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Hypertension is defined as a systolic blood pressure (SBP) > 120 mmHg and/or a diastolic blood pressure (DBP) > 90 mmHg.1 Approximately 80 million adults in the United States have hypertension and it is predicted that this number will continue to rise.2 Hypertension is among the leading modifiable risk factors for myocardial infarction, stroke, heart failure, and renal disease.2 Much debate exists regarding optimal BP goals, especially in older patients, to reduce the risk of these complications. There is also controversy about what age threshold should be used to differentiate BP goals in patients without co-morbid conditions such as renal disease, diabetes, or cardiovascular disease. Recommendations for BP goals vary among national organizations.

Committee members from the Eight National Joint Commission (JNC 8) recommended the following blood pressure goals in 2014:3

  • General patient population (without diabetes or chronic kidney disease (CKD)
    • Age < 60: SBP < 140 mmHg and DBP < 90 mmHg
    • Age > 60: SBP < 150 mmHg and DBP < 90 mmHg
  • Patients with diabetes or CKD, regardless of age
    • SBP < 140 mmHg and DBP < 90 mmHg


The following Table includes various BP goal recommendations from several national organizations:

Guideline/Statement Patient Group Goal (mmHg)
American Diabetes Association4 Diabetes

Those with diabetes who are younger patients, + albuminuria, and/or hypertension AND one or more additional atherosclerotic CV risk factor



American Heart Association Prevention/American College of Cardiology/American Hypertension Society5 Age > 80

CAD*, ACS^, or HF#

CAD*, post-MI, stroke/TIA, carotid artery disease, PAD or AAA




American Society of Hypertension/International Society of Hypertension6 Age 18-79

Age ≥ 80


Chronic kidney disease





Kidney Disease: Improving Global Outcomes7 No proteinuria




* a lower target BP may be appropriate for some patients with CAD
^ target BP of < 140/90 mmHg in patients with an ACS who are hemodynamically stable; a target BP of < 130/80 mmHg is a reasonable at time of hospital discharge
# may consider target BP of < 130/80 mmHg
AAA = abdominal aortic aneurysm; ACS = acute coronary syndrome; CAD = coronary artery disease; CV = cardiovascular; HF = heart failure; MI = myocardial infarction; PAD = peripheral arterial disease; TIA = transient ischemic attack

Clinicians raised several concerns regarding the BP goal recommendations provided by JNC8. One concern relates to the age threshold (e.g., 60 years) for the higher BP goal (i.e., < 150/90 mmHg) in the general patient population. The American Heart Association/American College of Cardiology recommends that the BP goal of < 150/90 mmHg be reserved for those over 80 years of age. Data suggest that a less aggressive BP goal for those aged > 60 years would put a significant number of patients with an already elevated cardiovascular risk at higher risk for complications from hypertension.8-10

Importantly, a proportion (28 to 33.1 %) of older patients have isolated systolic hypertension (ISH which is defined as SBP > 140 mmHg and a DBP < 90 mmHg), which occurs due to physiological changes leading to arterial stiffness and decreased compliance.12,13 In landmark clinical trials such as the Systolic Hypertension in the Elderly Program (SHEP) trial and the Systolic Hypertension in Europe (Syst-Eur) trial, and data from meta-analyses, treatment of ISH in patients > 60 years has resulted in a reduction in clinical outcomes such as stroke and cardiovascular events.14-16 SBP goals have been utilized as the target in recent hypertension trials. This is because there is a higher prevalence of ISH in the elderly. Additionally, it is well-established that the ideal DBP is < 90 mmHg in most instances.

In the Hypertension in the Very Elderly Trial (HYVET), patients > 80 years with a SBP of 160-199 mmHg were randomized to indapamide (with the option of perindopril as additional therapy) or placebo to achieve a BP goal of < 150/80 mmHg. The primary endpoint was non-fatal or fatal stroke. The trial was terminated early as there was a lower risk of stroke and all-cause death in the treatment group. At enrollment, the mean age of the 3845 participants was 83.6 years, with 22.4% aged 85-89 years and 4.6% aged 90 years or older. The median duration of follow-up was 1.8 years. At 2 years, 48% of patients in the active-treatment group vs. 19.9% in the comparator group achieved target BP. Treatment was associated with a 21% relative risk reduction in all-cause death (p = 0.02), a 30% non-significant relative risk reduction in fatal or non-fatal stroke (p = 0.06) and a 39% relative risk reduction in fatal stroke (p = 0.05). The benefits of therapy were seen within a year of treatment. Serious side effects were less common in the treatment group.11

