High blood pressure stands as a pervasive health concern globally, affecting billions and contributing significantly to cardiovascular morbidity and mortality. According to the Centers for Disease Control and Prevention (CDC), nearly one in two adults have high blood pressure, and only one-quarter have it under control.
As one of the leading risk factors for heart disease, stroke, kidney failure, and cardiovascular-related death, understanding its complexities and addressing its management are paramount for public health.
This article aims to provide practitioners and patients with insights into the latest guidelines, diagnostic strategies, and therapeutic interventions essential for effectively managing hypertension and reducing associated health risks.
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What Is High Blood Pressure?
Blood pressure is the force exerted by circulating blood against the walls of the arteries. It is expressed as two numbers: systolic and diastolic pressure, measured in millimeters of mercury (mmHg).
The systolic pressure (the first number) indicates the pressure in the arteries when the heart beats, while the diastolic pressure (the second number) represents the pressure when the heart is at rest between beats.
High blood pressure, or hypertension, is blood pressure that is consistently too high. Chronic hypertension damages the walls of blood vessels and contributes to the development of atherosclerosis, the narrowing of blood vessels.
This narrowing is a major risk factor for stroke, heart attack, kidney disease, vision loss, sexual dysfunction, and cognitive impairment.
What Is Considered High Blood Pressure?
The diagnostic criteria for high blood pressure vary by guidelines set by various professional organizations.
In 2014, the Eighth Joint National Committee (JNC 8) published guidelines for managing high blood pressure in adults. These guidelines define hypertension as 140/90 mmHg or higher blood pressure.
In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) released new guidelines for diagnosing and treating high blood pressure. These guidelines lowered the threshold for hypertension to 130/80 mmHg and created the following classification system:
- Normal Blood Pressure: < 120/80 mmHg
- Elevated Blood Pressure: systolic 120-129 mmHg and diastolic < 80 mmHg
- Hypertension Stage 1: systolic 130-139 mmHg or diastolic 80-89 mmHg
- Hypertension Stage 2: systolic > 140 mmHg or diastolic > 90 mmHg
A hypertensive crisis is a medical emergency when blood pressure suddenly increases to 180/120 mmHg or greater.
What Causes High Blood Pressure?
Primary (or essential) hypertension, the most common type, has no identifiable cause and develops gradually over many years, likely due to a combination of risk factors, including:
- Genetics
- Poor diet
- Sedentary lifestyle
- Caffeine and alcohol consumption
- Smoking
- Obesity
- Stress
- Age
- Sleep disorders
Secondary hypertension affects 5-10% of people with high blood pressure and results from an underlying medical condition. It may appear suddenly, cause higher blood pressure levels than primary hypertension, and be resistant to antihypertensive interventions. Causes include:
- Kidney disease
- Hormonal disorders
- Sleep apnea
- The use of certain medications
Symptoms and Diagnosis of High Blood Pressure
Hypertension is often called a "silent killer" because many people remain asymptomatic for many years despite high blood pressure readings. Symptoms of hypertension usually occur only when blood pressure reaches severely high levels (hypertensive crisis) and causes damage to organs.
Symptoms may include:
- Chest pain
- Shortness of breath
- Back pain
- Numbness
- Weakness
- Severe headache
- Changes in vision
- Difficulty speaking
- Confusion
- Dizziness
- Nausea and vomiting
Routine blood pressure monitoring allows for the early detection of hypertension before symptoms and complications develop. Blood pressure can be measured through several methods:
- In-office measurements by healthcare professionals
- Home monitoring using personal blood pressure devices
- Ambulatory blood pressure monitoring, which involves wearing a device that takes periodic blood pressure readings over 24 hours
The diagnosis of hypertension requires at least two elevated blood pressure readings taken on two separate occasions.
Follow these tips to measure blood pressure accurately:
- Empty your bladder before measuring blood pressure
- Rest for five minutes before taking a measurement
- Sit in a chair with your feet flat on the floor and your back supported
- Place the correctly sized cuff on a bare upper arm, ensuring it is level with your heart
- Avoid caffeine, exercise, and smoking for at least 30 minutes before measuring
- Take multiple readings at different times of the day and record the results
Additional Testing and Biomarkers
Additional testing is recommended for all patients with hypertension to evaluate for suspected causes of secondary hypertension, additional cardiovascular risk factors, and organ damage.
