What are the current guidelines for blood pressure management?

From the Guidelines

Blood pressure guidelines recommend maintaining blood pressure below 130/80 mmHg for most adults, as stated in the most recent guidelines from the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension 1. To achieve this, the following steps can be taken:

• Start with lifestyle modifications including reducing sodium intake to less than 2,300 mg daily, exercising regularly (150 minutes of moderate activity weekly), maintaining a healthy weight, limiting alcohol consumption, and following the DASH diet rich in fruits, vegetables, and whole grains.
• If lifestyle changes are insufficient, medication therapy typically begins with first-line agents such as thiazide diuretics (like hydrochlorothiazide 12.5-25 mg daily), ACE inhibitors (such as lisinopril 10-40 mg daily), ARBs (like losartan 25-100 mg daily), or calcium channel blockers (amlodipine 2.5-10 mg daily) 1.
• Many patients require multiple medications for adequate control.
• Regular home monitoring is recommended using a validated upper-arm cuff device, measuring twice daily (morning and evening), with two readings taken 1 minute apart.
• These guidelines are important because hypertension significantly increases risk for heart disease, stroke, kidney disease, and other complications, with each 20/10 mmHg increase above normal doubling cardiovascular risk. Some key points to consider:
• For older adults (≥65 years), who are noninstitutionalized, ambulatory, and community dwelling, the target is SBP <130 mm Hg, if tolerated 1.
• The optimal DBP target is defined as 70 to 79 mm Hg for all patients, but the emphasis is on controlling SBP, even when DBP is below these levels, provided the treatment is tolerated 1.
• Both guidelines provide recommendations for follow-up intervals, with the ACC/AHA suggesting 1 year for reevaluation of adults with a normal BP, 3 to 6 months for those treated with nonpharmacological therapy, and 1 month after initiation of antihypertensive drug therapy followed by 3 to 6 months after meeting the BP goal 1. The most recent and highest quality study, which is from 2022, provides the most up-to-date guidance on blood pressure management 1.

From the Research

Blood Pressure Guidelines

• The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document on hypertension in the elderly recommends that the blood pressure be reduced to less than 140/90 mmHg in adults aged 60-79 years and the systolic blood pressure to 140 to 145 mmHg if tolerated in adults aged 80 years and older 2.
• In adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended by guidelines, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 2.
• The 2013 JNC 8 guidelines recommend reducing the blood pressure to less than 140/90 mmHg in adults aged 60 years and older with diabetes mellitus or chronic kidney disease, but to less than 150/90 mmHg in adults aged 60 years and older without diabetes mellitus or chronic kidney disease 2.

Treatment of Hypertension

• Calcium channel blockers, beta blockers, and angiotensin receptor blockers have been shown to be effective in reducing blood pressure, with no significant difference in efficacy between the three 3.
• Combination therapy between calcium antagonists and beta-blockers or ACE inhibitors appears to be markedly effective and well tolerated 4.
• Diuretics and calcium-blocking drugs are more effective in elderly patients at lowering systolic blood pressure, while beta-blockers were relatively ineffective and had more side effects 5.

Blood Pressure Targets in Diabetes

• Evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes 6.
• Trying to achieve a lower systolic blood pressure target was associated with a significant increase in the number of other serious adverse events, but a reduction in the incidence of stroke 6.