Blood-Pressure Targets in Hypertension Management
Christos P. Kotanidis, Paul K. Whelton, Clinton B. Wright
N Engl J Med 2026;394:1026-1029
DOI: 10.1056/NEJMclde2505268
CASE VIGNETTE
A Man with Hypertension
Christos P. Kotanidis, M.D., D.Phil.
A 75-year-old man comes to your primary care practice for a routine follow-up appointment. His medical history is notable for hypertension that is managed with ramipril and amlodipine. He is a retired architect who lives with his partner. In recent months, he has had increasing difficulty with activities of daily living, such as climbing stairs and walking long distances, primarily because of chronic joint pain, which has led him to reduce his activity levels. He does not smoke and drinks alcohol only socially. He is particularly conscious of his health and keeps a daily blood-pressure diary. In addition to the blood-pressure medications, he takes atorvastatin, at a dose 40 mg daily, and occasionally takes nonsteroidal antiinflammatory drugs to manage his chronic joint discomfort.
On physical examination, his blood pressure is 138/86 mm Hg, and his heart rate is 78 beats per minute. You notice a bruise on his left forearm and right lower leg. He mentions having had a couple of falls when getting out of bed in the morning, although this has occurred only twice in the past 6 months. Heart examination and lung auscultation are normal. You perform a lying–standing blood-pressure measurement, which shows that the systolic blood pressure decreases by 11 mm Hg within 3 minutes after he stands from a supine position.
Laboratory testing shows a total cholesterol level of 200 mg per deciliter (5.2 mmol per liter) and a high-density lipoprotein cholesterol level of 65 mg per deciliter (1.7 mmol per liter). Kidney-function and liver-function tests and a complete blood count are normal. According to his blood-pressure diary, his average systolic blood pressure is 136 mm Hg. You calculate, on the basis of the Framingham risk score, that his 10-year risk of cardiovascular disease is 17.6%.
You must decide whether to intensify the antihypertensive therapy to target a systolic blood pressure of less than 120 mm Hg or to maintain the current therapy, with a systolic blood-pressure target of less than 140 mm Hg.
TREATMENT OPTIONS
Which one of the following approaches would you recommend for this patient? Base your choice on the literature, your own experience, published guidelines, and other information.
- Target a systolic blood pressure of less than 120 mm Hg.
- Target a systolic blood pressure of less than 140 mm Hg.
To aid in your decision making, we asked two experts in the field to summarize the evidence in favor of approaches assigned by the editors. Given your knowledge of the issue and the points made by the experts, which approach would you choose?
