Blood Pressure Management

Target Blood Pressure Ranges

• For the general adult population, the target blood pressure is <140/90 mmHg, with a more intensive target of <130/80 mmHg for those with diabetes, chronic kidney disease, coronary artery disease, and heart failure, as recommended by the American College of Cardiology 1, 2
• For elderly patients (≥65 years), the target blood pressure is 130-139/70-79 mmHg, while for very elderly patients (≥80 years), the target is <150/90 mmHg 1, 2, 3
• For patients with moderate-to-severe chronic kidney disease (CKD) and eGFR >30 mL/min/1.73m², the systolic target is 120-129 mmHg, and for those with CKD and albuminuria, ACE inhibitors or ARBs are recommended by the European Heart Journal 2
• For diabetic patients, the target blood pressure is <130/80 mmHg, with a systolic target of 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg, as recommended by the American College of Cardiology 1, 2
• For patients with heart failure with reduced ejection fraction (HFrEF), treatment should include ACE inhibitors/ARBs, beta-blockers, and diuretics/MRAs as needed, while for those with heart failure with preserved ejection fraction (HFpEF), SGLT2 inhibitors are recommended by the European Heart Journal 2
• For patients with a history of stroke or TIA and confirmed BP ≥130/80 mmHg, the target systolic blood pressure is 120-129 mmHg 2

Pharmacological Interventions

• ACE inhibitors, such as lisinopril, enalapril, and ramipril, are recommended as first-line therapy for CKD stage 3 patients, particularly beneficial for those with albuminuria, by the American College of Cardiology 4, 5, 6
• ARBs, such as losartan, valsartan, and irbesartan, are a reasonable alternative if ACE inhibitors are not tolerated, with similar efficacy to ACE inhibitors in slowing kidney disease progression 6, 4, 5
• Thiazide diuretics, such as chlorthalidone, are effective in mild-to-moderate CKD, while loop diuretics, such as furosemide and torsemide, are preferred in symptomatic heart failure and moderate-to-severe CKD (GFR <30 mL/min) 6, 7, 8
• CCBs, such as amlodipine and felodipine, can be added for additional BP control, particularly beneficial after kidney transplantation, but non-dihydropyridine CCBs should be avoided in HFrEF 6, 8, 7
• Beta-blockers, such as metoprolol succinate, carvedilol, and bisoprolol, are beneficial in patients with CKD and heart failure, but beta-blockers with intrinsic sympathomimetic activity should be avoided 6, 9, 8
• SGLT2 inhibitors, such as dapagliflozin and empagliflozin, are recommended for patients with HFrEF to reduce hospitalization and cardiovascular death, with benefits extending to patients with CKD stages 3 and 4 (eGFR >20 mL/min/1.73m²) 10
• Aldosterone antagonists, such as spironolactone and eplerenone, are beneficial in heart failure with reduced ejection fraction (HFrEF) but require careful monitoring for hyperkalemia, especially in advanced CKD 8

Monitoring and Follow-up

• The target BP for adults with hypertension and CKD is <130/80 mmHg, with monitoring of serum creatinine and potassium within 2-4 weeks of initiation or dose increase of ACE inhibitors or ARBs, and follow-up every 6-8 weeks until BP goal is safely achieved, then every 3-6 months, as recommended by the American College of Cardiology 6, 4, 5, 11, 12
• The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guideline suggests a systolic BP target of <120 mmHg when standardized measurement is used, and for patients with both CKD and CHF, a target of <130/80 mmHg is generally recommended, but less intensive targets may be considered for elderly or frail patients to avoid falls and hypotension 12, 7, 13, 14
• Monitoring for hyperkalemia, acute decline in GFR, and angioedema is recommended, and dual RAAS blockade should be avoided as it increases risk of hyperkalemia and acute kidney injury, with careful management of volume status and consideration of sodium restriction (<2g sodium per day) as an adjunct to medication therapy 11, 12, 7