What is the target blood pressure (BP) by age?

Target Blood Pressure by Age

For most adults under 65 years, target systolic blood pressure to 120-129 mmHg if tolerated; for adults 65-79 years, target 130-139 mmHg; and for those ≥80 years, target 130-150 mmHg with individualization based on frailty and tolerability. 1

General Adult Population (Age <65 Years)

The most recent 2024 ESC guidelines recommend an initial target of <140/90 mmHg for all adults, with subsequent targeting to 120-129 mmHg systolic if treatment is well tolerated. 1

• The diastolic target should be <80 mmHg for all hypertensive patients, with an optimal range of 70-79 mmHg 1
• This represents a shift toward more intensive blood pressure control based on contemporary trial evidence including SPRINT, STEP, and ESPRIT 2
• High-certainty evidence demonstrates that lower BP targets (compared to <150/90 mmHg) reduce stroke and likely reduce serious cardiovascular events 3

Older Adults Age 65-79 Years

For patients aged 65-79 years, the 2024 ESC guidelines recommend targeting systolic BP to 130-139 mmHg. 1

• This target balances cardiovascular benefit with tolerability in this age group 1
• The ACC/AHA guidelines suggest a more aggressive target of <130/80 mmHg for this age group, though this has been criticized for potentially not being tolerated in all elderly patients 4
• Meta-analyses demonstrate that age is not an effect modifier for treatment efficacy at least up to 85 years 1, 2

Very Elderly (Age ≥80 Years)

For patients ≥80 years, multiple international guidelines (ESH/ESC, NICE, CHEP) consistently recommend a target of <150/90 mmHg, based primarily on the HYVET trial. 1, 4

• The 2024 ESC guidelines recommend systolic BP be targeted to 130-139 mmHg in patients ≥65 years, but acknowledge that more lenient targets (e.g., <140 mmHg) should be considered for those ≥85 years 1
• The HYVET trial demonstrated cardiovascular risk reduction in patients >80 years with on-treatment systolic pressures that were not <140 mmHg 4
• For patients ≥80 years who are healthy and tolerating treatment well, a target SBP ≤140 mmHg can be considered 1

Critical Exceptions Requiring More Lenient Targets

Personalized and more lenient systolic BP targets (e.g., <140/90 mmHg rather than 120-129 mmHg) should be considered for patients with: 1

• Pre-treatment symptomatic orthostatic hypotension 1
• Age ≥85 years 1
• Clinically significant moderate-to-severe frailty at any age 1
• Limited predicted lifespan (<3 years) 1

Diastolic Blood Pressure Considerations

Maintain diastolic BP between 70-90 mmHg in very elderly patients, with caution not to reduce below 60 mmHg. 4

• If diastolic BP <60 mmHg, consider reducing therapy regardless of systolic BP 4
• The optimal DBP target is 70-79 mmHg for all patients, but emphasis should be on controlling systolic BP even when diastolic is below these levels if treatment is tolerated 1

Key Guideline Differences to Recognize

The 2024 ESC guidelines differ substantially from older recommendations: 1

• JNC 8 (2014) recommended <150/90 mmHg for all patients ≥60 years, which has been widely criticized and superseded 1, 5
• ACC/AHA (2017) recommends <130/80 mmHg for all adults regardless of age, which may be too aggressive for the very elderly 1, 4
• 2024 ESC provides age-stratified targets with 120-129 mmHg for younger adults, 130-139 mmHg for ages 65-79, and more lenient targets for ≥80 years 1

Common Pitfalls to Avoid

• Do not apply the same BP target to a 30-year-old and an 80-year-old despite some guidelines suggesting this approach 4
• Avoid reducing diastolic BP below 60 mmHg, which may compromise coronary perfusion 4
• Be vigilant for orthostatic hypotension, which increases fall risk in the very elderly 4
• Do not treat to excessively low targets in elderly patients, which may increase risk of falls and adverse events 6

Treatment Timeline

• Follow-up should occur within the first 2 months after initiating antihypertensive therapy 1, 2
• Target BP should be achieved within 3 months of initiating therapy 2, 6
• Once target is achieved, monitoring should occur every 3-6 months 2
• Allow at least 4 weeks to observe the full response to medication adjustments 4