What is the goal blood pressure (BP) for adults?

Goal Blood Pressure for Adults

The goal blood pressure for most adults with hypertension is <130/80 mmHg, based on the 2017 ACC/AHA guidelines which prioritize cardiovascular mortality and morbidity reduction. 1

General Adult Population

For adults with confirmed hypertension and elevated cardiovascular risk (10-year ASCVD risk ≥10%), target BP <130/80 mmHg. 1, 2, 3

• This recommendation is based primarily on the SPRINT trial, which demonstrated a 25% reduction in major cardiovascular events and 27% reduction in all-cause mortality with intensive BP lowering (target SBP <120 mmHg) compared to standard treatment (target SBP <140 mmHg). 2, 3
• The guideline translates SPRINT's intensive target (<120 mmHg achieved) into a clinical goal of <130/80 mmHg for practical implementation. 2, 3
• Thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are preferred first-line agents for most patients due to superior efficacy. 1, 2

Specific Populations

Adults with Diabetes Mellitus

Target BP <130/80 mmHg in adults with diabetes and hypertension. 1, 3

• Most adults with diabetes and hypertension have 10-year ASCVD risk ≥10%, automatically placing them in the high-risk category requiring treatment initiation at BP ≥130/80 mmHg. 1
• Although the ACCORD trial did not show statistically significant reduction in the primary composite CVD outcome with intensive BP lowering, meta-analysis combining SPRINT and ACCORD results suggested consistent findings across both trials. 1
• Post-hoc analysis of SPRINT showed patients with prediabetes derived similar benefit to normoglycemic patients, supporting the <130/80 mmHg target. 1

Adults with Chronic Kidney Disease (CKD)

Target BP <130/80 mmHg in adults with CKD and hypertension. 1, 2

• Patients with CKD are automatically assigned to high-risk category for ASCVD, with pharmacologic treatment threshold at BP ≥130/80 mmHg. 1
• SPRINT evidence specifically supports this target in CKD patients, showing mortality benefit (HR 0.72; 95% CI 0.53-0.99) in the CKD subset. 2
• Most patients with CKD die of cardiovascular complications rather than progression to end-stage renal disease, justifying the cardiovascular-focused BP target. 1

Older Adults (≥65 Years)

For community-dwelling, ambulatory, noninstitutionalized adults ≥65 years: target SBP <130 mmHg. 1, 3

• Both HYVET and SPRINT included older adults (including those ≥75 and ≥80 years) and demonstrated substantial benefit with intensive BP treatment, including reduced mortality in frail but independently living older adults. 1
• BP-lowering therapy is one of few interventions proven to reduce death risk in frail older adults. 1
• Critical caveat: Initiate therapy cautiously, especially when starting with 2 drugs, and monitor carefully for orthostatic hypotension and other adverse effects. 1

For older adults (≥65 years) with high comorbidity burden and limited life expectancy: individualize approach using clinical judgment and team-based care. 1, 3

• In frail, institutionalized, or highly comorbid older adults, a more conservative target (SBP 130-139 mmHg) may be reasonable. 3
• Patient preference and risk-benefit assessment are essential in this population. 1

Diastolic Blood Pressure Considerations

The DBP goal is <80 mmHg for all adults with hypertension. 1

• This recommendation carries expert opinion level of evidence, as only the HOT trial directly compared DBP goals, finding no benefit or harm with DBP <80 mmHg versus higher targets (except in diabetes subgroup). 1
• Important safety consideration: Avoid excessive DBP lowering below 60 mmHg, as DBP <60 mmHg independently increases cardiovascular events (HR 1.36; 95% CI 1.07-1.71) even when SBP is controlled. 3
• The J-curve hypothesis for DBP has not been demonstrated in randomized trials but remains a concern in observational analyses. 1

Treatment Initiation Strategy

For stage 2 hypertension (BP ≥140/90 mmHg or >20/10 mmHg above target): initiate 2 antihypertensive agents from different classes simultaneously. 1, 2, 3

• Patients with BP ≥160/100 mmHg require prompt treatment, careful monitoring, and rapid regimen adjustment until control is achieved. 1
• After initiating therapy, evaluate monthly for adherence and therapeutic response until BP control is achieved. 1, 2, 3

Common Pitfalls and Caveats

Populations Where SPRINT Evidence Does NOT Apply

Exercise extreme caution or use different targets in:

• Patients with history of stroke (excluded from SPRINT; use stroke-specific guidelines). 2
• Patients with dementia or cognitive impairment (excluded from SPRINT). 2
• Patients with heart failure (excluded from SPRINT). 2
• Institutionalized patients (excluded from SPRINT). 2
• Patients aged <50 years (excluded from SPRINT). 2

Blood Pressure Measurement Technique

Use standardized automated BP measurement following AHA protocol to ensure accuracy. 2

• Required protocol: validated automated oscillometric device, 5 minutes quiet rest before measurement, 3 readings averaged, patient seated alone or with staff present. 2
• SPRINT used automated office BP measurement, which typically yields readings 5-10 mmHg lower than conventional office measurements—this is critical for proper interpretation of the <130/80 mmHg target. 2

Monitoring for Adverse Events

Monitor carefully for specific adverse events associated with intensive BP lowering: 2, 3

• Hypotension and syncope
• Electrolyte abnormalities (hyperkalemia)
• Acute kidney injury and elevated serum creatinine
• Orthostatic hypotension (especially in older adults)
• Bradycardia

Do not target BP <120/80 mmHg in routine clinical practice, as mean achieved BP below this threshold increases adverse events without additional cardiovascular benefit. 3