What is the target blood pressure (BP) for a 75-year-old patient with a history of stroke and likely comorbidities such as hypertension, diabetes, or hyperlipidemia?

Target Blood Pressure for a 75-Year-Old with History of Stroke

For a 75-year-old patient with a history of stroke, target a systolic blood pressure of 120-130 mmHg (ideally <130/80 mmHg) to reduce recurrent stroke risk, based on the most recent 2024 European Society of Cardiology guidelines. 1

Primary Blood Pressure Target

• The 2024 ESC guidelines specifically recommend targeting systolic BP to 120-129 mmHg in patients with confirmed BP ≥130/80 mmHg who have a history of stroke or TIA, provided treatment is tolerated. 1

• The 2017 ACC/AHA guidelines support a BP target of ≤130/80 mmHg for older adults with high cardiovascular risk, which includes all patients with prior stroke. 1

• Moderate-quality evidence demonstrates that treating to an SBP of 130-140 mmHg in stroke patients reduces stroke recurrence by 24% (absolute risk reduction of 3.02%) compared to higher targets, though it does not significantly reduce cardiac events or all-cause mortality. 1

Age-Specific Considerations for 75-Year-Olds

• Despite advanced age, BP-lowering goals need not differ from younger adults for community-dwelling older persons, as no randomized trial has ever shown harm or less benefit for older versus younger adults with BP lowering. 1

• The 2024 ESC guidelines recommend an SBP range of 130-139 mmHg for older people aged ≥65 years with diabetes, but this more conservative target applies specifically to diabetic patients, not stroke patients. 1

• A subgroup analysis from SPRINT showed that patients aged ≥75 years had lower all-cause mortality with treatment to SBP <120 mmHg compared to <140 mmHg, though this trial excluded stroke patients. 1

Medication Selection

• Initiate or continue an ACE inhibitor or ARB combined with a thiazide diuretic, as this combination reduces recurrent stroke risk by approximately 30% in meta-analyses. 2, 3

• Alternative first-line agents include thiazide diuretics alone, calcium channel blockers, or ARBs as monotherapy, with selection individualized based on comorbidities. 1, 2

• Beta-blockers are not preferred as first-line agents for stroke prevention unless there are other indications such as heart failure or coronary disease. 1

Critical Implementation Pitfalls to Avoid

• Monitor carefully for orthostatic hypotension during treatment, as older persons are at increased risk. Check standing BP at each visit, particularly if the patient has a history of falls. 1

• Avoid excessively rapid titration of medications. Initiate therapy with one agent and titrate cautiously, adding a second agent only if needed to reach target. 1

• Do not lower diastolic BP below 60 mmHg, as excessive diastolic lowering may compromise coronary perfusion in patients with atherosclerotic disease. 4

• Patients with severe intracranial stenosis or bilateral carotid disease may require a more conservative target (closer to 130-140 mmHg systolic) to maintain cerebral perfusion. 3, 5

Special Circumstances Requiring Modified Targets

• For lacunar (small vessel) stroke specifically, target SBP <130 mmHg is particularly beneficial. 2, 3

• If the patient has diabetes in addition to stroke history, maintain the <130/80 mmHg target but monitor more closely for adverse effects. 1, 3

• For patients with chronic kidney disease (eGFR >30 mL/min/1.73 m²), target SBP 120-129 mmHg if tolerated, with individualized targets for lower eGFR. 1

Monitoring Strategy

• Titrate medications monthly until target BP is achieved. 3

• Recent meta-analyses confirm that intensive BP lowering to <130/80 mmHg significantly reduces recurrent stroke risk compared to standard management targeting <140/90 mmHg. 5

• The benefit of intensive BP management is most evident for reducing intracranial hemorrhage risk. 5

Contraindications to Intensive Lowering

• Patients residing in nursing homes, those with advanced dementia, multiple falls, or high comorbidity burden were excluded from major trials and may not tolerate intensive BP lowering. 1

• For frail elderly patients with multiple comorbidities requiring ≥4 medications, a more conservative target of <140/90 mmHg may be appropriate to minimize polypharmacy risks. 1