The ACC/AHA that all patients with hypertension receive the following initial testing:
- Fasting blood glucose
- Complete blood count (CBC)
- Lipid panel
- Serum creatinine with estimated glomerular filtration rate (eGFR)
- Serum electrolytes (sodium, potassium, and calcium)
- Thyroid-stimulating hormone (TSH)
- Urinalysis
- Electrocardiogram (ECG)
The ACC/AHA recommends the following as optional tests:
- Uric acid
- Urine albumin
- Echocardiogram, if history, physical exam, or ECG indicate structural heart disease
Targeted testing can be ordered to rule out causes of secondary hypertension. This should be guided by patient history and physical exam but could include:
- Cortisol
- Plasma or urinary metanephrines
- Parathyroid hormone (PTH)
- Aldosterone
- Kidney imaging
- Sleep study
Measuring the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) helps healthcare providers estimate an individual's likelihood of developing heart disease or stroke within the next decade. This enables them to tailor preventive measures and treatments based on the patient's specific risk profile.
A risk calculator, such as the ACC ASCVD Risk Calculator, can calculate this risk.
How to Reduce High Blood Pressure
A combination of lifestyle modifications, pharmaceutical antihypertensive medications, and natural supplements can reduce blood pressure.
Lifestyle Changes
Caloric restriction and increased physical activity for weight loss is recommended for overweight individuals. Patients should aim to meet their ideal body weight and expect a reduction in blood pressure of 1 mmHg per kilogram of weight loss. (65)
A heart-healthy diet, such as the DASH or Mediterranean diet, helps manage and eliminate dietary factors contributing to hypertension. Both diets emphasize incorporating nutrient-dense foods and naturally help individuals meet a sodium restriction goal of less than 1,500 mg daily and the recommended daily potassium intake of 3,500-5,000 mg daily.
The DASH diet has been shown to reduce both systolic and diastolic blood pressures by 11/5 mmHg. A meta-analysis concluded that the Mediterranean diet lowers systolic and diastolic blood pressure by 3 and 2 mmHg, respectively. (65)
Aerobic, dynamic resistance, and static isometric resistance exercise have all demonstrated blood pressure-lowering effects. Because of this, the AHA has published the following exercise guidelines for adults to support cardiovascular health:
- Get at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity per week,
- Engage in moderate-to-high intensity muscle-strengthening (resistance exercise) activity at least two days per week.
- Spend less time sitting.
- Be active for at least 300 minutes every week to experience more cardiovascular benefits.
Evidence shows that reducing alcohol consumption correlates to lower blood pressure readings, especially in people who drink more than two drinks per day. Measurable reductions in blood pressure by 5.5/4 mmHg are most evident in people who drink at least six alcoholic beverages daily and reduce their intake by 50%.
In general, the CDC recommends that everyone moderate alcohol intake to no more than two drinks daily for men and one drink daily for women.
Medications
The 2017 ACC/AHA guidelines recommend that antihypertensive medication be prescribed as first-line therapy for patients with:
- Stage 1 hypertension with clinical ASCVD or an estimated 10-year ASCVD risk of > 10%
- Stage 2 hypertension
Antihypertensive medications lower blood pressure by targeting various components of the cardiovascular system to reduce blood volume, relax blood vessels, and lower the heart's workload. First-class medications fall under the following categories:
- Thiazide diuretics
- Calcium channel blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin II receptor blockers (ARB)
Supplements
Dietary supplements can be integrated into a comprehensive antihypertensive treatment plan. Evidence-based blood pressure-lowering herbs and nutrients include:
- Magnesium: 500-1,000 mg daily
- Hibiscus tea: 1 cup three times daily
- Garlic: 600-900 mg aged garlic extract daily
- Coenzyme Q10 (CoQ10): 60-120 mg daily
- Omega-3 fatty acids: 3 grams daily
Long-Term Management and Monitoring
Continuous management and routine follow-ups with healthcare providers enhance adherence to treatment plans, improve health outcomes, and allow for timely adjustments to the therapy as needed.
Antihypertensive interventions typically take several weeks to show significant changes in blood pressure. The timing can vary depending on the severity of hypertension, the methods used to lower it, and comorbid conditions.
The JNC 8 and 2017 ACC/AHA guidelines provide specific blood pressure treatment goals:
- The JNC 8 recommends a target of less than 140/90 mm Hg for most adults under 60 years and those over 60 with diabetes or chronic kidney disease. For adults aged 60 and older without these conditions, the target is less than 150/90 mm Hg.
- The 2017 ACC/AHA guidelines are more stringent, recommending a target of less than 130/80 mm Hg for all adults, regardless of age or comorbid conditions.
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Key Takeaways:
- Diagnosing and managing high blood pressure is one aspect of heart disease, stroke, and kidney failure.
- Adhering to integrative treatment plans encompassing lifestyle modifications, natural supplements, and pharmaceutical medications can help patients achieve significant and lasting improvements in their blood pressure levels.
- Regular follow-ups with healthcare providers ensure adherence to therapy, facilitate timely adjustments and ultimately improve treatment outcomes.
- Embracing a heart-healthy lifestyle complements medical treatments and leads to healthier, longer lives.
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