BIHS 2025 Position Statement on BP Treatment Thresholds and Targets
BIHS 2025 Position Statement on BP Treatment Thresholds and Targets
Source: Hypertension News, ISH – December 2025
Key Concepts & Updates
1. Shift Toward More Aggressive BP Treatment
• The British and Irish Hypertension Society (BIHS) is the latest to call for lower treatment thresholds and tighter BP targets.
• New treatment threshold: ≥135/85 mmHg for diagnosing hypertension (regardless of BP measurement method).
• New treatment target: <130/80 mmHg for all hypertensive patients, irrespective of risk category or measurement method.
• This marks a significant shift aligning with a global trend toward earlier and more intensive BP management.
2. Evidence Supporting Lower BP Targets
SPRINT trial (2015)
• Demonstrated that targeting SBP <120 mmHg significantly reduces major cardiovascular events across adults ≥50 years.
• Compared to traditional targets (140/90 mmHg), intensive control had a clear benefit.
New Chinese trials confirming benefits of lower SBP targets:
STEP Trial (2021)
• 8,511 patients aged 60–80 yrs.
• Compared SBP target 110–130 mmHg vs. 130–150 mmHg.
• Intensive treatment reduced major CV events (HR 0.74, CI 0.60–0.92).
ESPRIT Trial (2024)
• 11,255 adults ≥50 yrs with high CV risk (diabetes, stroke history).
• Compared SBP <120 mmHg vs. <140 mmHg.
• Intensive control reduced MACE (HR 0.88, CI 0.78–0.99) over 3.4 years.
BPROAD Trial (2024–2025)
• 12,821 adults ≥50 yrs with type 2 diabetes.
• Compared SBP <120 mmHg vs. <140 mmHg.
• Intensive target significantly reduced MACE (HR 0.79, CI 0.69–0.90) across ~5 years.
3. Rationale for Lower Diagnosis Threshold (≥135/85 mmHg)
• Applies regardless of office, home, or ambulatory BP method.
• Similar to the 2017 ACC/AHA reclassification, which instantly labeled 13% more US adults as hypertensive (~30 million individuals).
• Newly reclassified patients tend to be younger (<45 yrs).
• Expected consequences:
• Higher healthcare utilization
• More medication prescriptions
• Increased risk of adverse effects in low-risk populations
Measurement consistency concerns
• Studies show modest reproducibility between office, home, and ambulatory BP.
• Variability decreases at lower BP ranges (SBP 120s).
• Cost-effectiveness models indicate that intensive targets remain cost-effective even with measurement errors.
4. One Target for All: Simplification or Overtreatment?
Benefits of unified thresholds/targets
• Simplifies clinical practice.
• Reduces therapeutic inertia.
• Aligns with trial evidence showing:
• “Lower is better” across subgroups:
• Prior CVD
• Diabetes
• Stroke
• CKD
• Elderly
Potential harms
• Clinical trials mainly included adults >50 yrs at moderate/high risk.
• Applying them to young adults (e.g., 26-year-old with BP 138/85 and ~2% 10-yr CV risk) may lead to:
• Questionable benefit
• 10 years of medication to reduce absolute risk from 2% → 1.4%
• Raises ethical questions of overtreatment in low-risk individuals.
5. Global Trend Toward Aggressive Management
• BIHS recommendations reflect broader global movement toward:
• Earlier treatment
• Lower BP targets
• Streamlined decision-making
• Potential population-level benefits:
• Lives saved
• Reduced healthcare costs
• But need to balance simplification with personalized care, especially using modern decision-support tools.
6. Table of BP Targets Across Global Guidelines (Page 5)
• The 2025 BIHS recommendations endorse a unified blood pressure target of <130/80 mmHg for all adults with hypertension.
• The ACC/AHA (2017 and 2025 updates) similarly recommend achieving <130/80 mmHg regardless of baseline cardiovascular risk.
• The 2025 Hypertension Canada guidelines focus primarily on systolic blood pressure, recommending a target of <130 mmHg, without specifying a diastolic BP target.
• The ESC/EAC 2024 guidelines advise that the optimal blood pressure range for most individuals is SBP 120–129 mmHg and DBP 70–79 mmHg.
• They also note that <120/70 mmHg represents an “optimal research target” achieved under controlled trial conditions, not necessarily a universal clinical goal.
• The ESH 2023 guidelines initially recommend reducing BP to <140/80 mmHg for most adults.
• If well tolerated, clinicians should aim for <130/80 mmHg in adults up to approximately 79 years of age.
• Systolic BP 120–129 mmHg may be considered for some patients but not below 120 mmHg.
• The ISH 2020 guidelines recommend a target of <130/80 mmHg for adults younger than 65 years, if tolerated.
• For older adults or those with frailty, less stringent targets are advised, typically <140/90 mmHg, or <140/80 mmHg for selected elderly patients.
• All guideline bodies emphasize that targets should be individualized upward when lower BP levels are not tolerated—especially in frail elderly patients—to achieve the lowest safe and clinically reasonable blood pressure.
Guidelines advise higher/lower targets if needed for frailty or intolerance.
7. References Included in the Article
• Eight major references listed, including SPRINT (2015), STEP (2021), ESPRIT (2024), BPROAD (2025), ACC/AHA 2017 guidelines, and meta-analyses on BP measurement reliability.
8. ISH Membership Promotion (Page 6)
• Invitation to join the International Society of Hypertension with membership categories:
• Member
• Associate Member
• Trainee
• Website: https://ish-world.com/join-ish/
(Taken from Hypertension News – December 2025, International Society of Hypertension)