What is the optimal BP range for a 70 year old male with Hypertension Atrial Fibrillation and a history of of renal artery stenosis

The evidence for this exact patient is thin, but the best available data points to a systolic target around 130-140 mmHg, not lower.

The most directly relevant study is a 2014 analysis of the AFFIRM trial, which looked at blood pressure and outcomes in 3,947 patients with atrial fibrillation [1]. It found a U-shaped relationship: the lowest risk of death was at a systolic pressure around 140 mmHg and a diastolic around 78 mmHg [1]. Going below 110 mmHg systolic raised the risk of death nearly fourfold (hazard ratio 3.9), and going above 160 mmHg roughly doubled it [1]. This is a post-hoc analysis, not a randomized trial testing targets, so it is suggestive, not definitive.

Your patient's renal artery stenosis adds another layer. A 2017 meta-analysis of nondiabetic patients with chronic kidney disease found that intensive blood pressure control (targets below 130/80) did not slow kidney disease progression compared to standard control [4]. The annual rate of GFR decline was nearly identical between groups, and there was no difference in the risk of end-stage renal disease [4]. A 2019 meta-analysis of 20 trials found that intensive control reduced major cardiovascular events but had no significant effect on all-cause mortality, heart failure, or end-stage renal disease [2]. The benefit on events was concentrated in high-risk patients, not low-risk ones [3].

The evidence does not support pushing this man's systolic pressure below 120 mmHg. The AFFIRM data warns of harm below 110 mmHg [1], and the kidney data shows no renal benefit from aggressive targets [4]. A reasonable target is systolic 130-140 mmHg, with careful monitoring for orthostatic hypotension, especially given his age and the risk of falls from over-treatment [5].

My call: target systolic 130-140 mmHg, not lower. Confidence: moderate, because the evidence comes from post-hoc analyses and meta-analyses, not a trial designed for this exact combination of conditions.