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8.5 Intensity of blood pressure-lowering

therapy and ideal treatment targets 8.5.1. Expected degree of blood pressure reduction with approved drugs The magnitude of BP reduction achieved with the main classes of BP-lowering medications (ACE inhibitors, ARBs, dihydropyridine CCBs, diuretics, and beta-blockers) as monotherapy is similar overall.528,529 BP reduction with standard doses of any of these five classes can be expected to be approximately 9/5 mmHg with office BP and 5/3 mmHg with ABPM.478 These BP-lowering effects may attenuate over time.530 Combination therapy (e.g. with three drugs at half standard dose) over the short term can lower office BP by up to 20/11 mmHg.478,531 The reason why beta-blockers are not considered first-line BP-lowering medications (outside of compelling indications) is not because of inferior BP-lowering properties (particularly for vasodilating beta-blockers),532 but because of inferior efficacy in reducing CVD events (particularly stroke) among patients with hypertension, and tolerance issues.533–536 The BP-lowering effect of each BP medication class generally increases with the dose administered, though this relationship is not linear.537 Effects of each medication can also vary at the individual level, sometimes requiring personalization by matching the patient with the best medication for them.490 The magnitude of BP reduction for any BP-lowering medication may increase as a function of the pre-treatment BP, which is also known as Wilders principle.538,539 The BP-lowering effect of pharmacological therapy is typically evident after 1–2 weeks of treatment,540 but the maximum effect might take longer to manifest. Therefore, the advised follow-up after 1–3 months (1 month preferred with a GP or specialist) allows for assessment of tolerance/safety, but also allows enough time to gauge the full BP-lowering effect of each drug titration (see Section 8.3.4).

8.5.2 The ideal target of blood pressure-lowering

treatment As discussed in Section 6, optimal control of BP translates into CVD risk reduction, thereby reducing morbidity and mortality in the population.116,478,541 BP threshold is defined as the BP at which BP-lowering treatment is initiated, while BP target is the BP goal with treatment. The BP threshold to initiate BP-lowering therapy is not necessarily the same as the recommended BP target once therapy is commenced (in other words, treatment threshold and treatment target may not be the same for a given patient). Specifically, for hypertensive patients in whom BP-lowering treatment is recommended above a baseline BP of ≥140/ 90 mmHg, the recommended target of BP-lowering therapy is 120–129/ 70–79 mmHg, provided treatment is well tolerated (see Supplementary data online). Persons with elevated BP who receive treatment are also recommended to achieve a target of 120–129/70–79 mmHg. Therefore, the treatment target in the 2024 Guidelines is always 120–129/70–79 mmHg (but only if treatment is tolerated and with certain exceptions where more lenient targets are advised). In contrast, the treatment threshold may differ based on CVD risk, specifically in the elevated BP category. For example, in addition to hypertensive adults with BP ≥140/90 mmHg, there are individuals with an office systolic BP of 130–139 mmHg and/or diastolic BP of 80–89 mmHg who have sufficiently high CVD risk to recommend BP-lowering drug treatment. The BP target range of 120–129/70–79 mmHg recommended in these guidelines reflects the most current evidence from contemporaneous RCTs135,136,146,542–545 and from meta-analyses of RCTs.131 Of note, this treatment target reduces CVD events in older adults136,523 with evidence for efficacy of more intensive BP-lowering treatment targets established up to age 85 years.131 Furthermore, research data indicate that, to optimally reduce CVD risk, achieving an ontreatment BP of 120/70 mmHg is the best point on the BP target range provided in our guideline recommendations (Figure 20). However, while we strongly considered recommending a treatment target of exactly 120/70 mmHg with out-of-office BP confirmation, we instead chose a target range of 120–129/70–79 mmHg (preferably with out-of-office BP confirmation but also allowing for office BP) for the following reasons: providing flexibility to patients and clinicians; feedback from external peer review; feedback from patients that lifestyle is preferred to medication unless BP is in the hypertensive range; the knowledge that contemporary treat-to-target intensive BP trials included only persons with baseline systolic BP of ≥130 mmHg; and a recognition that the BP values recorded under research conditions using systematic approaches to measurement (while strongly recommended by these guidelines) are not always the same as BP values recorded under routine clinical care, which can be 5–10 mmHg higher.65,66

In addition, the trial data confirming efficacy for our recommended treatment target of 120–129/70–79 mmHg do not necessarily apply to moderately-to-severely frail adults who were generally excluded from trials. Furthermore, the data supporting this BP target among adults aged >85 years are inconclusive.131 Frailty can occur at different ages and is, together with tolerability of BP-lowering treatment, an important characteristic when considering the BP target for a given patient. Accordingly, personalized BP-lowering treatment should be instituted in people aged ≥85 years and/or those with significant frailty. Recommended indicators of frailty in guiding BP-lowering treatment are given in Section 9. Several important nuances are highlighted and warrant consideration prior to implementing the new BP target of 120–129/70–79 mmHg among patients receiving BP-lowering therapy:

• Evidence for a systolic BP-lowering treatment target of 120–129 mmHg is strong (Class I, level of evidence A). • Evidence for a specific diastolic BP-lowering treatment target is less strong in those who are treated to a systolic target of 120–129 mmHg. While most adults treated to a systolic BP target of 120–129 mmHg will also achieve a diastolic BP of 70–79 mmHg, not all will.543,546 Furthermore, adults who achieve systolic BP control are generally at low relative risk for CVD, even when diastolic BP is 70–90 mmHg.547,548 Nonetheless, due in part to the known higher risk of isolated diastolic hypertension among younger adults,549 the task force agreed that it is reasonable to target an on-treatment diastolic BP of 70–79 mmHg among patients with diastolic BP of ≥80 mmHg who are already at the systolic BP target of 120–129 mmHg (Class IIb, level of evidence C). • The task force acknowledges the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice,170 which take a stepwise approach to their recommendations for BP-lowering treatment. The 2021 Guidelines recommended an on-treatment systolic BP target of 130–139 mmHg as the first step and then—based on patient preferences, risk, and frailty—to aim for a target on-treatment systolic BP of <130 mmHg as the second step. While we recognize the potential value of this two-step approach, which many clinicians may choose to follow, the current guidelines emphasize one ontreatment BP target (120–129/70–79 mmHg, provided treatment is tolerated). This one-step approach is based on the evidence, and motivated to discourage therapeutic inertia around BP lowering. As an illustrative example of the latter concern for therapeutic inertia, an Downloaded from academic.oup.com/eurheartj/article/45/38/3912/7741010 by guest on 07 October 2026