What are the recommended blood pressure targets for adults of different ages?

Blood Pressure Targets by Age

For most adults aged 18-64 years, target blood pressure <130/80 mmHg; for adults aged 65-79 years, target <130/80 mmHg if tolerated; and for adults aged ≥80 years, target 130-150/80 mmHg systolic with individualized approach based on frailty and tolerability. 1, 2

Adults Under 65 Years

Target blood pressure <130/80 mmHg for all adults with hypertension or 10-year ASCVD risk ≥10%. 1, 2

• The 2024 ESC guidelines recommend an initial default systolic target of 120-129 mmHg in most adults if tolerated, with 120 mmHg being the optimal point in this range. 1, 2
• The 2017 ACC/AHA guidelines provide a strong (Class I) recommendation for <130/80 mmHg in adults with known CVD or ≥10% 10-year ASCVD risk. 1
• For lower-risk individuals without CVD, the same <130/80 mmHg target may be reasonable (Class IIb), though the evidence is based more on observational data. 1
• Diastolic blood pressure should target 70-79 mmHg optimally, though systolic control takes priority even when diastolic falls below this range if treatment is tolerated. 1

Adults Aged 65-79 Years

Target systolic blood pressure <130 mmHg for noninstitutionalized, ambulatory, community-dwelling older adults. 1, 2

• The ACC/AHA guidelines provide a Class I recommendation for SBP <130 mmHg in adults ≥65 years with average SBP ≥130 mmHg, based on high-quality evidence including SPRINT. 1
• In SPRINT, adults aged 75 and older (mean age 79.9 years) treated to intensive SBP goal had 34% lower risk of major cardiovascular events compared to standard target, with benefits consistent regardless of baseline frailty status. 1
• Meta-analyses demonstrate that age is not an effect modifier of treatment efficacy at least up to 85 years, supporting similar targets across age groups. 1, 2
• The 2024 ESC guidelines recommend 120-129 mmHg as the initial default target if tolerated, noting this applies to most adults including those in their 60s. 1, 2

Key Evidence Supporting Lower Targets in Older Adults

• SPRINT enrolled adults with no upper age limit and demonstrated cardiovascular benefit in those ≥75 years without increased overall serious adverse events. 1
• Approximately 44% of older SPRINT participants had baseline eGFR <60 mL/min/1.73 m², and low eGFR did not modify the benefits of intensive SBP lowering. 1
• Intensive treatment did not increase orthostatic hypotension, syncope, or falls in those aged 75 and older. 1
• Recent trials including SPRINT, STEP, and ESPRIT have consistently demonstrated cardiovascular benefits with more intensive blood pressure control in older adults. 1, 2

Adults Aged ≥80 Years

Target systolic blood pressure 130-150 mmHg, with careful consideration of frailty, comorbidity burden, and tolerability. 1, 3

• The 2024 ESC guidelines recommend considering a more lenient target (e.g., <140/90 mmHg) for individuals ≥85 years with pretreatment symptomatic orthostatic hypotension. 1
• For those with moderate-to-severe frailty or limited life expectancy (<3 years), more lenient targets may be considered (Class IIb). 1, 2
• NICE guidelines recommend a target below 150/90 mmHg for adults aged 80 years and older, based largely on the HYVET study. 3
• The ACC/AHA recommends that for older adults with high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and team-based assessment should guide intensity of BP lowering (Class IIa). 1

Critical Caveat for Very Elderly

• No randomized trial of BP lowering in persons >65 years has shown harm or less benefit for older versus younger adults. 1
• However, large RCTs have excluded older persons living in nursing homes, those with prevalent dementia, and those with advanced heart failure. 1
• Patients with prevalent and frequent falls, advanced cognitive impairment, and multiple comorbidities may be at risk of adverse outcomes with intensive BP lowering, especially when requiring multiple medications. 1

Special Populations Requiring Modified Targets

Patients with Chronic Kidney Disease

Target <130/80 mmHg for patients with CKD, with ACE inhibitor or ARB if albuminuria present. 1, 2, 4

• The ESC/ESH recommends SBP target of 130-140 mmHg for adults with hypertension and CKD. 1
• Use of ACE inhibitors or ARBs in the setting of severely increased urine albumin excretion has been shown to reduce CKD progression. 1

Patients with Diabetes

Target <130/80 mmHg for patients with diabetes and hypertension. 1, 2, 4

• Intensive SBP lowering should not be combined with intensive glucose lowering (hemoglobin A1c target <7%) based on ACCORD BP trial findings showing increased serious adverse events with dual intensive therapy. 1
• Diabetic patients are at least as likely to benefit from BP-lowering treatment compared to non-diabetic patients due to higher frequency of cardiovascular events. 4

Patients with History of Stroke/TIA

Consider target systolic blood pressure <140 mmHg to reduce risk of recurrent stroke. 1

• The ACP/AAFP provides a weak recommendation (moderate-quality evidence) for initiating or intensifying treatment to achieve SBP <140 mmHg in adults ≥60 years with history of stroke or TIA. 1

Practical Implementation Considerations

Monitoring and Titration

• After initiating treatment, follow-up should occur within the first 2 months to assess efficacy and tolerability. 2, 4
• Once target BP is achieved, monitoring should occur every 3-6 months. 1, 2
• The goal should be to achieve target BP within 3 months of initiating therapy. 2, 3
• Older persons need careful monitoring for orthostatic hypotension during treatment, though SPRINT excluded those with low (<110 mmHg) standing BP on study entry. 1

Medication Selection

• Two or more antihypertensive medications are typically required to achieve BP target <130/80 mmHg in most adults, especially in Black adults. 1
• First-line medications include ACE inhibitors, ARBs, calcium channel blockers, and thiazide or thiazide-like diuretics. 1, 2
• Initiation of antihypertensive therapy with two agents should be undertaken cautiously in older persons with careful monitoring for orthostatic hypotension and falls history. 1

Common Pitfalls to Avoid

• Do not use the 2017 JNC 8 recommendation of <150/90 mmHg for adults ≥60 years without diabetes or CKD—this outdated target will likely lead to increased cardiovascular events and mortality. 5
• Do not apply the 2023 ESH recommendation against targeting BP below 120/70 mmHg—this contradicts high-quality evidence from SPRINT, STEP, and ESPRIT showing benefits of intensive control. 1
• Do not withhold treatment based solely on age—clinical trials indicate benefit to therapy in older adults with no age threshold above which antihypertensive therapy should be withheld. 6
• Do not treat to excessively low targets in elderly patients with symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy without careful risk-benefit assessment. 1, 2, 3
• Do not assume that intensive BP lowering increases falls in older adults—SPRINT showed no increase in orthostatic hypotension, syncope, or falls with intensive treatment in those ≥75 years. 1

Adverse Events and Safety

• Treatment to lower BP targets may increase specific adverse events including hypotension, electrolyte abnormalities, and acute kidney injury by 1.0-1.5% compared to standard targets. 1
• However, overall serious adverse events were not increased in the intensive group compared to standard group in SPRINT, including in those aged 75 and older. 1
• The lower BP target likely does not increase withdrawals due to adverse effects (RR 0.99,95% CI 0.74-1.33). 7
• Most serious adverse events can be managed successfully with medication adjustments based on individual clinical response. 1