Senior Medical Advisor · Last reviewed January 2025
Hypertension — persistently elevated blood pressure — affects approximately 116 million American adults (47% of the adult population), according to the American Heart Association. Despite the availability of effective treatments, only about 1 in 4 adults with hypertension have their condition adequately controlled. Hypertension is the leading modifiable risk factor for cardiovascular disease, stroke, and kidney failure.
Blood Pressure Classifications
The 2017 ACC/AHA hypertension guidelines classify blood pressure as follows:
- Normal: Systolic <120 mmHg AND diastolic <80 mmHg
- Elevated: Systolic 120–129 AND diastolic <80
- Stage 1 Hypertension: Systolic 130–139 OR diastolic 80–89
- Stage 2 Hypertension: Systolic ≥140 OR diastolic ≥90
- Hypertensive Crisis: Systolic >180 and/or diastolic >120
Lifestyle Modifications
Lifestyle modification is the foundation of hypertension management at all stages. The DASH diet (Dietary Approaches to Stop Hypertension) — rich in fruits, vegetables, low-fat dairy, and reduced sodium — can reduce systolic blood pressure by 8–14 mmHg. Sodium restriction to less than 2,300 mg/day (ideally less than 1,500 mg/day) reduces SBP by 2–8 mmHg. Aerobic exercise (150 minutes/week of moderate intensity) reduces SBP by 4–9 mmHg. Weight loss, alcohol reduction, and smoking cessation each contribute additional benefit.
Pharmacotherapy
When lifestyle modification is insufficient, pharmacotherapy is indicated. First-line agents include thiazide diuretics (chlorthalidone, hydrochlorothiazide), calcium channel blockers (amlodipine), ACE inhibitors (lisinopril), and ARBs (losartan). ACE inhibitors and ARBs are preferred in patients with diabetes or chronic kidney disease due to renoprotective effects. Beta-blockers are first-line for hypertension with co-occurring heart failure with reduced ejection fraction or after myocardial infarction. Most patients with Stage 2 hypertension require combination therapy.
Blood Pressure and Mental Health
Chronic stress, anxiety disorders, and depression are all associated with elevated blood pressure. The behavioral mechanisms (reduced physical activity, poor dietary choices, increased alcohol use) and physiological mechanisms (HPA axis activation, sympathetic nervous system upregulation) are well-characterized. Treating co-occurring mental health conditions can contribute to blood pressure improvement beyond pharmacotherapy alone.
Related: Heart Disease · Diabetes · Preventive Care