What is the target blood pressure (BP) for a patient with a history of cerebrovascular accident (CVA), myocardial infarction (MI), and chronic kidney disease (CKD)?

Target Blood Pressure for Patient with CVA, MI, and CKD

For this patient with a history of stroke, myocardial infarction, and chronic kidney disease, target a systolic blood pressure of 120-129 mmHg and diastolic <80 mmHg, as recommended by the most recent European Society of Cardiology guidelines, which provide the strongest evidence for reducing cardiovascular outcomes and mortality in this high-risk population. 1, 2

Rationale for This Target

The 2024 ESC guidelines specifically address patients with both CKD and prior stroke, recommending a systolic BP target of 120-129 mmHg when confirmed BP is ≥130/80 mmHg 1, 2. This recommendation is based on:

• Stroke history: Patients with confirmed BP ≥130/80 mmHg and a history of TIA or stroke should target systolic BP 120-129 mmHg to reduce cardiovascular outcomes, provided treatment is tolerated 1, 2
• CKD consideration: For moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², the same 120-129 mmHg systolic target applies if tolerated 1, 2
• Cardiovascular disease: The presence of MI further solidifies this patient as high cardiovascular risk, warranting the lower target 1

Medication Strategy

Start with a renin-angiotensin system (RAS) blocker plus either a calcium channel blocker or thiazide-like diuretic 1, 2:

• RAS blockers (ACE inhibitor or ARB) are particularly important if albuminuria ≥300 mg/day or albumin-to-creatinine ratio ≥300 mg/g is present 1, 2
• In post-MI patients requiring BP treatment, beta-blockers and RAS blockers are recommended as part of therapy 1
• Most patients will require two or more antihypertensive medications to achieve BP <130/80 mmHg 1

Critical Safety Thresholds

Do not allow systolic BP to drop below 110 mmHg or diastolic BP below 80 mmHg 2:

• Diastolic BP <70 mmHg may increase cardiovascular risk in CKD patients 3
• Monitor for symptoms of hypoperfusion including fatigue, lightheadedness, and orthostatic symptoms 2
• Test for orthostatic hypotension before starting or intensifying therapy by measuring BP after 5 minutes sitting/lying, then 1 and/or 3 minutes after standing 1

Monitoring Protocol

• Check basic metabolic panel within 2-4 weeks after initiating or titrating medications 2
• Use home blood pressure monitoring to avoid hypotension 2
• Follow up every 6-8 weeks until BP goal is safely achieved 2
• Serum creatinine may increase up to 30% when starting ACE inhibitors/ARBs due to reduced intraglomerular pressure; further decline requires investigation 1

Important Caveats

The KDIGO recommendation of systolic BP <120 mmHg is controversial and requires standardized automated BP measurement 1, 4:

• This target was based primarily on SPRINT trial data, which excluded diabetic patients and used automated unattended BP measurement 1
• Applying the <120 mmHg target using routine office BP measurement may increase risks of falls, fractures, acute kidney injury, and hospitalization in elderly, frail, or multimorbid CKD patients 1, 4
• The ESC target of 120-129 mmHg provides a safer range with similar cardiovascular benefits 1, 2

Never apply aggressive BP targets (<120 mmHg) to dialysis patients (CKD stage 5D) 2, 4:

• A U-shaped mortality curve exists in dialysis patients, with both systolic BP <120 mmHg and >180 mmHg associated with increased death risk 4

Divergent Guideline Perspectives

While the 2017 ACC/AHA guidelines recommend BP <130/80 mmHg for all CKD patients 1, and KDIGO suggests <120 mmHg for select patients 4, the 2024 ESC guidelines provide the most recent and nuanced approach with the 120-129 mmHg target range 1. This range:

• Acknowledges cardiovascular benefits of lower BP in high-risk patients 1
• Avoids the potential harms of overly aggressive BP lowering 1, 4
• Provides a practical target achievable with routine office BP measurement 1, 2

Given this patient's triple high-risk profile (CVA, MI, CKD), the 120-129 mmHg systolic target represents the optimal balance between cardiovascular protection and safety 1, 2.