According to the 2022 AAFP hypertension guideline, which outcomes are reduced by targeting a blood pressure below 135/85 mm Hg?

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Target Blood Pressure of <135/85 mmHg: Outcomes Reduced

According to the 2022 AAFP hypertension guideline, targeting a blood pressure below 135/85 mmHg reduces cardiovascular disease events and mortality, particularly in high-risk populations, though the evidence supporting this specific target is primarily driven by intensive blood pressure lowering trials.

Evidence Base and Outcomes

The target of <135/85 mmHg is positioned between traditional (<140/90 mmHg) and intensive (<120 mmHg systolic) blood pressure goals. The American Diabetes Association specifically recommends this target during pregnancy, where achieving ≤135/85 mmHg reduces the likelihood of accelerated maternal hypertension without adverse infant outcomes 1.

Cardiovascular Outcomes Reduced

  • Heart failure is significantly reduced with intensive blood pressure control, as demonstrated in the SPRINT trial where targeting systolic BP <120 mmHg (equivalent to approximately 130-135 mmHg by conventional measurement) reduced heart failure events 1.

  • Stroke shows reduction with lower blood pressure targets, with one trial (ACCORD-BP) demonstrating stroke reduction at intensive targets, though the primary composite endpoint was not reduced 1.

  • All-cause mortality was reduced by 27% in SPRINT when targeting intensive systolic BP control, though this was primarily driven by heart failure reduction 1, 2.

  • Major adverse cardiovascular events (MACE) were reduced by 25% in SPRINT with intensive BP lowering, though this benefit was concentrated in one trial rather than consistently across multiple studies 1.

Important Context and Caveats

Measurement Methodology Matters

The blood pressure target of <135/85 mmHg corresponds to different measurement techniques. Home blood pressure monitoring ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension requiring treatment intensification 1. This target is approximately 10 mmHg lower than conventional office measurements due to the absence of white-coat effect 1.

Population-Specific Considerations

  • In pregnancy with diabetes, the target of ≤135/85 mmHg specifically reduces accelerated maternal hypertension without harming the fetus 1.

  • In high-risk non-diabetic patients (those with CVD risk >10-15%, chronic kidney disease, or established cardiovascular disease), intensive BP lowering to achieve approximately 135/85 mmHg by home monitoring reduces cardiovascular events 1.

  • In diabetic patients, the ACCORD trial did not show benefit from intensive BP lowering to <120 mmHg systolic, suggesting the <135/85 mmHg target may be more appropriate than more aggressive goals 1.

Outcomes NOT Consistently Reduced

  • Myocardial infarction was not reduced in trials of intensive BP lowering, including SPRINT 1.

  • Cognitive outcomes showed mixed results, with SPRINT showing reduction in mild cognitive impairment but not in probable dementia as the primary endpoint 1.

Adverse Events Increased

Withdrawals due to adverse effects increased substantially with intensive BP targets (RR 8.16) 3. Specific harms include:

  • Hypotension increased by 105% with intensive BP control 4.
  • Acute kidney injury and hyperkalemia risks increase with intensive BP lowering, particularly when multiple renin-angiotensin system agents are used 1.
  • Electrolyte abnormalities and syncope are more common with aggressive BP targets 1.

Clinical Application Algorithm

For most patients, the evidence suggests:

  1. Confirm hypertension with home BP ≥135/85 mmHg or ambulatory BP ≥130/80 mmHg 1.

  2. Assess cardiovascular risk: The <135/85 mmHg target is most beneficial in high-risk patients (10-year ASCVD risk ≥15%, established CVD, chronic kidney disease, or stroke history) 1, 2.

  3. In pregnancy, target ≤135/85 mmHg to reduce maternal hypertension complications 1.

  4. In general hypertension without high-risk features, the traditional <140/90 mmHg target remains appropriate, as lower targets have not shown consistent benefit and increase adverse events 3, 5.

  5. Monitor for adverse effects closely when targeting <135/85 mmHg, particularly orthostatic hypotension, acute kidney injury, and electrolyte disturbances 1, 3.

Critical Limitations

The evidence supporting <135/85 mmHg specifically is limited. Most data comes from SPRINT, which targeted <120 mmHg systolic using automated office BP measurement (equivalent to approximately 130-135 mmHg conventional measurement) 1. External generalizability is limited because SPRINT excluded patients with diabetes, stroke, dementia, heart failure, and those <50 years old 1. The trial was also terminated early, which may overestimate benefit and underestimate harm 1.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Treatment of Hypertension: Which Goal for Which Patient?

Advances in experimental medicine and biology, 2017

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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