What are the hypertension (HTN) management goals by age, considering factors such as comorbid conditions like diabetes and impaired renal function?

Hypertension Management Goals by Age

For most adults, the blood pressure target should be <130/80 mmHg regardless of age, with specific modifications based on comorbidities rather than age alone. 1

General Adult Population (<60 years)

• Target BP: <130/80 mmHg for adults under 60 years of age with hypertension 1
• This target applies to most patients without specific comorbidities and is supported by meta-analyses showing significant reductions in major cardiovascular events, stroke, heart failure, and myocardial infarction with lower BP targets 1
• The 2017 ACC/AHA guideline represents the most current evidence-based approach, superseding older recommendations that used <140/90 mmHg as the general target 1

Adults Aged 60-79 Years

• Target BP: <130/80 mmHg for community-dwelling adults aged 60-79 years who are ambulatory and non-institutionalized 1
• This recommendation is based on evidence showing that patients ≥60 years achieved similar cardiovascular benefits with lower BP targets as younger populations, with significant reductions in major cardiovascular events, stroke, and heart failure 1
• Controversial alternative: Some guidelines (JNC-8, ACP/AAFP) recommend a less aggressive target of <150/90 mmHg for adults ≥60 years, but this represents older evidence and has been debated extensively in the literature 1

Adults Aged ≥80 Years

• Target BP: <130/80 mmHg for fit, community-dwelling adults ≥80 years with preserved functional status 1
• The SPRINT and HYVET trials demonstrated substantial cardiovascular benefits in adults over 80 years, including those who were frail but living independently in the community 1
• Critical caveat: Initiation of BP-lowering therapy should be done cautiously with careful monitoring for orthostatic hypotension and adverse effects 1
• For institutionalized or severely frail elderly with significant loss of activities of daily living, treatment goals require individualized assessment with consideration of deprescribing when appropriate 2

Patients with Diabetes Mellitus (All Ages)

• Target BP: <130/80 mmHg for all adults with diabetes and hypertension 1
• Most adults with diabetes and hypertension automatically qualify as high cardiovascular risk (≥10% 10-year ASCVD risk), warranting initiation of drug therapy at BP ≥130/80 mmHg 1
• Meta-analyses including ACCORD and SPRINT data support this lower target, showing consistent cardiovascular benefits in diabetic patients 1
• Older guidelines (JNC-7, ESH/ESC 2007) also recommended <130/80 mmHg for diabetic patients, with some evidence supporting even lower targets (<125/75 mmHg) for those with significant proteinuria 1

Patients with Chronic Kidney Disease (All Ages)

• Target BP: <130/80 mmHg for all adults with CKD and hypertension 1
• Patients with CKD are automatically classified as high cardiovascular risk, warranting aggressive BP control 1
• SPRINT provided strong evidence supporting this target, showing cardiovascular benefits in patients with CKD 1
• With proteinuria: Some guidelines suggest even more aggressive control (<125/75 mmHg) when significant proteinuria is present, as this reduces progression of renal disease 1
• ACE inhibitors or ARBs are preferred first-line agents in CKD patients due to renoprotective effects 1

Patients with Established Cardiovascular Disease (All Ages)

• Target BP: <130/80 mmHg for patients with history of stroke, myocardial infarction, heart failure, or other cardiovascular disease 1
• These patients are at very high cardiovascular risk and benefit from intensive BP lowering 1
• The 2017 ACC/AHA Heart Failure Focused Update specifically recommends <130/80 mmHg for patients at increased risk of developing cardiovascular disease 1

Key Implementation Principles

• Measurement accuracy is critical: Proper technique requires 5 minutes of rest, seated position with back supported, feet flat on floor, arm supported at heart level, appropriate cuff size on bare arm, and no talking during measurement 3
• Confirm diagnosis: Hypertension diagnosis requires average of ≥2 readings on ≥2 separate occasions, with out-of-office monitoring (home or ambulatory) strongly recommended to exclude white coat hypertension 3
• Staged approach for older adults: When initiating therapy in adults ≥65 years, start cautiously and monitor closely for adverse effects including orthostatic hypotension, syncope, electrolyte abnormalities, and acute kidney injury 1
• Systolic BP priority: For patients ≥50 years, achieving systolic BP goal is the primary focus, as most will reach diastolic goal once systolic target is achieved 1
• Lifestyle modifications: All patients should receive lifestyle interventions including sodium restriction (<1500 mg/day ideal), weight loss if overweight, DASH diet, regular physical activity, and alcohol moderation, as these enhance medication efficacy 1, 4