Two of the most recent landmark hypertension trials have focused on determining the optimal BP goal for patients with elevated cardiovascular risk. In the Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus (ACCORD BP) study, patients were randomized to intensive (SBP < 120 mmHg) or standard therapy (SBP < 140 mmHg). Patients with type 2 diabetes and risk factors for cardiovascular disease were included. The mean age was 62.2 years with 34% of participants aged > 65 years. There was no difference in the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) between groups. There was no difference in the primary endpoint when comparing those < 65 to those > 65 years of age.17

In the Systolic Blood Pressure Intervention Trial (SPRINT), 9361 patients > 50 years of age who were at an increased risk of CV events were randomized to an intensive SBP target (< 120 mmHg) or standard SBP target (< 140 mmHg). Notable exclusion criteria were those with diabetes, history of stroke and an estimated glomerular filtration rate of < 20 ml/min/1.73 m2.  The mean age of participants was 67.9 years; 28.2% were > 75 years. The mean baseline SBP was approximately 139 mmHg and over 90% of participants were receiving an antihypertensive agent before enrollment. The primary outcome was the composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes.  The trial was stopped early, at a median of 3.26 years of follow-up, due to the benefits with intensive BP lowering. The rate of the primary outcome was significantly lower in those randomized to the intensive SBP target (0.41%/year vs. 2.19%/year, p < 0.0001). The risk of heart failure (1.3 %/year vs. 0.67%/year, p = 0.002) and death from any cause (1.03%/year vs. 1.4%/year, p = 0.005) was lower in the intensive group. There was no difference in the rate of the other individual components of the primary outcome between groups.  Overall, there was no difference in serious adverse events between groups. Hypotension, syncope, acute kidney injury/renal failure, and serious electrolyte abnormalities were rare but significantly higher in the intensive treatment group.18

In a subsequent paper, the results of those aged > 75 years (n = 2636) enrolled in SPRINT were reported. The primary outcome was again significantly lower with the intensive SBP goal among those 75 years or older (2.59%/year vs. 3.85%/year; hazard ratio 0.66 [95 % confidence interval 0.49 – 0.91)). The effect of intensive therapy on the primary outcome appeared to be more pronounced among those aged > 75 years with a number needed to treat of 27 vs. 61 over a 3 year period in the overall SPRINT results. There was no difference in the rate of serious side effects between groups. There was a lower risk of injurious falls in the intensive treatment group (4.9% vs. 5.5%) and a higher risk of orthostatic hypotension with dizziness in the intensive treatment group (1.9% vs. 1.3%), although neither finding was statistically significant.19

Concerns have also been raised regarding the risk of cognitive impairment with anti-hypertensive use. It is well-established that hypertension during mid-life increases the risk of dementia later in life. It is not clear, at this time, that treating hypertension later in life delays or slows the progression of cognitive decline.20-21 However, there is the risk that too aggressively or abruptly changing blood pressure in older patients can impact cognition. Given the known benefits of treating hypertension, clinicians should follow a common phrase in managing hypertension in older patients – start low, and go slow! If acute cognitive decline occurs with initiation or titration of anti-hypertensive therapy, then therapy should be modified to determine if less aggressive treatment can restore previous cognitive function.

There is no need to sprint to a target BP in older patients. Doing so can increase the risk of side effects, such hypotension, acute kidney injury, and cognitive decline. The effects of anti-hypertensive therapy are not immediate and therefore it is prudent to gradually lower BP to a safe target for patients. BP goals should not be one-size-fits-all. The goal should be tailored based on the presence of co-morbid conditions, fall risk, tolerability of therapy, life-expectancy, and other patient-specific factors.

Bottom Line
Given the results of HVYET, SPRINT and other trials, recommendations for BP goals include:

  • BP goal < 150/90 mmHg for those > 80 years old without diabetes, chronic kidney or cardiovascular conditions
  • BP goal < 140/90 mmHg for those with diabetes and chronic kidney disease regardless of age
  • Lower goal may be considered for select patients with elevated cardiovascular risk and/or chronic kidney disease


Kristin Watson, PharmD, BCPS-AQ Cardiology

Dr. Watson is an associate professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, and practices as a clinical pharmacy specialist in the ambulatory heart failure clinic at the Veterans Affairs Medical Center in Baltimore, MD. Follow her on Twitter @cards_pharm_gal



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Should we be SPRINTing to Lower Blood Pressure Goals in Older Patients?

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