Life's Essential 8™ - Blood Pressure

My blood pressure is usually 130-135/80-85 - do I really have hypertension or is this normal?

Yes, this is Stage 1 hypertension by current definition (≥130/80) - not "normal" but not immediately dangerous. Whether you need medication depends on your overall CV risk. Context of 2017 guideline change: Previously, hypertension defined as ≥140/90. 2017 ACC/AHA lowered threshold to ≥130/80 based on evidence showing: (1) CV risk increases continuously above 120/80 (no magic threshold), (2) Treating Stage 1 HTN in high-risk patients (SPRINT trial) → ↓ CV events 25%. Does NOT mean everyone 130-139/80-89 needs medication immediately. Your situation - 130-135/80-85 = Stage 1 HTN. Management depends on CV risk: If HIGH CV risk (prior MI/stroke, diabetes, 10-year ASCVD risk ≥10%, CKD): YES, medication indicated (in addition to lifestyle). Evidence shows benefit treating at these levels if high risk. If LOW-MODERATE CV risk (young, no other risk factors, 10-year ASCVD risk <10%): Lifestyle modification first (DASH diet, weight loss if overweight, exercise, sodium reduction). Recheck 3-6 months. If BP ↓ <130/80 with lifestyle → continue monitoring. If BP remains 130-139/80-89 despite lifestyle → consider medication. If BP ↑ ≥140/90 → medication indicated. Why treat 130-139 at all? Even this "mild" elevation over years → ↑ LVH, arterial stiffness, target organ damage. Earlier intervention prevents progression, reduces lifetime CV risk. Easier to control now than waiting until BP ≥160 with established damage. Practical approach: (1) Calculate your ASCVD risk (tools.acc.org), (2) Optimize lifestyle aggressively (3-6 months trial), (3) If high risk OR lifestyle fails → start medication (single agent, usually thiazide or ACE-I/ARB or CCB), (4) Regular monitoring, adjust as needed. Don't dismiss 130-135/80-85 as "borderline" or "not a big deal" - it IS hypertension, DOES increase CV risk, and SHOULD be addressed (lifestyle at minimum, medication if high risk).

I'm on medication and my BP is controlled - can I stop taking it, or do I need it forever?

Most people with hypertension need lifelong medication - stopping typically results in BP returning to elevated levels within weeks-months. Why hypertension usually requires lifelong treatment: (1) Primary (essential) HTN = chronic condition without cure. Medications control BP but don't "fix" underlying cause (genetic predisposition, vascular changes, etc.). (2) Stopping medication → BP returns: Studies show 50-70% people who stop antihypertensives (even after years of control) → BP ↑ to hypertensive range within 6-12 months. (3) Structural changes irreversible: Years of HTN → LVH, arterial stiffness, kidney damage - these don't fully reverse with treatment. BP control prevents further damage but doesn't restore normal physiology. Exceptions (when might discontinue): (1) Secondary HTN: If underlying cause identified and treated (e.g., removed aldosterone-secreting adenoma, revascularized renal artery stenosis, treated sleep apnea) → HTN may resolve. (2) Substantial lifestyle changes: If lost 20-30 lbs, adopted DASH diet, exercising regularly, stopped excess alcohol → BP may normalize off meds. BUT must sustain lifestyle (regain weight → BP ↑ again). Trial off medication ONLY with close monitoring. (3) Medication-induced HTN: If BP elevated due to NSAIDs, steroids, or other drugs, stopping culprit → HTN resolves. (4) Overtreatment: If BP now consistently <110/70 (symptomatic hypotension - dizziness, fatigue) → may cautiously reduce medications under supervision. Should you try stopping? Generally NOT recommended if: (1) BP only controlled WITH medication (off meds → ↑), (2) History CVD (prior MI, stroke), (3) Target organ damage (LVH, CKD, retinopathy), (4) No major lifestyle changes. Could consider trial off medication if: (1) Lifestyle modifications dramatic (30+ lbs weight loss, perfect DASH adherence, exercise 300 min/week), (2) BP on treatment <120/80 consistently, (3) No CVD or target organ damage, (4) Willing/able to monitor BP closely (daily home monitoring × 4 weeks after stopping). How to stop (if attempting): (1) Discuss with doctor (don't stop on your own), (2) Taper gradually (especially beta-blockers, clonidine - abrupt stop → rebound HTN), (3) Monitor BP daily × 4 weeks, then weekly × 3 months, (4) If BP ↑ ≥130/80 on multiple readings → restart medication. Reality: Most people need lifelong medication. Think of HTN like diabetes - chronic condition requiring ongoing management. Not "failure" to need medication - it's appropriate treatment preventing MI, stroke, HF, death. Better to take 1 pill daily than risk devastating CV event.

