Blood pressure treatment targets

What it is

The JNC 8 goals for chronic hypertension are two lines: under 60 years old, less than 140/90; 60 and older, less than 150/90. The full table sets the goal by age, diabetes and chronic kidney disease. General population with no diabetes or CKD, age 60 and over: SBP <150 mm Hg, DBP <90 mm Hg. Same group, age under 60: SBP <140 mm Hg, DBP <90 mm Hg. Diabetes present without CKD, all ages: SBP <140, DBP <90. CKD with or without diabetes, all ages: SBP <140, DBP <90. A second set of targets separates the clinic reading from HBPM and ABPM. Age under 80: clinic BP <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg. Age 80 and over: clinic BP <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg. With postural hypotension, base the target on standing BP; with frailty or multimorbidity, use clinical judgement. A third set of targets goes by 65 years of age rather than by 80. In non-diabetic chronic kidney disease with a normal urine albumin to creatinine ratio, drug therapy is initiated when the BP is 140/90 or above, with the aim to lower it to 130/80 or below if tolerated; where the albumin to creatinine ratio is 3-30 mg/mmol or above 30 mg/mmol, therapy starts at 130/80 and aims to maintain the pressure below it. In the patient with diabetes the aim is 130/80 or lower under 65 years of age and in those at high risk for CVD, and below 140/80 at 65 years and over. After a transient ischemic attack or a stroke the pressure should be maintained below 130/80 if tolerated, especially in patients younger than 65 years of age, and below 140/90 in patients older than 65. The national guideline sets its office targets by age, and its office table sets one target for hypertension alone and for hypertension with diabetes, CKD, CAD or a previous stroke or TIA: under 65 years, target the systolic to 130 or lower if tolerated; at 65 years and over, including those with comorbidities, lower the systolic to a range of 130-139 if tolerated. The office diastolic target is 70-79 mmHg, and a diastolic level less than 80 mmHg should be targeted for all patients regardless of the level of risk or comorbidities. The same guideline also gives, in its text, less than 140/80 in elderly patients of 65 years and over with diabetes if tolerated, and below 140/90 in patients older than 65 after a transient ischemic attack or stroke.

The national diabetes guideline writes the same targets out for the patient with diabetes. Hypertension there is defined as a blood pressure of 140/90 mmHg or above, it is an extremely common co-morbid condition in patients with diabetes, and blood pressure should be checked during each clinic visit. It substantially increases the risk of both macro- and micro-vascular complications, including stroke, coronary artery disease, peripheral vascular disease, retinopathy and nephropathy. Aim for a blood pressure target of 130/80 or below in patients less than 65 years of age and those at high risk for CVD, and below 140/80 in elderly patients of 65 years and over if tolerated.