Understanding Your Blood Pressure Goals: A Patient's Guide to Hypertension Treatment

Table of Contents

• Key Points
• Introduction: Why Blood Pressure Goals Matter
• The Overall Approach to Blood Pressure Goals
• Why How Blood Pressure Is Measured Matters
• Understanding Risk: Absolute Versus Relative Risk
• Blood Pressure Goals for Higher-Risk Patients
• The SPRINT Trial: Key Findings in Detail
• Limitations of the Research
• Frequently Asked Questions
• Source Information

Key Points

• Blood pressure goals depend on how pressure is measured and on your personal cardiovascular risk.
• Preferred measurement methods include standardized office, automated oscillometric, home, and 24-hour ambulatory monitoring; routine office readings run 5-15 mmHg higher.
• Higher-risk patients gain more absolute benefit from intensive lowering; for those with cardiovascular disease, goal is 120-125/<80 mmHg using preferred methods.
• In SPRINT, targeting systolic below 120 mmHg reduced heart attacks, heart failure, strokes, and death compared with below 140 mmHg, but increased kidney events, fainting, and low sodium.
• SPRINT excluded patients with diabetes, heart failure, stroke, significant proteinuria, and nursing home residents, so treatment should be individualized with your doctor.

Introduction: Why Blood Pressure Goals Matter

High blood pressure, also called hypertension, is extremely common around the world. In fact, treating hypertension is one of the most frequent reasons for medical office visits among nonpregnant adults and for the use of prescription medications. Decades of research have clearly shown that lowering blood pressure reduces the risk of heart attacks, strokes, and other cardiovascular problems—but an important question remains: Exactly how low should blood pressure go?

This article looks at the evidence-based answer to that question. It explains when to start blood pressure medication, how many medications may be needed, and what target blood pressure numbers patients and doctors should aim for. Along the way, we will cover the different ways blood pressure can be measured, why your personal risk profile matters, and what large clinical trials tell us about the benefits and risks of intensive blood pressure lowering.

It is worth noting that many other related topics—such as screening for hypertension, lifestyle changes (diet, salt restriction, weight loss, and exercise), and choosing specific blood pressure medications—are covered in separate articles. Here, our focus is specifically on the goal blood pressure.

The Overall Approach to Blood Pressure Goals

According to the authors, a variety of randomized trials have addressed the question of what blood pressure target is best. These trials form the basis of the recommendations discussed below. Two general principles guide the approach:

• Blood pressure targets depend on how the measurement is taken. Blood pressure measured in a medical office should be obtained in a careful, standardized way. There are two ways to do this properly: automated oscillometric blood pressure monitoring (AOBPM), which requires special equipment, and standardized office-based measurement using proper preparation and technique, which uses ordinary equipment. These two methods were used in nearly all major outcome trials in hypertension, and they give readings that closely match daytime ambulatory monitoring and home blood pressure readings.
• Blood pressure targets depend on the patient's individual risk for having a future cardiovascular event (such as a heart attack or stroke). Patients at higher risk are recommended to aim for lower blood pressure numbers.

The authors recommend a more intensive (lower) blood pressure goal for most patients who have one or more of the following higher-risk characteristics:

• Established atherosclerotic cardiovascular disease (prior coronary artery disease, prior stroke or transient ischemic attack [TIA, sometimes called a "mini-stroke"], or documented peripheral arterial disease)
• Heart failure
• Diabetes mellitus
• Chronic kidney disease (CKD)
• Older age (over 65 years)
• Multiple cardiovascular risk factors with an estimated 10-year risk of future cardiovascular events of 10 percent or greater

Patients without any of these characteristics are considered lower risk, and a less intensive (higher) blood pressure goal is recommended for them.

The authors emphasize that strong data support treatment decisions in some populations—such as people with severely elevated blood pressure (for example, diastolic pressure of 110 mmHg or higher), those at high cardiovascular risk, and older adults. However, for many other patient groups, the evidence is weaker and largely indirect. As a result, good clinical judgment and shared decision-making between patient and provider are essential.

Interestingly, the lower blood pressure targets recommended for higher-risk groups apply to a large portion of the population. The authors note that pursuing more intensive blood pressure lowering in such patients is likely to be cost-effective, even though it requires more medications and additional monitoring.

