What Should Your Blood Pressure Be?
Getting blood pressure to target is key to reducing future cardiovascular risk.
“What should my blood pressure be?”
This is one of the most common questions I get as a cardiologist.
The answer is pretty simple, but most people get this wrong, and doing so increases their future risk of heart attack and strokes.
The problem is that high blood pressure is not some obscure risk that only impacts a small percentage of the population.
High blood pressure is the leading cause of preventable death worldwide1.
We do a bad job at preventing and managing high blood pressure.
We need to do better if we want to majorly impact rates of cardiovascular disease worldwide.
Lifestyle measures, including good nutrition, regular exercise, adequate sleep, and appropriate stress management, are the best ways to maintain normal blood pressure throughout life.
But despite close attention to these factors high blood pressure often continues to be an issue.
If necessary, medications should be used to lower blood pressure to target.
The question is, ‘What Target?’.
Historically, consistently achieving a systolic blood pressure of less than 140 mmHg was considered ‘getting to target’.
While this does reduce future risk.
It is not enough.
We need to go lower, and the evidence to support this goal is substantial.
Lifetime Blood Pressure.
Like other risk factors for heart disease, the key is to maintain normal blood pressure for as long as possible.
The problem is when blood pressure is high for too long.
If you consider a 10-year period and compare people with systolic blood pressures of, on average, 142 mmHg and compare them to those with an average blood pressure of 108 mmHg, the difference in future risk is considerable2.
Those in the lower blood pressure group will postpone the onset of cardiovascular disease by over 5 years and extend their lifespan by over 4 years.
Therefore, lifespan AND health span improve.
Do not take this as an indication to lower systolic blood pressure to below 110 mmHg with medications, only that maintaining blood pressure in this range without the need for medications is advantageous.
But What About Targets For Those On Medications?
The answer here is clear.
Maintaining a blood pressure of 120 mmHg has significant benefits.
Here is how much benefit.
If you take people with a systolic blood pressure of >130 mmHg and treat them to 120 mmHg compared to the mid 130’s mmHg, the future risk of major heart events is reduced by 25%3.
And this is only over a 3-year time frame.
Those in the lower blood pressure group also had a 27% reduction in the risk of dying from any cause, also known as all-cause mortality.
For those who had treatment started in their 50s, the benefit was estimated to add close to 3 additional years of life.
These are huge changes.
This study, known as the SPRINT trial, was criticised for a variety of reasons, but subsequent similar studies have shown very similar results.
The STEP trial looked at a similar group of people with high blood pressure and targeted similarly low blood pressure to the SPRINT trial, and the benefits were almost identical.
A 26% reduction in future heart events with lower target blood pressure.
What was interesting about this trial was that when you only looked at those who achieved the lower blood pressures (Some didn’t), the reduction in future heart events was now 39%4.
Multiple other studies have come to the same conclusion.
Routinely hitting systolic blood pressures of at least 120 mmHg significantly reduces the future risk of heart events compared to keeping blood pressures in the 130’s or above.
Some older patients or those who are intolerant to a more aggressive approach will not be suitable candidates, but for most people, the target systolic blood pressure for someone on medications is 120 mmHg.
Some patients may benefit from an even lower systolic blood pressure, but you need to be careful about lowering blood pressure too much, and this needs to be individualised with your doctor5.
What Medication To Get To Target?
There is a range of blood pressure-lowering medications available.
Most people with high blood pressure will be treated with an ACE inhibitor, ARB, calcium channel blocker or a diuretic.
There are others also.
But in my view, what matters most is not the choice of medication but that the target blood pressure is achieved.
Outcome over process, in my view, works best here.
When examining patients with high blood pressure over 13 years and the choice of blood pressure medication was examined, there were no clear differences6.
Just get to target.
Don’t worry so much about how you get to target.
If you maintain normal blood pressure for as long as possible in life without needing medications, you will substantially reduce your future risk of heart disease.
But if you do need to use medications to get to lower your blood pressure, make sure you are getting to the right target.
And for now that target is 120 mmHg.
As long as you are hitting the low 120’s systolic range, we can safely say you are doing better than those sitting in the mid-130s who are frequently told that this blood pressure range is ‘OK’.
But in my view, the data is clear.
OK blood pressure is not OK.
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The global epidemiology of hypertension. Nat Rev Nephrol. 2020 Apr;16(4):223-237.
Association of Cumulative Systolic Blood Pressure With Long-Term Risk of Cardiovascular Disease and Healthy Longevity. Hypertension. 2021;77:347–356
A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26;373(22):2103-16.
Yue Deng and others, On behalf of the STEP Study Group, Achieved systolic blood pressure and cardiovascular outcomes in 60–80-year-old patients: the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial, European Journal of Preventive Cardiology, 2023;, zwad142,
Optimal Antihypertensive Systolic Blood Pressure: A Systematic Review and Meta-Analysis. Hypertension. 2024 Nov;81(11):2329-2339.
Mortality and Morbidity Among Individuals With Hypertension Receiving a Diuretic, ACE Inhibitor, or Calcium Channel Blocker: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2023;6(12):e2344998.
Many thanks Doctor for your continued education on heart health! One thing I noticed when my doctor asked me to take high blood pressure medicine (all three types you mentioned!), my A1C also started to climb. I have read there is a correlation of high blood pressure medicine and higher blood sugar - so May I ask if you have seen that and what can I do about it! Many thanks!!