Why High Blood Pressure Treatment Needs New Approaches

Author: Wake Forest Baptist Medical Center
Published: 14 Dec 2014 - Updated: 5 Oct 2026
Publication Type: Reports & Proceedings

Table of Contents:
Synopsis - Definition - Overview - FAQs - Insights, Updates - Related Content

Synopsis

This report covers research from Wake Forest Baptist Medical Center that challenges two long-standing assumptions about high blood pressure: that the condition works the same way in women and men, and that pushing readings as low as possible is always the safest course. Dr. Carlos M. Ferrario's study found significant differences in the biological mechanisms behind hypertension in women compared with men, pointing to a need for sex-specific drug choices, combinations and dosages, while Dr. Carlos J. Rodriguez's observational study found that lowering systolic pressure below 120 did not significantly reduce the risk of heart attack, heart failure or stroke. The information carries weight because it comes directly from the investigators at an established hypertension research center, and it is useful to anyone managing the condition - particularly seniors, women, and people with disabilities or chronic illness who often take several medications - because it explains why treatment is not one-size-fits-all and why patients should feel comfortable asking their doctor the reasoning behind a particular drug or target.*

At a Glance

• 1 - Most people with hypertension have no symptoms and only learn of it when they see a doctor for another reason.
• 2 - Hypertension was first described as a disease in the early 1800s, and the inflatable cuff used to measure blood pressure was invented in 1896.
• 3 - There are nine categories of anti-hypertension drugs, and most people with the condition need two or more prescription medications to keep their readings at healthy levels.
• 4 - Ethnicity can affect how well medications work - African Americans, for example, tend to respond better to calcium channel blockers than to drugs in the angiotensin inhibitor category.

Topic Definition

Hypertension (High Blood Pressure)

Hypertension, commonly called high blood pressure, is a long-term condition in which the force of blood pushing against the artery walls stays higher than it should. It is recorded as two numbers measured in millimeters of mercury: systolic pressure, taken when the heart beats, over diastolic pressure, taken when the heart rests between beats. Under current American Heart Association and American College of Cardiology guidelines, a reading below 120/80 is normal and a sustained reading of 130/80 or higher is classed as hypertension. Because it usually produces no symptoms, the condition often goes unnoticed for years while it strains the heart and damages blood vessels, raising the risk of heart attack, stroke, heart failure and kidney disease. It is typically managed with a combination of lifestyle changes and one or more medications.

Overview

That blood pressure plays a role in human health has been known for quite a while. Hypertension - the medical term for high blood pressure - was first described as a disease in the early 1800s, and the inflatable cuff that's used in measuring blood pressure was invented in 1896.

That doesn't, however, mean there's nothing new about hypertension, its triggers and its effects. In fact, findings published in 2014 punctured some long-held beliefs about the condition and the best ways to treat it.

For example, a study led by Dr. Carlos M. Ferrario, professor of surgery and founder of the Hypertension and Vascular Research Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C., found that there were significant differences in the biological mechanisms that cause high blood pressure in women as compared to men.

"The medical community has thought that high blood pressure was the same for both sexes, and treatment has been based on that premise," said Ferrario, an internationally recognized expert in the field and then president of the Inter-American Society of Hypertension. "Our findings suggest a need to better understand the female sex-specific underpinnings of the hypertensive processes to tailor optimal treatments for this population. We need to evaluate new protocols - what drugs, in what combination and in what dosage - to treat women with high blood pressure."

Another Wake Forest Baptist researcher, Dr. Carlos J. Rodriguez, directed a study of people with hypertension which found that lowering their systolic blood pressure - the first number in a standard reading, as in 140/90 ("140 over 90") - below 120 wasn't necessarily beneficial over the long term.

"Frequently we treat patients' blood pressure to the lowest it will go, thinking that is what's best," said Rodriguez, an associate professor of public health sciences. "But our observational study found that treating to low pressures doesn't significantly reduce the risk of dangerous events like heart attack, heart failure and stroke. This calls into question the common notion that lower is always better."

• Blood pressure is simply a measure of how hard blood pushes against the walls of arteries as it moves through the body.
• Blood pressure is expressed in two numbers, with the systolic reading (when the heart is pumping) followed by the diastolic reading (between heartbeats).
• Blood pressure is generally considered normal when it's lower than 120/80 and high when it's 130/80 or above.
• A systolic reading of 120 to 129 with a diastolic reading below 80 is classified as elevated blood pressure.

Hypertension can cause damage to the heart and blood vessels and lead to heart attack, stroke and other serious health problems. Nearly half of all American adults have high blood pressure, and the rate is substantially higher among men over 55 and women over 65.

High Blood Pressure is Treatable

The good news is that high blood pressure is treatable, most commonly by a combination of medicine and lifestyle changes.

But even though it's common, easily identified and controllable, hypertension does have its quirks. In most cases there aren't any symptoms; most people don't find out they have high blood pressure until they go to a doctor for another reason. Because a wide variety of factors can contribute to raised blood pressure - including obesity, diabetes, smoking, drinking too much alcohol, eating too much salt, stress, physical inactivity, kidney disease, having a family history of high blood pressure and aging - and because there are nine categories of anti-hypertension drugs, determining the best course of treatment can be complicated. In fact, most people with hypertension need to take two or more prescription drugs to keep their blood pressure at healthy levels.