Why How Blood Pressure Is Measured Matters

One of the most important—and often overlooked—factors in setting blood pressure goals is the method of measurement. Blood pressure readings can differ significantly depending on how and where they are taken. The four preferred methods are:

1. Standardized office-based measurement – Blood pressure is taken manually or with an oscillometric device, but with proper patient preparation and proper technique (e.g., the patient empties their bladder first, rests seated for three to five minutes with both feet on the floor, avoids conversation, and uses the correct cuff size).
2. Automated oscillometric blood pressure monitoring (AOBPM) – A specialized device is programmed to average multiple consecutive readings after the patient has rested in a seated position for five minutes. The device is activated by a care provider, who can then leave the room.
3. Home blood pressure monitoring – Patients measure their own blood pressure at home using an automated oscillometric device that has been checked for accuracy in the clinician's office. Typically, multiple readings are taken daily over several consecutive days and then averaged. A common approach is for patients to take two to four readings daily for five to seven days before a clinic visit.
4. Ambulatory blood pressure monitoring (ABPM) – A wearable device takes blood pressure readings over a 24-hour period, usually every 15 to 30 minutes during the daytime and every 30 to 60 minutes during sleep.

These four methods are referred to in the article as "non-routine" methods because, unfortunately, they are not commonly used in everyday practice. The method that is typically used worldwide is called the "routine" method: a single blood pressure reading taken in the office with a stethoscope or oscillometric device, without proper patient preparation or technique. While this routine method is faster and less cumbersome, it is considered inferior because readings can vary widely from office to office and from one provider to the next.

The key point: "Routine" measurements are generally 5 to 15 mmHg higher than "non-routine" measurements on a population level, in part because the "white coat" effect (anxiety-induced elevation in blood pressure in the medical setting) may be absent and because proper preparation and technique are often skipped. However, this is an average difference—some individual patients do not experience a white coat effect, so there is some uncertainty when setting goals according to the method of measurement.

This measurement difference has real practical consequences. For example, a blood pressure of 135/85 mmHg measured with the routine method might actually correspond to a lower reading (closer to 120/80 mmHg) when measured with a preferred method. The authors emphasize that the non-routine methods should ideally be used when making decisions about blood pressure management.

Understanding Risk: Absolute Versus Relative Risk

Another key concept is the difference between absolute and relative risk reduction. This may sound abstract, but it has major implications for treatment decisions. In general, therapeutic decisions should be based on absolute benefits and harms—not just relative benefits.

Here is a concrete example from the article. Suppose that lowering blood pressure by 10/5 mmHg produces a 20 percent relative risk reduction (a relative risk of 0.80) for major cardiovascular events. Now consider two different hypertensive patients:

• Patient A is a 50-year-old, nonsmoking, nondiabetic, African-American woman with a total cholesterol of 190 mg/dL, a "good" (HDL) cholesterol of 45 mg/dL, and a systolic blood pressure of 135 mmHg. Her predicted 10-year risk of having a major atherosclerotic cardiovascular event is 3 percent.
• Patient B is a 50-year-old, diabetic, African-American woman who smokes cigarettes, has a total cholesterol of 200 mg/dL, an HDL cholesterol of 35 mg/dL, and a systolic blood pressure of 135 mmHg. Her predicted 10-year risk of having a major atherosclerotic cardiovascular event is 20 percent.

Usually, the relative risk reduction from treatment is similar across patients with different baseline risks. So antihypertensive therapy would reduce the relative risk of cardiovascular events by 20 percent for both patients. But the absolute benefit is very different:

• Patient A's absolute risk reduction is 0.6 percent (from 3 percent to 2.4 percent). In a population like Patient A, 167 patients would need treatment for 10 years to prevent one major cardiovascular event.
• Patient B's absolute risk reduction is 4.0 percent (from 20 percent to 16 percent). In a population like Patient B, only 25 patients would need treatment for 10 years to prevent one event.

This illustrates a crucial point: the absolute benefit is larger among higher-risk patients, even though the relative benefit is similar. Studies support this conclusion. For instance, a 2014 meta-analysis of 11 randomized trials comparing antihypertensive therapy with placebo stratified patients according to their estimated five-year risk of having a major cardiovascular event (heart attack, stroke, or heart failure), using information such as age, sex, body mass index, prior history of cardiovascular disease, smoking, and diabetes. The findings:

• In patients with the highest overall cardiovascular risk (five-year risk greater than 21 percent), the absolute risk reduction was 3.8 percent, meaning the number needed to treat was 26 patients for five years.
• In patients with the lowest overall cardiovascular risk (five-year risk of approximately 6 percent), the absolute risk reduction was 1.4 percent, meaning the number needed to treat was 71 patients for five years.

Blood Pressure Goals for Higher-Risk Patients

For patients with established atherosclerotic cardiovascular disease (a prior history of coronary disease, cerebrovascular disease, or peripheral arterial disease), the authors recommend a goal blood pressure of 120 to 125/<80 mmHg when using the preferred (non-routine) measurement methods—standardized office-based measurement, AOBPM, home blood pressure, or ABPM. If routine office measurements are used instead, the recommended goal is 125 to 130/<80 mmHg. This blood pressure target applies to patients with established cardiovascular disease, and the best supporting evidence comes from the SPRINT trial described below.

