What are the blood pressure (BP) management recommendations for individuals 75 and older?

Blood Pressure Management for Adults 75 Years and Older

For most community-dwelling adults aged 75 and older with hypertension, target a blood pressure of <130/80 mmHg, with individualization based on frailty status—robust older adults should aim for <130/80 mmHg while those with moderate-to-severe frailty may target 140-150 mmHg systolic. 1

Blood Pressure Targets by Patient Characteristics

Robust, Community-Dwelling Older Adults (≥75 years)

• Target BP <130/80 mmHg for noninstitutionalized, ambulatory, community-dwelling adults with average systolic BP ≥130 mmHg 1
• This intensive target reduces stroke (high-certainty evidence) and total serious cardiovascular events (moderate-certainty evidence) without increasing falls or orthostatic hypotension 1, 2
• The SPRINT trial demonstrated significant reductions in cardiovascular events, all-cause mortality, and mild cognitive impairment in adults ≥75 years treated to systolic BP <120 mmHg compared to <140 mmHg 1
• Treatment to <130/80 mmHg does not increase serious adverse events overall in this age group, though monitoring for hypotension, electrolyte abnormalities, and acute kidney injury is essential 1

Frail Older Adults or Those with High Comorbidity Burden

• Target systolic BP 140-150 mmHg for patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy 1
• The 2020 ISH guidelines recommend individualizing targets for elderly based on frailty, with a minimum goal of reducing BP by at least 20/10 mmHg, ideally to 140/90 mmHg 1
• For patients with high comorbidity burden and limited life expectancy, clinical judgment and team-based assessment of risks/benefits should guide intensity of BP lowering 1

Age-Stratified Approach (Alternative Framework)

The 2023 ESH guidelines provide an age-based stratification that some clinicians may find useful:

• Ages 65-79 years: Target <140/80 mmHg (or 140-150 mmHg for isolated systolic hypertension) 1
• Ages ≥80 years: Target systolic BP 140-150 mmHg with diastolic <80 mmHg 1
• However, the 2024 ESC guidelines moved away from strict age-based targets, noting that meta-analyses show age is not an effect modifier of BP-lowering treatment efficacy up to age 85 1

Critical Caveats and Safety Considerations

What to Monitor Closely

• Orthostatic hypotension: Measure standing BP at each visit, though intensive BP control does not increase orthostatic hypotension risk in trials 1
• Acute kidney injury: Incidence increases by 1.0-1.5% with intensive treatment but is manageable with monitoring 1
• Electrolyte abnormalities: More common with intensive treatment, requiring periodic laboratory monitoring 1
• Falls and syncope: Despite concerns, intensive BP control does not increase fall risk in community-dwelling older adults 1

Exclusions from Intensive Targets

Do NOT pursue intensive BP targets (<130/80 mmHg) in:

• Nursing home residents (excluded from major trials) 1
• Patients with prevalent dementia 1
• Those with standing systolic BP <110 mmHg 1
• Advanced heart failure patients 1

Common Pitfall to Avoid

Do not avoid intensive BP targets solely based on age. The evidence clearly shows that chronological age alone should not determine BP targets—functional status, frailty, and comorbidity burden are far more important 1. Every major trial in older adults has shown benefit without harm for those who are community-dwelling and ambulatory 1.

Pharmacological Approach

First-Line Medications

For non-Black patients aged ≥75:

• Start with low-dose ACEI or ARB 1
• Add dihydropyridine calcium channel blocker (DHP-CCB) if needed 1
• Progress to thiazide-like diuretic (chlorthalidone or indapamide preferred over HCTZ) 1

For Black patients aged ≥75:

• Start with low-dose ARB plus DHP-CCB or DHP-CCB plus thiazide-like diuretic 1

Treatment Principles for Older Adults

• Simplify regimens with once-daily dosing and single-pill combinations to improve adherence 1
• Start low, go slow with careful titration and monitoring 1
• Achieve target within 3 months while monitoring for adverse effects 1
• Consider two-drug therapy if BP is >20/10 mmHg above goal 3

Evidence Quality and Guideline Divergence

The recommendation for <130/80 mmHg in robust older adults is supported by:

• High-certainty evidence for stroke reduction 2
• Moderate-certainty evidence for cardiovascular event reduction 2
• Low-certainty evidence for all-cause mortality (showing no harm but unclear benefit) 2

The 2017 ACC/AHA guidelines provide the strongest recommendation (Class I, Level A evidence) for treating community-dwelling adults ≥65 years to <130 mmHg 1. The 2020 ISH guidelines emphasize individualization based on frailty rather than age alone 1. The 2024 ESC guidelines align with intensive targets but add consideration for very frail patients 1.

The key controversy: Some guidelines (ESH 2023) recommend against targeting BP <120/70 mmHg based on J-curve concerns 1, while SPRINT data support even lower targets in carefully selected high-risk patients 1. For clinical practice in adults ≥75, the <130/80 mmHg target represents a safe, evidence-based middle ground that balances efficacy with safety.