By age 40, more than half of Americans have high blood pressure, but many are unaware of it. Hypertension has long been known as the silent killer. When it's left untreated it can be deadly. And it's considered a silent threat since most people have no symptoms. You can't feel the pressure in your blood vessels increasing.
New recommendations from the American Heart Association aim for early treatment, including lifestyle changes and medications, once systolic blood pressure rises above 130/80 mm Hg, (which stands for millimeters of mercury, a measure of pressure). Experts say it's clear that the sooner you take action, the more you can protect yourself.
Hypertension is a leading cause of heart disease, which is the #1 cause of death of both men and women in the U.S. High blood pressure also increases the risk of kidney disease and dementia. And, research shows that hypertension can lead to damage in small blood vessels in the brain, which is linked to cognitive decline.
"There's a really enormous preventive health opportunity in treating hypertension earlier," says Dr. Jordana Cohen, a nephrologist and hypertension specialist at the University of Pennsylvania. She says millions of adults in the U.S. could benefit from medications and lifestyle changes.
"If you catch it early, and treat it early, you can end up with many more years of healthy life expectancy," Cohen says, pointing to a reduced risk of heart attacks, strokes, kidney damage and dementia.
The new guidelines point to decades old advice about the benefits of a low-sodium diet, which can be challenging to follow, given more than half the calories consumed in the U.S. come from ultra-processed foods, which tend to be high in salt.
The new guidelines also emphasize lifestyle strategies including exercise, limiting alcohol consumption, and stress reduction in the form of meditation, yoga, or deep breathing. For people with systolic blood pressure ( the upper number) in the 130s, the recommendation is to start with these diet and lifestyle-related changes, then move to medication if blood pressure doesn't improve.
For people who hit the risky range of a systolic blood pressure of 140 or higher, which is considered stage 2 hypertension, evidence shows starting on high blood pressure medications is beneficial.
"For all people with a blood pressure over 140/ 90, mm Hg, we recommend beginning with two medications," Dr. Dan Jones, chair of the guideline writing committee at the Heart Association, told NPR. Research shows one medication alone is often not enough to lower blood pressure to the optimal range, he says.
Jones says even when people are aware they have hypertension, more than half don't manage to lower it to the normal range, which is 120 /80 mm Hg or lower. Some of the challenges include side effects of the medications and individual differences in how well the medication works, as well an unwillingness to take medicines among some people. In addition, some people struggle the everyday hurdles of making lifestyle changes. Jones points out that healthcare providers also use a risk calculator to estimate a person's individual risk of heart disease, as part of a treatment plan.
When George Solomon was told about the risks of high blood pressure he was hesitant to take medications. "I felt fine," he says. Then, at age 63, he had a stroke.
Solomon had retired from a career in law enforcement, and was settling into a new routine, making time for exercise and hobbies, such as splitting wood on his farm. One day in the spring of 2023, he started to feel off.
" I went upstairs to watch TV, and when I sat down in the chair, I couldn't get back up. I had a sensation that came up across my back," he recalls and he lost feeling in his arm and leg. An ambulance took him to Duke University Hospital, near his home, where he underwent treatment and rehab for a stroke.
He estimates that he's now about 80% recovered, and back to exercising and working on his farm. He realizes now that he needs healthy lifestyle habits and medications to prevent another stroke.
" I feel I'm on the right path ," he says. He's lost weight and he's doing more cardio and strength training. He's sharing his story in hopes it encourages others to take action.
Medications: what's out there, what's coming
There are several types of medications used to treat hypertension. They include diuretics that help the body get rid of extra salt and water, ACE inhibitors that help block the production of a hormone called angiotensin II, and help relax the blood vessels and calcium channel blockers that slow down the movement of calcium into cells, which can help lower pressure.
But many people with hypertension don't get enough reduction with current medications, and University of Pennsylvania's Cohen says there's a lot of interest in a new class of medication that works by targeting the hormone aldosterone, which helps regulate fluid and sodium in the body. Too much of the hormone is one cause of high blood pressure. The drug is not yet on the market, but new study results could pave the way for a new treatment option.
"In hypertension, we haven't seen anything new that's effective since the nineties," Cohen says. So another tool in the toolkit for treatment could be beneficial, she says.
A study published in the New England Journal of Medicine found the aldosterone blocking drug, known as baxdrostat, was effective in lowering blood pressure in many people who have difficulty controlling their hypertension.
The study included about 800 people who, despite taking two or three medications, still had not lowered their blood pressure to the normal range. "What we saw is that after 12 weeks of treatment, there was about a ten point improvement in blood pressure in the patients treated with baxdrostat, over the placebo effect, Dr. Jennifer Brown, a cardiologist at Brigham and Women's Hospital, who is one of the researchers behind the study, told NPR. The study was sponsored by drugmaker Astra Zeneca, which plans to share its data with regulatory authorities by the end of the year.
A 10 point drop in systolic blood pressure is linked to about a 20% reduction in the risk of heart attacks and strokes, and also a decreased risk of dementia.
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