What are the target supine, sitting, and standing blood pressure (BP) goals for this patient?

Blood Pressure Goals by Position

For most patients with hypertension, blood pressure should be measured and targeted in the sitting position, with a goal of 120-129/70-79 mmHg if tolerated, but standing BP must also be checked to screen for orthostatic hypotension. 1

Primary BP Target: Sitting Position

The sitting position is the standard measurement position for blood pressure targets in clinical practice. 2

• Initial target: <140/90 mmHg for all hypertensive patients 1, 2
• Optimal target: 120-129/70-79 mmHg if treatment is well tolerated, with 120 mmHg being the optimal systolic point in this range 1, 2
• For diabetes: Target systolic BP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
• For chronic kidney disease: 120-129 mmHg systolic if eGFR >30 mL/min/1.73 m² and treatment is tolerated 1

Supine BP Considerations

Supine BP is not routinely used as a treatment target but should be measured when assessing for orthostatic hypotension. 3

• Supine measurements are primarily used to calculate the drop in BP when transitioning to standing 3
• No specific supine BP target exists in guidelines; the focus is on detecting excessive drops upon standing 3

Standing BP: Critical Safety Monitoring

Standing BP must be checked to identify orthostatic hypotension, which is a contraindication to aggressive BP lowering. 1, 3

• Measure BP after 1-3 minutes of standing to assess for orthostatic hypotension 3
• A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension 3
• Patients with pre-treatment symptomatic orthostatic hypotension should have more lenient BP targets and follow the "as low as reasonably achievable" (ALARA) principle 1

Special Population Modifications

Elderly Patients (≥65 years)

• Ages 65-79: Target 130-139/70-79 mmHg in sitting position 1, 4
• Ages ≥80: Target 130-139 mmHg systolic, with more lenient targets (up to 140-150 mmHg) acceptable if lower targets not tolerated 1, 4
• Ages ≥85 or with significant frailty: Target systolic BP "as low as reasonably achievable" rather than rigid 120-129 mmHg goal 1, 4
• Critical caveat: Diastolic BP should not fall below 60-70 mmHg in elderly patients due to risk of coronary hypoperfusion 4, 2

High-Risk Patients

• Patients with established cardiovascular disease, diabetes, or chronic kidney disease should target <130/80 mmHg in sitting position 1, 2
• Those with proteinuria (protein-creatinine ratio >500 mg/g) should target <130 mmHg systolic for renal protection 1

Measurement Technique Requirements

All BP measurements should use validated automated upper arm cuff devices with appropriate cuff size. 2, 3

• Take average of at least 2 readings per visit 2
• Measure in both arms at first visit; use arm with higher readings for subsequent measurements 2
• Patient should be seated with back supported, feet flat on floor, arm at heart level 2

Common Pitfalls to Avoid

• Do not ignore standing BP: Failure to check for orthostatic hypotension can lead to falls, syncope, and adverse events with aggressive BP lowering 1, 3
• Do not push diastolic BP below 60 mmHg: This increases cardiovascular risk, particularly in elderly patients and those with coronary disease 4, 2
• Do not apply intensive targets to frail elderly: Patients ≥85 years or with significant frailty may not tolerate BP <130 mmHg and should have individualized, more lenient targets 1, 4
• Beware of the "white coat effect": Confirm office BP measurements with home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) 2