2.3.4.0 Individualization of Treatment Targets
Patients and clinicians should engage in a shared decision-making process to determine individual blood pressure targets (17). This approach acknowledges that the benefits and risks of intensive blood pressure targets are uncertain and may vary across patients and is consistent with a patient-focused approach to care that values patient priorities and provider judgment (35). Secondary analyses of ACCORD BP and SPRINT suggest that clinical factors can help determine individuals more likely to benefit and less likely to be harmed by intensive blood pressure control (36).
Absolute benefit from blood pressure reduction correlated with absolute baseline cardiovascular risk in SPRINT and in earlier clinical trials conducted at higher baseline blood pressure levels (11,37). Extrapolation of these studies suggests that patients with diabetes may also be more likely to benefit from intensive blood pressure control when they have high absolute cardiovascular risk. Therefore, it may be reasonable to target blood pressure <130/80 mmHg among patients with diabetes and either clinically diagnosed cardiovascular disease (particularly stroke, which was significantly reduced in ACCORD BP) or 10-year ASCVD risk ≥15%, if it can be attained safely. This approach is consistent with guidelines from the American College of Cardiology/American Heart Association, which advocate a blood pressure target <130/80 mmHg for all patients, with or without diabetes (38).
Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, acute kidney injury, and electrolyte abnormalities) should also be taken into account (28,39–41). Patients with older age, chronic kidney disease, and frailty have been shown to be at higher risk of adverse effects of intensive blood pressure control (41). In addition, patients with orthostatic hypotension, substantial comorbidity, functional limitations, or polypharmacy may be at high risk of adverse effects, and some patients may prefer higher blood pressure targets to enhance quality of life. Patients with low absolute cardiovascular risk (10-year ASCVD risk <15%) or with a history of adverse effects of intensive blood pressure control or at high risk of such adverse effects should have a higher blood pressure target. In such patients, a blood pressure target of <140/90 mmHg is recommended, if it can be safely attained.