BACKGROUND: With the rise in older population globally, the optimal blood pressure (BP) target for antihypertensive therapy in those aged 60 and above remains to be evaluated in the real-world practice. This study evaluated the effectiveness and safety of standard versus lower BP targets in old (aged 60-79) and very old (aged ≥80) patients with hypertension in real-world clinical settings. METHODS: We emulated a target trial using electronic medical records from the Hong Kong Hospital Authority, including patients aged 60 years or above with a diagnosis of hypertension, uncontrolled BP and records of antihypertensives adjustments from 2008 to 2013. Patients were first categorized into 3 age groups (60-69, 70-79, ≥ 80) and then assigned to BP targets of either 130-140/80-90 mmHg or below 130/80 mmHg. Outcomes included major cardiovascular disease (CVD), end-stage renal disease, all-cause mortality and major adverse events related to antihypertensive treatment. RESULTS: Of 132 430 eligible patients identified, 52 553, 28 661 and 7106 patients aged 60-69, 70-79 and ≥ 80 years had BP targets of 130-140/80-90 mmHg, respectively; 11 148, 5636 and 1203 of patients in the same age groups had targets below 130/80 mmHg. Lower BP target was associated with reduced overall CVD and all-cause mortality: aged 60-69 years (CVD HR: 0.91 [95% CI, 0.85-0.96]; all-cause mortality: 0.89 [0.81-0.98]), aged 70-79 years (CVD: 0.87 [0.82-0.93]; all-cause mortality: 0.84 [0.78-0.91]), and aged≥80 years (CVD: 0.77 [0.69-0.86]; all-cause mortality: 0.80 [0.72-0.89]). No significant increase in major adverse events was observed in any age group. Results were consistent across all subgroups. CONCLUSION: Lowering BP of below 130/80 mmHg in old and very old patients was associated with better cardiovascular and mortality outcomes without increased adverse events. These findings suggest that a lower BP target may be beneficial and safe for older patients with hypertension.