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........................... patients, it may be difficult to achieve the recommended target BP range due to poor tolerability or adverse effects, and high-quality measurement and monitoring for tolerability and adverse effects is especially important in these groups.580 Compared to previous ESC/ESH Hypertension Guidelines,4 we changed the cut-off for identifying who is ’older’ from 65 to 70 years for reasons of consistency with other parts of the current guidelines. Although a single age cut-off is provided, it is important to stress that biological age influences this threshold in clinical practice. For example, a very fit 75-year-old person may qualify for a treatment policy normally reserved for those <70 and, vice versa, a very frail 65-year-old person should sometimes be considered ‘older’. BP targets for patient subgroups with various comorbidities are shown in Table 18. 4.7.5.3.1. Blood pressure targets according to ambulatory and home blood pressure monitoring. There are no outcome-based trials that have used ABPM or HBPM to guide treatment. Therefore, ......................................................................................................................................................... Table 18 Recommended office blood pressure target ranges. The first step in all groups is a reduction to systolic blood pressure <140 mmHg. The subsequent optimal goals are listed below. Age group Office SBP treatment target ranges (mmHg) Hypertension 1 DM 1 CKD 1 CAD 1 Stroke/TIA 18 2 69 years 120130 120130 <140130 120130 120130 Lower SBP acceptable if tolerated 70 years <140 mmHg, down to 130 mmHg if tolerated Lower SBP acceptable if tolerated DBP treatment target (mmHg) <80 for all treated patients CAD = coronary artery disease; CKD = chronic kidney disease; DBP = diastolic blood pressure; DM = diabetes mellitus; SBP = systolic blood pressure; TIA = transient ischaemic attack. Initial therapy Dual combination Consider beta-blockers at any treatment step, when there is a specific indication for their use, e.g. heart failure, angina, post-myocardial infarction, atrial fibrillation, or younger women with, or planning, pregnancy Consider monotherapy in low-risk grade 1 hypertension (systolic BP <150mmHg), or in very old (≥80 years) or frailer patients ACEi or ARB + CCB or diuretic 1 pill Consider referral to a specialist centre for further investigation Step 3 Triple combination + spironolactone or other drug Step 2 Triple combination ACEi or ARB + CCB + diuretic Resistant hypertension Add spironolactone (25-50 mg o.d.) or other diuretic, alpha-blocker or beta-blocker 1 pill 2 pills Beta-blockers Figure 16 Core drug treatment strategy for hypertension. This algorithm is appropriate for most patients with hypertension-mediated organ damage, diabetes mellitus, cerebrovascular disease, and peripheral artery disease. ACE = angiotensin-converting enzyme; AF = atrial fibrillation; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker; HF = heart failure; o.d. = omni die (once a day). ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026