Does stress really cause high blood pressure, or is that a myth?

Acute stress DOES cause temporary BP elevation ("white coat" phenomenon), but chronic stress as CAUSE of sustained hypertension is less clear - likely contributes but not sole cause. Acute stress effects (well-documented): (1) Fight-or-flight response: Stress → sympathetic nervous system activation → ↑ adrenaline/noradrenaline → ↑ heart rate, ↑ cardiac contractility, vasoconstriction → BP ↑ 10-30 mmHg acutely. (2) Resolves when stressor removed (minutes to hours). (3) Examples: White coat hypertension (anxiety in medical setting), public speaking, acute life stressors (accident, argument, deadline). Chronic stress and sustained hypertension (complex, debated): Observational associations: Job strain (high demand, low control), financial stress, caregiving burden, discrimination, low socioeconomic status → associated ↑ HTN prevalence. Proposed mechanisms: (1) Sustained sympathetic activation: Chronic stress → ↑ baseline catecholamines, cortisol → ↑ BP. BUT usually modest effect (2-5 mmHg), not enough alone to cause HTN. (2) Behavioral pathways (indirect): Stress → poor coping behaviors (↑ alcohol, ↑ smoking, ↑ junk food, ↓ exercise, poor sleep) → obesity, metabolic syndrome → HTN. Stress may be triggering factor for unhealthy lifestyle. (3) Vascular effects: Chronic inflammation, endothelial dysfunction with stress. Evidence limitations: (1) Difficult to prove causality: Can't randomize people to "chronic stress" vs "no stress" (ethical, impractical). Observational studies have confounding. (2) Stress interventions (meditation, yoga, relaxation) → modest BP ↓: Meta-analyses show 2-5 mmHg reduction - beneficial but not curative. Suggests stress contributes but not primary driver. (3) Most hypertension multifactorial: Genetics (30-50% heritability) + diet (sodium) + obesity + aging + stress. Rarely one single cause. Clinical relevance: (1) Stress management DOES help (modestly) - mind-body practices, therapy, stress reduction valuable adjuncts. Worth pursuing for overall wellbeing even if BP effect modest. (2) NOT sufficient alone: "Just relax and your BP will normalize" = overly simplistic. If BP 160/100, meditation won't bring it to 120/80. Need lifestyle (diet, exercise, weight) + often medication. (3) Address behavioral pathways: If stress → poor health behaviors, addressing those (quit smoking, improve diet, increase exercise) probably more impactful than stress itself. Bottom line: Acute stress temporarily ↑ BP (well-established). Chronic stress likely contributes to sustained HTN (modest effect, primarily via behavioral pathways), but not sole cause. Stress management beneficial adjunct but can't replace lifestyle modification + medication when indicated. Don't blame yourself ("my stress caused this") - HTN multifactorial. But do address stress constructively.

My systolic BP is high (145) but diastolic is normal (75) - is that a problem?

