≥65 years are automatically considered high-risk and should initiate drug therapy at BP ≥130/80 mm Hg 1
• For patients ≥80 years, a more lenient target of 130-150 mm Hg systolic may be appropriate, particularly in those with frailty, limited life expectancy, or orthostatic hypotension 3

Special Population Targets

Diabetes Mellitus

• Initiate drug therapy at BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg 1
• Most adults with diabetes and hypertension have 10-year ASCVD risk ≥10%, automatically qualifying them for intensive BP control 1

Chronic Kidney Disease

• Target BP is <130/80 mm Hg for adults with CKD (stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d) 1
• ACE inhibitors or ARBs are reasonable first-line agents to slow kidney disease progression 1
• For patients with significant proteinuria, maintaining BP even below 125/75 mm Hg may provide additional renal protection 2

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Target systolic BP is <130 mm Hg after management of volume overload 1
• Use ACE inhibitors or ARBs plus beta blockers titrated to achieve this target 1

Post-Renal Transplantation

• Target BP of <130/80 mm Hg is reasonable after kidney transplantation 1
• Calcium channel blockers are reasonable first-line agents based on improved GFR and kidney survival 1

Treatment Initiation Strategy

Stage 1 Hypertension (130-139/80-89 mm Hg)

• Begin with single antihypertensive agent and titrate before adding additional drugs 2
• High-risk patients (age ≥65, diabetes, CKD, known CVD, or 10-year ASCVD risk ≥10%) should initiate drug therapy immediately 1
• Low-risk patients can attempt lifestyle modifications first 1

Stage 2 Hypertension (≥140/90 mm Hg)

• Initiate treatment with two-drug combination when BP is >20/10 mm Hg above goal 1
• Typical combinations include thiazide diuretic plus ACE inhibitor, ARB, or calcium channel blocker 2
• Patients with BP ≥160/100 mm Hg should be treated promptly with careful monitoring 1

Important Caveats and Pitfalls

Avoid Excessive BP Lowering

• Do not reduce BP below 120/70 mm Hg, as this may increase cardiovascular mortality and adverse events 4
• Diastolic BP should generally not fall below 60 mm Hg, which may compromise coronary perfusion 3
• Watch for signs of organ hypoperfusion including orthostatic hypotension, dizziness, weakness, and creatinine elevation 4

Gradual Titration in Older Adults

• Start with low doses and titrate slowly in patients ≥65 years 3
• Allow at least 4 weeks to observe full medication response before adjusting 3
• Be particularly vigilant for orthostatic hypotension, which increases fall risk 3

Monitoring Requirements

• Follow-up monthly after initiating therapy until BP control is achieved 1, 2
• Assess both medication adherence and therapeutic response at each visit 2
• Monitor renal function and potassium within 3 months when using ACE inhibitors, ARBs, or diuretics 2
• Home BP monitoring improves control and should be encouraged 2, 5

Evidence Strength Considerations

The <130/80 mm Hg target is based primarily on the SPRINT trial, which demonstrated significant cardiovascular benefit from intensive BP lowering to <120 mm Hg systolic 1, 4. However, most patients will require two or more medications to achieve BP goals 2, 5. The magnitude of BP reduction with standard first-line agents is approximately 9/5 mm Hg 2.

Recent research suggests that while lower targets reduce cardiovascular events in high-risk populations, there may be little to no mortality benefit in patients with established cardiovascular disease when targeting <135/85 mm Hg versus standard targets 6. This underscores the importance of individualizing targets based on patient characteristics, particularly in older adults and those with multiple comorbidities 3, 7.