What is the goal blood pressure for a general adult population, including those with hypertension and those at high risk for cardiovascular disease?

Goal Blood Pressure for Adults

For most adults with hypertension, the goal blood pressure is <130/80 mmHg, with treatment initiation at BP ≥130/80 mmHg for high-risk patients (10-year ASCVD risk ≥10%) and ≥140/90 mmHg for lower-risk patients. 1, 2

General Adult Population

The 2017 ACC/AHA guidelines establish <130/80 mmHg as the universal treatment target for adults with confirmed hypertension, regardless of initial ASCVD risk level once treatment is initiated. 2 This represents a shift from the previous <140/90 mmHg standard and is supported by evidence demonstrating:

• A 25% reduction in major cardiovascular events (myocardial infarction, acute coronary syndromes, stroke, heart failure, or cardiovascular death) with intensive treatment targeting SBP <120 mmHg versus standard treatment targeting SBP <140 mmHg 3
• A 27% reduction in all-cause mortality with intensive BP control 3
• Each 10 mmHg reduction in systolic BP decreases cardiovascular events by approximately 20-30% 4

The strength of recommendation varies by risk level: Class I (strongest) evidence supports the <130/80 mmHg target for patients with known cardiovascular disease or 10-year ASCVD risk ≥10%, while Class IIa (moderate strength) applies to lower-risk adults without CVD and <10% 10-year ASCVD risk. 2

High-Risk Populations

Adults with Diabetes

Initiate antihypertensive therapy at BP ≥130/80 mmHg with a treatment goal of <130/80 mmHg. 1, 2 The rationale is straightforward:

• Most adults with diabetes and hypertension automatically have ≥10% 10-year ASCVD risk, placing them in the high-risk category 1
• While the ACCORD trial did not show statistically significant reduction in the primary composite outcome, it was underpowered and used a less BP-sensitive endpoint 1
• Meta-analysis of SPRINT and ACCORD results demonstrated consistency between trials, supporting the lower target 1

Adults with Chronic Kidney Disease

Initiate treatment at BP ≥130/80 mmHg with a target of <130/80 mmHg. 1, 2 Key considerations include:

• Patients with CKD are automatically assigned to the high-risk category for ASCVD 1
• Most patients with CKD die of cardiovascular complications rather than kidney failure progression, making cardiovascular risk reduction paramount 1
• Evidence from SPRINT specifically supports this lower target in the CKD population 1

Older Adults (≥65 Years)

For noninstitutionalized, ambulatory, community-dwelling adults ≥65 years, target systolic BP <130 mmHg. 1, 2, 5 This recommendation is based on robust evidence:

• Both SPRINT and HYVET trials demonstrated substantial cardiovascular benefit in older adults, including those aged 75 and 80+ years, with more intensive BP lowering 1, 5
• BP-lowering therapy is one of the few interventions proven to reduce mortality risk in frail older adults living independently 1, 5
• Clinicians can assume adults ≥65 years with hypertension have ≥10% 10-year ASCVD risk, automatically qualifying them for the high-risk treatment threshold 1, 5

Critical caveat: For older adults with high comorbidity burden and limited life expectancy, a more conservative target of 130-139 mmHg systolic may be appropriate. 3 However, this applies to a minority of older patients who are institutionalized or have severe frailty, not the typical community-dwelling older adult.

Treatment Initiation Strategy

Stage 1 Hypertension (130-139/80-89 mmHg)

• High-risk patients (10-year ASCVD risk ≥10%): Initiate pharmacotherapy immediately 2
• Lower-risk patients (<10% 10-year ASCVD risk): Initiate at BP ≥140/90 mmHg after lifestyle modification trial 2

Stage 2 Hypertension (≥140/90 mmHg)

Initiate therapy with two antihypertensive agents from different classes when BP is >20/10 mmHg above target. 1, 2 For patients with BP ≥160/100 mmHg:

• Treat promptly with combination therapy 1
• Monitor carefully with monthly follow-up until control is achieved 1, 2
• Thiazide diuretics (especially chlorthalidone) combined with ACE inhibitors or ARBs provide the most effective cardiovascular event reduction 3

Important Monitoring Parameters

After initiating or adjusting therapy, conduct monthly evaluations until BP control is achieved, then follow-up every 3-6 months once at goal. 2 Critical monitoring includes:

• Orthostatic hypotension assessment, particularly in older adults 1
• Electrolyte abnormalities (hyperkalemia) 3
• Acute kidney injury 3
• Hypotension and syncope 3

Common Pitfalls to Avoid

Do not target BP <120/70 mmHg in routine clinical practice. 2, 3 While SPRINT achieved mean SBP <120 mmHg, this was measured using automated office BP after 5 minutes of rest, which reads approximately 10-15 mmHg lower than usual office BP. 6 Additionally:

• Maintain diastolic BP ≥60 mmHg, as DBP <60 mmHg independently increases cardiovascular events (HR 1.36) even when systolic BP is controlled 3
• Recognize that proper BP measurement technique is essential—automated office BP preceded by 5-minute rest reads significantly lower than routine office measurements 6
• In older adults, initiate therapy cautiously, especially when starting two drugs simultaneously, and monitor closely for adverse effects 1

Contradictory Evidence Consideration

A 2020 Cochrane review found little to no difference in mortality or serious adverse events comparing lower targets (≤135/85 mmHg) to standard targets (140-160/90-100 mmHg) in patients with established cardiovascular disease. 7 However, this meta-analysis included only 6 trials with 9,484 participants and was limited by:

• Heterogeneous BP targets across studies
• Moderate to low-quality evidence
• Inability to detect smaller but clinically meaningful differences

A 2024 Cochrane review comparing higher targets (<150-160 mmHg) to lower targets (≤140 mmHg) in older adults found high-certainty evidence that the lower target reduces stroke (RR 1.33) and moderate-certainty evidence for reduction in serious cardiovascular events (RR 1.25). 8 This supports the ACC/AHA recommendation for <130 mmHg in older adults.

The European Society of Hypertension recommends against targeting BP <120/70 mmHg due to potential J-curve harm 2, which aligns with the practical implementation of the ACC/AHA guidelines that target <130/80 mmHg, not <120/70 mmHg, in routine practice.