YES - isolated systolic hypertension (ISH) is common (especially older adults), carries same CV risk as combined systolic + diastolic HTN, and should be treated. What is isolated systolic hypertension? Systolic ≥130-140 mmHg AND diastolic <80-90 mmHg (widened pulse pressure = systolic - diastolic). Prevalence: ↑ With age - rare <50 years, affects 15% age 50-59, 25% age 60-69, >50% age ≥80. Why ISH occurs (especially older adults): (1) Arterial stiffening (arteriosclerosis): With age, aorta/large arteries lose elasticity (collagen replaces elastin). Stiff arteries can't expand during systole → ↑ systolic pressure. (2) ↓ Diastolic pressure: Stiff arteries collapse more completely during diastole → ↓ diastolic (wide pulse pressure). (3) Other contributors: Atherosclerosis, chronic HTN (even if previously combined, diastolic may "normalize" with stiffening). CV risk: Systolic BP more predictive CV events than diastolic (especially after age 50). ISH → ↑ stroke, MI, HF, CKD - SAME risk as combined HTN. NOT benign. Widened pulse pressure itself = independent risk factor (reflects arterial stiffness). Should it be treated? ABSOLUTELY YES. Evidence: SHEP trial (Systolic Hypertension in Elderly Program): Adults ≥60 years with ISH (systolic ≥160, diastolic <90), treated with diuretic ± beta-blocker vs placebo. Result: Treatment → ↓ 36% stroke, ↓ 27% coronary events, ↓ 32% HF. Clear benefit treating ISH. Treatment approach: (1) Lifestyle: Same as combined HTN (DASH, weight loss, exercise, sodium reduction). (2) Medications: Start if systolic ≥140 (or ≥130 if high CV risk). Thiazide diuretics or CCBs preferred for ISH (most effective lowering systolic). ACE-I/ARBs also effective. (3) Goal: Systolic <130 mmHg (or <140 if older/frail). Diastolic usually stays normal or even ↓ slightly with treatment (acceptable if >60-70 mmHg). (4) Caution: If diastolic <60-70 mmHg (very low) + coronary disease → risk ↓ coronary perfusion during diastole (coronary arteries fill during diastole). Balance: Lower systolic without excessively lowering diastolic. May require careful medication selection/dosing. Your case (145/75): Systolic 145 = Stage 2 HTN (≥140). Diastolic 75 = normal. Pulse pressure 70 mmHg (widened - normal ~40-50). This IS hypertension, DOES increase CV risk, SHOULD be treated. Lifestyle + medication (likely thiazide or CCB) to bring systolic <130. Don't ignore just because diastolic normal. Message: Systolic BP matters MORE than diastolic (especially after age 50). Isolated systolic HTN = real hypertension, real risk, requires treatment. Benefits proven.

I feel fine - no symptoms at all. Are you sure I really have hypertension and need treatment?

YES - hypertension is called "the silent killer" precisely because most people feel completely fine until serious complications occur. Absence of symptoms does NOT mean absence of harm. Why HTN causes no symptoms (usually): (1) Gradual onset: BP rises slowly over years-decades. Body adapts to higher pressures - you don't "feel" the difference between 120/80 vs 140/90 day-to-day. (2) No pain receptors in arteries: Arteries don't have nerves that sense pressure. Vascular damage accumulates silently. (3) Symptoms appear LATE: When target organ damage severe: Heart: Chest pain (angina), shortness of breath (heart failure) - but requires years of damage, Brain: Stroke symptoms (weakness, speech difficulty), severe headache (hypertensive crisis) - but usually after prolonged uncontrolled HTN, Kidneys: Edema, fatigue (CKD) - but only when GFR <30-40% (significant damage), Eyes: Vision changes (hypertensive retinopathy) - but requires very high BP or long duration. Common misconception: "I feel great, so my BP can't be that bad." Reality: You can have BP 160/100 and feel COMPLETELY NORMAL - meanwhile arteries, heart, brain, kidneys being damaged silently. Studies documenting asymptomatic damage: Adults with untreated HTN (no symptoms): 30-50% already have LVH (echocardiogram), 20-30% have retinopathy (eye exam), 10-20% have microalbuminuria (early kidney damage), Accelerated atherosclerosis (carotid IMT, coronary calcium). All ASYMPTOMATIC but progressing toward MI, stroke, HF. What about people who say "I FEEL different when my BP is high"? Small minority (~10-20%) report headaches, dizziness, flushing with very high BP (>180/110). Most don't feel anything even at these levels. Severe hypertensive crisis (>180/120 + organ damage) CAN cause symptoms: Severe headache, vision changes, chest pain, shortness of breath, nosebleeds (rare), nausea → MEDICAL EMERGENCY. But routine HTN (140-160/90-100) = no symptoms. Why treat if asymptomatic? Prevent future events: Treating HTN → ↓ 40% stroke, ↓ 25% MI, ↓ 50% heart failure. These are devastating, often fatal/disabling events. Would you rather: (1) Take 1 pill daily, feel fine (because you already feel fine), prevent MI/stroke, OR (2) Take no pills, feel fine (same), have MI/stroke in 5-10 years? Analogy: "I don't wear seatbelt - never been in accident, feel fine without it. Why bother?" Seatbelt doesn't make you feel different day-to-day, but critical when accident happens. HTN treatment similar - prevents future catastrophe you can't feel coming. Treatment doesn't make you feel better (because you weren't feeling bad), but prevents you from feeling MUCH worse later. Message: Asymptomatic ≠ harmless. HTN = silent killer - damage accumulating even when you feel great. By time symptoms appear, irreversible complications often occurred. Treat based on BP numbers and CV risk, NOT symptoms. Prevention > reaction after damage done.