Blood pressure targets: Should we go higher or lower?

Globally, more than one billion adults between the ages of 30 and 79 live with high blood pressure (aka hypertension), a condition that leads to over 10 million deaths every year (1;2). Due to its often-symptomless nature, high blood pressure has been dubbed the “silent killer,” as many with the condition go undiagnosed and untreated (1;3). For those who do receive a diagnosis, treatment plans developed by a healthcare professional can include lifestyle changes and the use of medications to reach a target or desired blood pressure (1;3).

Whether it’s walking a certain number of steps a day or reading a specific number of books a year, goal setting is always an important part of any plan. However, for older adults with high blood pressure, determining the best blood pressure target or goal has been a little difficult. This is seen in varying recommendations on what that number should be, with some approaches being more aggressive and others more relaxed (3-5).

To help us better understand, let’s break this down further. A normal blood pressure reading is less than 120/80 mmHg (millimeters of mercury), while a high blood pressure reading is 130/80 mmHg or higher. The number at the top represents systolic pressure and the number at the bottom represents diastolic
pressure (6). More aggressive approaches aim for lower blood pressure targets, like a systolic blood pressure of less than 140 mmHg, while looser approaches allow for higher blood pressure targets like a systolic blood pressure of less than 150 to 160 mmHg (3).

So, what approach works best in older adults (aged 65 and over) with high blood pressure? Do we go high or low? Let’s turn to an updated systematic review to see where the current evidence stands (3).

What the research tells us

The review presents several key takeaways.

First, compared to higher or more relaxed blood pressure targets, high certainty evidence shows that aiming for lower or more aggressive blood pressure targets decreases the risk of experiencing a stroke in older adults with high blood pressure. Second, moderate certainty evidence demonstrates that this more aggressive approach is also likely to decrease the risk of suffering dangerous heart-related issues like heart attacks. However, evidence also indicates that lower targets may have hardly any impact (if any impact at all) on the risk of dying from any cause. That said, this finding is uncertain, meaning it may change as more research emerges. Similarly, we aren’t currently able to comment on the effects of higher and lower blood pressure targets for some older adults, like those who are frail or 80 years old and over.

Safety is also always top of mind! After all, medications, even those used to reach blood pressure targets, can come with side effects. Here, we see that more clarity is needed on the risks of experiencing minor and serious consequences. Ultimately, these gaps in understanding present opportunities for future research and learnings (3).

So, what are the next steps? Step one is identifying if there’s a problem by getting your blood pressure checked by a healthcare professional. If an issue is detected, discuss your treatment options and whether your case can benefit from a more aggressive or relaxed approach. Remember, multiple factors including your age and additional conditions you may have will need to be taken into consideration.

References

1. World Health Organization. Hypertension. [Internet] 2023. [cited January 2024].  Available from: https://www.who.int/news-room/fact-sheets/detail/hypertension
2. Our World in Data. Number of deaths from hypertension. [Internet] 2024. [cited January 2024].  Available from: https://ourworldindata.org/grapher/deaths-due-to-high-blood-pressure
3. Falk JM, Froentjes L, Kirkwood JEM, et al. Higher blood pressure targets for hypertension in older adults. Cochrane Database Syst Rev. 2024; 12: CD011575. doi: 10.1002/14651858.CD011575.pub3.
4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2017; 71(6):1269-324. doi: 10.1161/HYP.0000000000000065.
5. NICE Hypertension in Adults Guideline Committee. Hypertension in adults: diagnosis and management; NICE guideline (NG136).
6. Mayo Clinic. High blood pressure (hypertension). Available from : https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410

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