{"id":30461,"date":"2026-06-08T04:47:00","date_gmt":"2026-06-07T20:47:00","guid":{"rendered":"https:\/\/csccm.org.cn\/?p=30461"},"modified":"2026-06-08T05:32:30","modified_gmt":"2026-06-07T21:32:30","slug":"nejm%e4%b8%b4%e5%ba%8a%e5%86%b3%e7%ad%96%ef%bc%9a%e9%ab%98%e8%a1%80%e5%8e%8b%e7%ae%a1%e7%90%86%e7%9a%84%e8%a1%80%e5%8e%8b%e7%9b%ae%e6%a0%87%ef%bc%88%e7%ad%94%e6%a1%882%ef%bc%89","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=30461","title":{"rendered":"[NEJM\u4e34\u5e8a\u51b3\u7b56]\uff1a\u9ad8\u8840\u538b\u7ba1\u7406\u7684\u8840\u538b\u76ee\u6807\uff08\u7b54\u68482\uff09"},"content":{"rendered":"\n

CLINICAL DECISIONS<\/a><\/p>\n\n\n\n

Blood-Pressure Targets in Hypertension Management<\/h1>\n\n\n\n

Christos P. Kotanidis, Paul K. Whelton, Clinton B. Wright<\/h3>\n\n\n\n

N Engl J Med 2026;394:1026-1029<\/h3>\n\n\n\n

DOI: 10.1056\/NEJMclde2505268<\/h3>\n\n\n\n

CASE VIGNETTE<\/h2>\n\n\n\n

A Man with Hypertension<\/p>\n\n\n\n

Christos P. Kotanidis, M.D., D.Phil.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

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\u2013standing 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.<\/p>\n\n\n\n

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%.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

TREATMENT OPTIONS<\/h2>\n\n\n\n

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.<\/p>\n\n\n\n

    \n
  1. Target a systolic blood pressure of less than 120 mm Hg.<\/li>\n\n\n\n
  2. Target a systolic blood pressure of less than 140 mm Hg.<\/li>\n<\/ol>\n\n\n\n

    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?<\/p>\n\n\n\n

    OPTION 2<\/h3>\n\n\n\n

    Target a Systolic Blood Pressure of Less Than 140 mm Hg<\/p>\n\n\n\n

    Clinton B. Wright, M.D.<\/p>\n\n\n\n

    The choice of this patient\u2019s blood-pressure target relates to several health outcomes, including cardiovascular events, death, falls, and dementia. The most recent American College of Cardiology and American Heart Association (ACC\u2013AHA) blood-pressure management guidelines recommend a target of less than 130\/80 mm Hg for older adults who have an assumed 10-year risk of atherosclerotic cardiovascular disease of more than 10%.6<\/a><\/sup>However, the blood pressure of the patient in the vignette is within some other U.S. and international guideline-based targets for older adults, and only Canadian and Australian guidelines currently recommend targeting less than 120 mm Hg for systolic blood pressure. The Systolic Blood Pressure Intervention Trial (SPRINT) was stopped early when intensive blood-pressure therapy was found to reduce the incidence of cardiovascular events and death, but too few participants had blood pressures in this patient\u2019s range at baseline for precise comparisons across treatment groups.7<\/a><\/sup><\/p>\n\n\n\n

    For assessment of antihypertensive therapy in older adults and those at risk, the ACC\u2013AHA guidelines recommend screening for orthostatic hypotension. This recommendation is motivated by the concern that orthostatic hypotension can cause syncopal events and falls but also contributes to longer-term cognitive deficits. Population-based data have associated orthostatic hypotension, and blood-pressure variability in general, with cognitive impairment and dementia.8<\/a><\/sup> This patient did not meet orthostatic hypotension criteria because his systolic blood pressure dropped less than 20 mm Hg when measured from supine to standing; although we have no information on the patient\u2019s diastolic blood pressure and heart-rate changes, autonomic dysfunction is still likely.<\/p>\n\n\n\n

    Therefore, we need to narrow the possibilities to hypovolemia, medication effects, supine hypertension, and baroreflex dysfunction. This patient\u2019s report of early-morning falls and evidence of bruising suggest orthostatic hypotension. Nighttime hypertension \u2014 so-called nondipping \u2014 might contribute, causing pressure natriuresis from decreased proximal tubule sodium resorption and worsening orthostatic hypotension. In addition, ramipril, a renin\u2013angiotensin inhibitor, can exacerbate vasodilatation. Ambulatory blood-pressure monitoring could be informative in this case.<\/p>\n\n\n\n

    Aging causes decreased sensitivity in both parasympathetic (vagal) and sympathetic (noradrenergic) baroreflex axes, and questions should target symptoms suggestive of neurogenic baroreflex failure. Probing for heat intolerance (poor compensatory vasodilatation), postprandial lightheadedness (poor compensation for splanchnic shunting), neck cramping in a \u201ccoat hanger\u201d pattern (inadequate perfusion of tonically activated neck stabilizers), and hyposmia or trouble sleeping (suggesting rapid-eye-movement [REM]\u2013sleep behavior disorder from an occult synucleinopathy) is important. Other causes of falls include cardiac arrhythmias such as atrial fibrillation, and these possibilities should prompt cardiac monitoring.<\/p>\n\n\n\n

    Repeated blood-pressure and heart-rate measurements with the Valsalva maneuver can help discern underlying causes of orthostatic hypotension. Supine positioning for 10 minutes followed by standing, with blood pressure and heart rate measured for at least 3 minutes, is the correct procedure. The Valsalva maneuver should cause an immediate rise in blood pressure owing to increased intrathoracic pressure, followed by a decrease caused by reduced venous return and cardiac filling, resulting in sympathetic noradrenergic disinhibition and compensatory increases in blood pressure and heart rate. In neurogenic failure, a drop in blood pressure is followed by a slow recovery after the Valsalva maneuver and no compensatory increase in heart rate.<\/p>\n\n\n\n

    Some argue that a blood-pressure target of less than 120 mm Hg benefits patients with orthostatic hypotension, and a recent meta-analysis of clinical trials, including SPRINT, supports this idea with numerous caveats, especially that patients with neurogenic orthostatic hypotension were probably underrepresented.4<\/a><\/sup> But, although fewer participants in the intensive blood-pressure group had cognitive impairment or dementia, and participants who underwent magnetic resonance imaging of the head had less white-matter lesion progression, post hoc data have linked blood-pressure variability and hypotensive episodes to cognitive decline, and independent of blood-pressure variability, hypotensive episodes have shown decrements in processing speed, a domain associated with subcortical vascular damage.9<\/a><\/sup><\/p>\n\n\n\n

    In summary, although this older patient who is at an elevated risk for cardiovascular events has blood pressure within the target range according to some guidelines, more data are needed to define blood-pressure targets that minimize complications from orthostatic hypotension. Additional randomized trials involving such high-risk patients are needed before a blood-pressure target of less than 120 mm Hg can be broadly recommended in older adults at risk for overtreatment.<\/p>\n","protected":false},"excerpt":{"rendered":"

    CLINICAL DECISIONS Blood-Pressure Targets in Hypertensi […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[13,18],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30461"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=30461"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30461\/revisions"}],"predecessor-version":[{"id":30463,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30461\/revisions\/30463"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=30461"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=30461"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=30461"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}