Blood Pressure Targets Debate: Should Hypertension Goals Be Lower Than 140/90?

What Did the SPRINT Trial Reveal About Blood Pressure Targets?

The Systolic Blood Pressure Intervention Trial (SPRINT), published in the New England Journal of Medicine in 2015, was a landmark randomized controlled trial that fundamentally changed the conversation around blood pressure management. The trial enrolled 9,361 adults aged 50 and older with systolic blood pressure of 130-180 mmHg and increased cardiovascular risk, but excluded patients with diabetes and prior stroke. Participants were randomized to an intensive treatment target of less than 120 mmHg or a standard target of less than 140 mmHg.

The results were striking. The trial was stopped early after a median follow-up of 3.26 years because the intensive treatment group showed a 25% reduction in major cardiovascular events (heart attack, stroke, heart failure, and cardiovascular death) and a 27% reduction in all-cause mortality. The intensive group achieved a mean systolic blood pressure of 121.4 mmHg compared to 136.2 mmHg in the standard group, requiring an average of one additional antihypertensive medication.

However, intensive treatment was not without trade-offs. The intensive group experienced higher rates of serious adverse events including hypotension (2.4% vs. 1.4%), syncope (2.3% vs. 1.7%), electrolyte abnormalities (3.1% vs. 2.3%), and acute kidney injury or renal failure (4.1% vs. 2.5%). These findings underscored the importance of individualized treatment decisions, particularly in elderly patients and those with chronic kidney disease, where the balance between benefit and harm requires careful clinical judgment.

How Do Current ACC/AHA and ESC Guidelines Differ on Blood Pressure Targets?

The 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults marked a paradigm shift by lowering the diagnostic threshold for hypertension from 140/90 to 130/80 mmHg. Under this classification, Stage 1 hypertension is defined as 130-139/80-89 mmHg, and Stage 2 as 140/90 mmHg or higher. The guideline recommends pharmacological treatment for patients with Stage 1 hypertension who have established cardiovascular disease or a 10-year ASCVD risk of 10% or greater, with a treatment target of less than 130/80 mmHg for all treated patients.

The European Society of Cardiology and European Society of Hypertension (ESC/ESH) updated their guidelines in 2023, moving closer to the American position while maintaining some key differences. The ESC now recommends an initial target of below 140/90 mmHg for all patients, followed by a more aggressive target of 120-129 mmHg systolic for most patients aged 18-64 if treatment is tolerated. For patients aged 65-79, the target is 130-139 mmHg systolic, and for those 80 and older, 130-139 mmHg if tolerated. The diastolic target is 70-79 mmHg across all age groups.

Both sets of guidelines emphasize lifestyle modifications as the foundation of hypertension management. These include the DASH diet (rich in fruits, vegetables, and low-fat dairy with reduced saturated fat), sodium restriction to less than 2,300 mg per day (ideally 1,500 mg), regular aerobic exercise (at least 150 minutes per week), weight management (targeting a BMI of 20-25 kg/m2), moderation of alcohol consumption, and smoking cessation. For patients requiring pharmacological treatment, first-line agents include ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics.

Why Is Hypertension Called the Silent Killer and How Is It Diagnosed?

Hypertension affects an estimated 1.28 billion adults aged 30-79 globally, according to the WHO, yet nearly 46% of adults with the condition are unaware they have it. This makes hypertension the most significant undiagnosed chronic condition worldwide. The disease rarely causes symptoms until target organ damage occurs, which can manifest as heart failure, stroke, kidney disease, retinopathy, or peripheral artery disease. Untreated hypertension doubles the risk of cardiovascular disease for each increment of 20/10 mmHg above 115/75 mmHg.

Accurate diagnosis requires careful measurement technique and multiple readings. The ACC/AHA recommends using an automated oscillometric device with the patient seated quietly for at least five minutes, feet flat on the floor, arm supported at heart level, with an appropriately sized cuff. At least two readings should be taken at each visit, separated by one to two minutes, and averaged. Out-of-office measurements, through either home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM), are recommended to confirm the diagnosis and exclude white coat hypertension, which affects 15-30% of individuals with elevated office readings.

The global burden of hypertension is particularly severe in low- and middle-income countries, where access to diagnosis and treatment remains limited. The WHO HEARTS technical package provides a standardized approach to cardiovascular disease management in primary care settings, emphasizing simplified treatment protocols, team-based care, and access to essential medications. Achieving global blood pressure control could prevent an estimated 10 million deaths per year, including 4.9 million from ischemic heart disease and 3.5 million from stroke.