What is the recommended blood pressure (BP) goal for a patient 65 years and older?

Blood Pressure Goal for Patients 65 Years and Older

For noninstitutionalized, ambulatory, community-dwelling adults aged 65 years and older, the blood pressure goal is systolic BP <130 mmHg (ideally 130-139 mmHg range) and diastolic BP <80 mmHg, provided treatment is well tolerated. 1

Primary Target for Most Elderly Patients

• The ACC/AHA guidelines recommend a systolic BP target of <130 mmHg for community-dwelling adults ≥65 years with hypertension (Class I, Level A evidence), based primarily on the SPRINT trial which demonstrated a 34% reduction in cardiovascular events (myocardial infarction, stroke, cardiovascular death, heart failure) in adults ≥75 years treated to intensive targets. 1

• The 2024 ESC guidelines recommend targeting systolic BP to 130-139 mmHg in older patients (aged ≥65 years) receiving BP-lowering drugs, representing the most recent high-quality guideline recommendation. 1

• Diastolic BP should be targeted to <80 mmHg but not <70 mmHg to avoid compromising coronary and cerebral perfusion. 1, 2

Critical Lower Limits to Avoid

• Do not lower systolic BP below 120 mmHg as this threshold has not been adequately studied for safety in routine clinical practice and may increase risk of hypoperfusion. 1

• Do not lower diastolic BP below 70 mmHg as this is associated with increased cardiovascular risk and may compromise organ perfusion, particularly in elderly patients. 1, 2, 3

When to Individualize and Use More Lenient Targets

More lenient BP targets (systolic <140 mmHg rather than <130 mmHg) should be considered in the following specific circumstances:

• Patients aged ≥85 years may benefit from more conservative targets given limited trial data in this age group. 1

• Patients with clinically significant moderate-to-severe frailty at any age should have individualized targets, as intensive lowering may not provide net benefit. 1

• Patients with limited life expectancy (<3 years) may not derive meaningful benefit from intensive BP control. 1

• Patients with pre-treatment symptomatic orthostatic hypotension require careful assessment and potentially higher targets to avoid falls and syncope. 1

• Institutionalized elderly or those with high burden of comorbidity warrant a team-based approach using clinical judgment and patient preference (Class IIa, Level C evidence). 1

Evidence Supporting Intensive Treatment in Elderly

• SPRINT enrolled 2,636 adults ≥75 years (mean age 79.9 years) and demonstrated clear cardiovascular benefit with intensive SBP lowering, with benefits extending even to the frailest participants. 1

• Approximately 44% of older SPRINT participants had baseline eGFR <60 mL/min/1.73 m², and the presence of reduced kidney function did not modify the benefits of intensive BP lowering. 1

• Frailty status did not modify benefits in SPRINT, with the frailest participants showing the greatest reduction in cardiovascular events with intensive treatment. 1

Practical Implementation Approach

Initiation and titration require careful monitoring:

• Start with low doses and titrate slowly, allowing at least 4 weeks between adjustments to observe full response and monitor for adverse effects. 2

• Two or more antihypertensive medications are typically required to achieve BP targets <130/80 mmHg in most elderly patients. 1

• Measure standing BP at each visit to detect orthostatic hypotension, which is common in elderly hypertensive patients and increases fall risk. 2, 4

Medication Selection

• First-line therapy should include a RAAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic (such as chlorthalidone or indapamide). 1, 2

• Simplify regimens with once-daily dosing and single-pill combinations when possible to improve adherence in elderly patients. 2

Common Pitfalls to Avoid

• Do not combine intensive BP lowering with intensive glucose lowering (HbA1c target <7%) in diabetic patients, as this combination increases serious adverse events. 1

• Do not ignore symptoms of hypoperfusion (dizziness, falls, cognitive changes) in pursuit of numerical targets—these warrant immediate reassessment and possible treatment adjustment. 1, 5

• Do not assume all elderly patients are too frail for intensive treatment—SPRINT and HYVET demonstrated safety and efficacy even in frail community-dwelling elderly. 1

• Monitor carefully for orthostatic hypotension, especially when initiating therapy or uptitrating doses, as this is a leading cause of falls and injury in elderly patients. 1, 5