The SPRINT Trial: Key Findings in Detail

The Systolic Blood Pressure Intervention Trial (SPRINT) provides some of the strongest evidence for intensive blood pressure lowering. SPRINT was a multicenter, randomized, open-label trial conducted in the United States. Here are the key details:

Who was enrolled?

• The trial enrolled 9,361 patients aged 50 years or older.
• More than 90 percent were already on antihypertensive therapy.
• All had a systolic blood pressure of 130 to 180 mmHg.
• All had at least one additional cardiovascular risk factor, such as age ≥75 years, clinically evident cardiovascular disease (except stroke), subclinical cardiovascular disease (elevated coronary artery calcium score, left ventricular hypertrophy, or an ankle-brachial index below 0.9), an estimated glomerular filtration rate (eGFR) of 20 to 59 mL/min/1.73 m², or a 10-year Framingham Risk Score of 15 percent or greater.
• The trial excluded patients with diabetes, symptomatic heart failure, history of stroke, significant proteinuria (≥1 g/day total protein or ≥600 mg/day albumin), and nursing home residents.

The average (mean) patient characteristics at the start of the study:

• Age: 68 years
• Body mass index (BMI): 30 kg/m² (classified as obese)
• Framingham 10-year Risk Score: 20 percent
• Blood pressure: 140/78 mmHg
• Clinical or subclinical cardiovascular disease present in 22 percent of patients

How was the trial designed?

Patients were randomly assigned to one of two groups:

• Standard treatment group: targeted systolic blood pressure to <140 mmHg
• Intensive treatment group: targeted systolic blood pressure to <120 mmHg

The diastolic pressure goal in both groups was <90 mmHg. Blood pressure during the trial was measured using attended or unattended AOBPM.

The medication approach used an ACE inhibitor or an angiotensin receptor blocker (ARB)—but not both together—a long-acting dihydropyridine calcium channel blocker (typically amlodipine), or a thiazide-like diuretic (chlorthalidone rather than hydrochlorothiazide), or a combination of these. Other medications were added if needed. In the standard treatment group, medications were actively withdrawn if systolic blood pressure fell below 130 to 135 mmHg, even in patients without symptoms.

At one year, approximately half of the patients in the intensive-treatment group had achieved a systolic pressure below 120 mmHg. The mean systolic pressures in the two groups at one year were 121 mmHg (intensive) and 136 mmHg (standard). The mean number of antihypertensive medications used was 2.8 in the intensive group and 1.8 in the standard group.

What were the main results?

The trial was halted early for benefit after a median follow-up of 3.33 years. The key findings:

1. Fewer cardiovascular events: Intensive treatment significantly reduced the rate of the primary endpoint—a combination of heart attack, acute coronary syndrome, stroke, heart failure, or cardiovascular death—from 7.6 percent to 5.6 percent. This difference was driven by reductions in:
   • Heart failure: 1.4 versus 2.2 percent
   • Heart attack (myocardial infarction): 2.2 versus 3.0 percent
   • Cardiovascular death: 0.9 versus 1.5 percent
2. Lower overall mortality: Intensive treatment significantly reduced death from any cause (3.5 versus 4.6 percent).
3. More kidney-related events: Acute kidney injury (AKI) occurred more often with intensive therapy (3.8 versus 2.3 percent). However, most cases were mild—61 percent were stage 1, and 17 percent were stage 2—and AKI completely or partly resolved in approximately 95 percent of patients. The authors note that mild to moderate AKI does not typically require reducing treatment unless hyperkalemia (high blood potassium) is also present.
4. Chronic kidney disease (CKD): New-onset CKD, defined as a substantial decline in eGFR from ≥60 to <60 mL/min/1.73 m², was more common with intensive therapy (3.7 versus 1.0 percent). However, this excess was accompanied by decreased levels of kidney injury biomarkers, suggesting that the rise in creatinine during intensive blood pressure lowering may reflect a benign, reversible functional change in kidney filtration due to reduced blood flow rather than actual kidney damage.
5. Other side effects: Fainting (syncope) was more common with intensive therapy (3.2 versus 2.1 percent), as was hyponatremia (low blood sodium; 4.0 versus 2.2 percent). However, the rates of injurious falls—those leading to an emergency department visit or hospitalization—were similar between the groups.
6. Quality of life preserved: There were no differences between the groups regarding physical and mental health-related quality of life, symptoms of depression, or satisfaction with care.
7. Brain health benefits: There was no increase in the development of dementia with intensive treatment. In fact, intensive blood pressure lowering reduced the rate of mild cognitive impairment (6.1 versus 7.5 percent over a median follow-up of 5.1 years) and reduced the accumulation of cerebral white matter lesions seen on MRI scans.

