Chronic Blood Pressure Definitions and Goals

Jiun-Ruey Hu, MD, MPH | Created 5/15/22

BP Definitions
In 2018, the AHA/ACC/ASH released the 2017 HTN guidelines, which replaced the JNC 7 guidelines from 2003
(In 2013, the NHLBI relinquished its role in producing JNC reports and passed hypertension guideline writing
responsibility to the AHA/ACC). The term “prehypertension” (previously SBP 120-139) has been retired. Now
SBP 120-129 is considered “elevated BP” and SBP 130-139 is considered “hypertension stage 1” (previously
SBP 140-159). This means that 14% more US adults are now considered to have hypertension. In addition,
now, any SBP≥140 is automatically classified as “hypertension stage 2”.

Figure from 2017 ACC/AHA/ASH HTN guidelines

BP Goals
Before 2018: In 2018, The ACC/AHA/ASH unified all BP goals:
KDIGO No proteinuria ≤140/90
(2012) Proteinuria ≤130/90
JNC 8 Elderly >60yo <150/90
(2014) Age 30-59yo <140/90
Diabetes <140/90
CKD <140/90
ASH/ISH Elderly ≥80yo <150/90
(2014) 18-79yo <140/90
Diabetes <140/90
CKD <140/90
ADA (2015) Diabetes <140/90
AHA/ACC Elderly >80yo <150/90
(2015) CAD, ACS, or HF <140/90
CAD, post-MI, <130/80
stroke/TIA, carotid
artery dz, PAD, or AA

Figure from 2017 ACC/AHA/ASH HTN guidelines

I anticipate that this blanket goal of 130/80 will change in the next guideline. Read Kaul (2018, Circulation,
“How Strong Is the Evidence to Support Blood Pressure Treatment Goal of 130/80 mm Hg?”)
In 2021, KDIGO further lowered the BP goal in CKD patients to <120/80 based on the cardioprotective,
survival, and potentially cognitive benefits shown in SPRINT, although there is no renoprotective effect
(Cheung, 2021, KI). It is a weak recommendation (2b) as it is based on a single, albeit high-quality RCT (SPRINT)
of SBP<120 vs SBP<140. KDIGO’s <120/80 recommendation does not apply to patients with a kidney
transplant or those on dialysis.

Comparison of American and European Guidelines

The main difference is that ACC/AHA/ASH feels that all people with BP>130/80 have hypertension, and that BP
should be lowered to <130/80 in everyone. Meanwhile, ESC/ESH feels that people with BP>140/90 have
hypertension, and goal BP is <140/90, with targeting adjusted to <130/80 in patients at high cardiovascular
risk. The ESC/ESH point out that an 80yo should not have the same goal (i.e. <130/80) as a 30yo, especially in
patients with poor vascular compliance and high pulse pressures, noting that SPRINT excluded these patients.
While the ACC/AHA uses
the ASCVD risk calculator to
generate individualized
cardiovascular risk
estimates for patients, the
ESC/ESH uses the
Systematic Coronary Risk
Evaluation system.

In terms of concordant new

recommendations, both
guidelines recommend use
of home and ambulatory BP
monitoring and proper BP
measurement. Regarding
medication, both guidelines
now restrict beta-blockers
only to patients with
comorbidities or compelling
indications requiring their
use, such as angina, post-
MI, HF, or AF), because
trials of beta blockers used
solely for hypertension
failed to show a mortality
benefit (although these
trials only used once daily
dosing of atenolol instead
of the standard twice daily
dosing).