[Which blood pressure target for the frail older patient?]

Recent guidelines, including the ESC, have moved towards lower targets (<140 mmHg, 130 if tolerated systolic, < 80 mmHg diastolic) for antihypertensive treatment in older adults. The evidence for clinically relevant benefit against limited risk of side effects applies to relatively fit older adults, representing less than 30 % of older patients in clinical practice. We discuss that formal evidence of treatment benefit for frail older adults is absent, although there is limited evidence that this benefit is similar for frail and non-frail participants in clinical trials (e.g. SPRINT). On the other hand, we discuss that the evidence for harm associated with antihypertensive treatment in frail older adults is weak when critically appraised. This applies to the risk of cerebral hypoperfusion, orthostatic hypotension, coronary hypoperfusion, and renal hypoperfusion. The frequently cited J-curve reflects patient characteristics, but is not evidence of harm induced by treatment-induced blood pressure lowering. In this context of absent solid evidence for both benefit and harm, we provide practical treatment advice for hypertension in frail older adults.