For patients who already had known cardiovascular disease at baseline, the risk of the primary endpoint was also lower with intensive treatment (11.0 versus 13.3 percent), although this difference was not statistically significant.

Limitations of the Research

While SPRINT's findings are powerful, the authors point out several important limitations and considerations that affect how the results should be applied in everyday practice:

• Healthier trial participants: Many SPRINT patients had controlled hypertension at baseline, and patients enrolled in clinical trials are generally healthier than others with the same condition. This means the adverse event rates seen in SPRINT may be an underestimate of what would occur with intensive treatment in routine practice.
• Medication burden: Patients in routine practice may need more medications than SPRINT participants. The average number of medications in the intensive treatment group was three, and approximately one-fourth required four or more medications. More medications could increase the risk of side effects and drug interactions.
• Measurement method: Blood pressure in SPRINT was measured with attended and unattended AOBPM, which corresponds more closely with mean daytime ambulatory blood pressure than with the routine (casual) office measurements typically used. This means the specific target numbers from SPRINT (<120 mmHg) apply to AOBPM measurements, not necessarily routine office readings.
• Not all populations were included: SPRINT excluded patients with diabetes, symptomatic heart failure, stroke, or significant proteinuria, and it did not include nursing home residents. The results may not fully apply to those groups.

Given these considerations, the authors stress that treatment decisions should be individualized. Shared decision-making between the patient and their clinician is crucial—weighing the expected benefits of more intensive blood pressure control against the risks of side effects and the burden of additional medications.

Frequently Asked Questions

What is the difference between routine and non-routine blood pressure measurement?

Routine measurement is a single office reading without special preparation. Non-routine methods include standardized office measurement, automated oscillometric monitoring (AOBPM), home blood pressure monitoring, and 24-hour ambulatory monitoring. On average, routine readings are 5 to 15 mmHg higher than non-routine readings. This difference affects what blood pressure target is appropriate for each patient.

Why do blood pressure goals depend on my personal risk?

People at higher risk for heart attacks or strokes get a larger absolute benefit from lowering blood pressure. For example, a person with 20% 10-year risk may prevent one event per 25 patients treated, while someone at 3% risk may need 167 treated. So doctors recommend lower blood pressure targets for higher-risk patients.

What blood pressure goal is recommended for higher-risk patients?

For patients with established atherosclerotic cardiovascular disease, the recommended goal is 120 to 125/<80 mmHg when using preferred measurement methods like standardized office or home monitoring. If routine office measurements are used, the recommended goal is 125 to 130/<80 mmHg. Individual treatment decisions should be made with your doctor.

What did the SPRINT trial find about intensive blood pressure lowering?

In about 9,300 patients aged 50 or older, targeting a systolic pressure below 120 mmHg reduced heart attacks, heart failure, strokes, and deaths compared with the standard target below 140 mmHg. However, intensive treatment also increased kidney events, fainting, and low blood sodium. Blood pressure was measured with a specialized technique.

Are there risks to intensive blood pressure lowering?

Yes. In the SPRINT trial, intensive treatment increased acute kidney injury, new-onset chronic kidney disease (often reversible), fainting, and low blood sodium. However, quality of life, depression symptoms, and satisfaction with care were similar to standard treatment. Most kidney events resolved completely or partially, so risks should be weighed against benefits.

Should I measure my blood pressure at home?

Home blood pressure monitoring is one of four preferred methods. Typically, patients take two to four readings daily for five to seven days and average them. Home readings closely match daytime ambulatory monitoring and can help guide treatment decisions. Always confirm your home device's accuracy at the doctor's office and discuss results with your clinician.

Does the SPRINT trial apply to everyone with high blood pressure?

No. SPRINT excluded people with diabetes, symptomatic heart failure, a history of stroke, significant proteinuria (protein in urine), and nursing home residents. Trial participants were generally healthier than others with the same condition. Because of this, results may not fully apply to all patients, and shared decision-making with your clinician is essential.

Source Information

Original article title: Goal blood pressure in adults with hypertension - UpToDate

Authors: Johannes FE Mann, MD, and Karl F Hilgers, MD

Section Editors: George L Bakris, MD; William B White, MD; Scott E Kasner, MD; David M Nathan, MD

Deputy Editors: John P Forman, MD, MSc; Jane Givens, MD, MSCE

Publication details: Literature review current through November 2022; topic last updated June 15, 2022. Published by UpToDate, a peer-reviewed clinical resource. This article references the SPRINT trial (SPRINT Research Group, New England Journal of Medicine, 2015) and the 2014 meta-analysis of antihypertensive therapy by Sundström et al.

Disclaimer: This patient-friendly article is based on peer-reviewed research. It is provided for educational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your doctor or other qualified health provider with questions about your blood pressure and treatment plan.