Target Systolic Blood Pressure Range
The target systolic blood pressure for most adults is 120-129 mmHg (Answer: A - 120-140 mmHg is closest, though the upper limit should be 129 mmHg, not 140 mmHg). 1
Primary Target for Most Adults
The 2024 European Society of Cardiology guidelines establish a Class I recommendation that treated systolic blood pressure should be targeted to 120-129 mmHg in most adults to reduce cardiovascular risk, provided treatment is well tolerated. 1
- Within this range, 120 mmHg is the optimal point if tolerated 1
- This target applies to both hypertensive patients (baseline BP ≥140/90 mmHg) and those with elevated BP receiving treatment 1
- The diastolic target is 70-79 mmHg when systolic BP is at goal 1, 2
Stepwise Approach to Blood Pressure Targets
The initial objective should be to lower BP to <140/90 mmHg in all patients, then progress to the optimal target of 120-129 mmHg if well tolerated 1
- This staged approach reduces the risk of adverse events while achieving cardiovascular benefit 3
- Meta-analyses confirm that SBP <130 mmHg significantly reduces major cardiovascular disease (HR 0.78) and all-cause mortality (HR 0.89) compared to targets ≥130 mmHg 4
Important Exceptions Requiring More Lenient Targets
Older adults ≥65 years should target 130-139 mmHg 1, 2
Patients ≥85 years or with pre-treatment symptomatic orthostatic hypotension should consider targets <140 mmHg 1
Patients with clinically significant moderate-to-severe frailty at any age or limited predicted lifespan (<3 years) may consider targets <140/90 mmHg 1
When Target Cannot Be Achieved
If the 120-129 mmHg target is not tolerated, follow the "as low as reasonably achievable" (ALARA) principle 1
- Avoid lowering BP below 120/70 mmHg, as excessive reduction may increase cardiovascular mortality 3
- Monitor for signs of organ hypoperfusion including orthostatic hypotension, dizziness, weakness, and creatinine elevation 3
- Diastolic BP <60 mmHg is associated with increased cardiovascular events when systolic BP is <130 mmHg 2
Evidence Base
The SPRINT trial demonstrated that intensive treatment (target <120 mmHg) reduced major cardiovascular events by 25% compared to standard treatment (target <140 mmHg) 2, 5
- Recent meta-analyses support SBP targets <120 mmHg for reducing major CVD (HR 0.82) in selected populations 4
- The 2024 ESC guidelines emphasize that an on-treatment systolic BP of 135 mmHg is not optimal relative to more intensive control 1
Common Pitfalls to Avoid
Do not confuse automated office BP (AOSBP) with usual office BP measurements - AOSBP is approximately 10-15 mmHg lower than usual office BP 6
Confirm BP with out-of-office measurements (ABPM or HBPM) before intensifying treatment to avoid overtreatment based on white-coat hypertension 1
Watch for increased adverse events with intensive treatment, including hypotension, syncope, electrolyte abnormalities, acute kidney injury, and falls, particularly in elderly patients 2