What is the target systolic blood pressure (BP) for an 85-year-old individual?

Blood Pressure Target for an 85-Year-Old

For an 85-year-old patient, target a systolic blood pressure of 130-140 mmHg (with diastolic <80 mmHg), or accept up to 140-150 mmHg systolic if the lower target causes symptomatic side effects, orthostatic hypotension, or if the patient has moderate-to-severe frailty. 1, 2

Primary Recommendation Based on Most Recent Guidelines

The 2024 European Society of Cardiology guidelines represent the most current evidence and recommend:

• Standard target: 120-129 mmHg systolic for most adults if tolerated 1
• However, for patients ≥85 years, a more lenient target of <140/90 mmHg should be considered (Class IIa recommendation) 1
• Diastolic blood pressure should remain 70-79 mmHg 1

The key distinction is that age ≥85 years is specifically identified as an exception to the aggressive 120-129 mmHg target that applies to younger adults. 1

Age-Stratified Approach from Current Guidelines

The 2023 European Society of Hypertension provides age-specific targets that differ from ESC:

• For patients ≥80 years: systolic BP 140-150 mmHg with diastolic <80 mmHg (Class I) 1
• This can be lowered to 130-139 mmHg if treatment is well tolerated (Class II) 1

The American College of Cardiology/American Heart Association takes a less age-stratified approach, recommending <130/80 mmHg for most adults including those ≥65 years, though this has been criticized for very elderly patients. 3, 2, 4

Critical Factors That Modify the Target

Frailty status is paramount in determining the appropriate target for an 85-year-old:

• If robust and healthy: Aim for 130-139/70-79 mmHg 1, 2
• If moderate-to-severe frailty present: Accept 140-150/70-79 mmHg 1, 2
• If symptomatic orthostatic hypotension: Use the more lenient 140-150 mmHg target 1
• If limited life expectancy (<3 years): Accept up to 140-150 mmHg 1, 2

Evidence Supporting Lower Targets in Octogenarians

Recent high-quality trials have shifted recommendations toward lower targets even in older adults:

• Meta-analyses demonstrate that age is not an effect modifier for treatment efficacy up to 85 years, meaning older adults benefit similarly from BP lowering as younger adults 1, 3
• The SPRINT, STEP, and ESPRIT trials showed cardiovascular benefits with intensive BP control in older populations 1
• A 2024 Cochrane review found that lower BP targets (<140/90 mmHg) reduce stroke (high-certainty evidence) and likely reduce total serious cardiovascular events (moderate-certainty evidence) compared to targets of 150-160 mmHg 5

Safety Considerations

The lower target does not increase adverse effects in most elderly patients:

• Lower BP targets likely do not increase withdrawals due to adverse effects (moderate-certainty evidence) 5
• However, diastolic BP should not fall below 60-70 mmHg as this may compromise coronary perfusion 2
• Monitor carefully for orthostatic hypotension, which increases fall risk 2

Practical Implementation Algorithm

1. Assess frailty, orthostatic symptoms, and life expectancy 1, 2
2. If robust/healthy: Target 130-139/70-79 mmHg 1, 2
3. If any of the following apply, use 140-150/70-79 mmHg target: 1, 2
   • Moderate-to-severe frailty
   • Symptomatic orthostatic hypotension
   • Limited life expectancy (<3 years)
   • Intolerance to lower BP (symptomatic hypotension, falls, syncope)
4. Titrate slowly over 3 months, allowing 4 weeks between dose adjustments 2
5. Monitor for orthostatic hypotension at each visit 2

Common Pitfalls to Avoid

• Do not use a blanket 150/90 mmHg target for all patients ≥80 years – this older recommendation has been superseded by evidence showing benefit of lower targets in robust elderly 1, 5
• Do not aggressively pursue 120-129 mmHg in frail patients – this increases risk without proven benefit 1
• Do not allow diastolic BP to drop below 60 mmHg regardless of systolic target 2
• Do not ignore orthostatic symptoms – measure standing BP if any dizziness or falls occur 2