Ethnicity, Sex and Treatment Intensity

It is known that ethnicity can be a factor in the effectiveness of medications - African-Americans, for example, are more responsive to drugs classified as calcium channel blockers than those in the angiotensin inhibitor category - but Ferrario's study clearly indicates that gender should also be a primary consideration in selecting the most appropriate treatment. And while Rodriguez's research findings, which were being put to the test in a large clinical study, suggest that less aggressive therapies may be sufficiently beneficial in treating hypertension, other researchers, including Ferrario, believe that pre-hypertension, as it was then called, should be treated more aggressively to delay the occurrence of high blood pressure and thus reduce the risk of cardiovascular damage over time. NOTE: That study (SPRINT) reported in 2015 and found the opposite: a target below 120 cut cardiovascular complications by 25 percent and death by 27 percent.

Ferrario also advocates that clinical trials should look at long-term morbidity and mortality rates of different medications in addition to the magnitude of blood pressure reduction when weighing the effectiveness of hypertension treatments.

But Ferrario is quick to emphasize that research is not an end in itself.

"In a sense, it's not that we need more research, it's that we need to apply what we know in day-to-day care," he said. "What's the point of doing lots of studies if very little of that is translated into immediate benefits for patients?"

To close what he called an "enormous gap" between what has been learned about hypertension and how it is treated, Ferrario said physicians need to be better educated about research findings so they can make appropriate adjustments to their practice patterns. And patients can contribute, too, by learning what they can do about their condition and being proactive about their care. "It never hurts," he said, "for a patient to ask a doctor why he or she is recommending a particular treatment or drug."

Frequently Asked Questions

NOTE: Researched FAQs by Disabled World (DW)

What blood pressure reading is considered high under current U.S. guidelines?

The American Heart Association and American College of Cardiology guideline classifies normal blood pressure as less than 120/80 mm Hg. Elevated blood pressure is a systolic reading of 120 to 129 with a diastolic reading below 80, stage 1 hypertension is 130 to 139 systolic or 80 to 89 diastolic, and stage 2 hypertension is 140 or higher systolic or 90 or higher diastolic.

What did the SPRINT trial find about lowering systolic blood pressure below 120?

The Systolic Blood Pressure Intervention Trial, sponsored by the National Institutes of Health, followed 9,361 adults aged 50 and older who had raised systolic pressure and at least one cardiovascular risk factor. Treating to a systolic target below 120 instead of below 140 cut heart attack, heart failure and stroke complications by 25 percent and the risk of death by 27 percent, although fainting and acute kidney injury were more common in the intensive group.

How many adults in the United States have high blood pressure?

The Centers for Disease Control and Prevention reports that nearly half of U.S. adults, 48.1 percent or about 119.9 million people, have hypertension when it is defined as a reading above 130/80 mm Hg or taking medication for it. Only about 1 in 4 of those adults has the condition under control.

What is a hypertensive crisis?

A hypertensive crisis is a blood pressure reading higher than 180/120 mm Hg. If a reading that high comes with chest pain, shortness of breath, back pain, numbness, weakness, vision changes or difficulty speaking, it is a medical emergency and 911 should be called right away.

How should blood pressure be measured at home?

Use a validated upper arm cuff monitor and avoid caffeine, exercise and smoking for 30 minutes beforehand. Sit quietly for about five minutes in a chair with back support, keep both feet flat on the floor, rest the arm at heart level, stay still and silent during the reading, and record the results to share with a health care professional.

What is the DASH eating plan?

DASH stands for Dietary Approaches to Stop Hypertension. It is an eating pattern built around vegetables, fruits, whole grains, legumes, nuts, seeds, low-fat dairy and lean protein, with limits on sodium, saturated fat and added sugars, and it is recommended in U.S. guidelines for preventing and lowering high blood pressure.

How much sodium is recommended for people with high blood pressure?

The American Heart Association advises no more than 2,300 mg of sodium a day, which is about one teaspoon of table salt, and moving toward an ideal limit of less than 1,500 mg a day. Most sodium in the American diet comes from packaged and restaurant foods, so reading nutrition labels matters more than putting away the salt shaker.

What are the first-line medications used to treat high blood pressure?

The main first-line drug classes are thiazide-type diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers. Other classes, including beta blockers, are usually added when a person has another condition that calls for them or when blood pressure stays above target on first-line treatment.

Insights, Analysis, and Developments

Editorial Note: What stands out in this account is Ferrario's blunt admission that the larger problem is not a shortage of studies but the "enormous gap" between what researchers already know and what happens in the exam room. That gap has real consequences for the millions of older adults and people with chronic conditions who rely on blood pressure medication every day, and it has only become more visible since this piece first appeared: the question of how low to treat was later tested in the large federally funded SPRINT trial, and U.S. guidelines have since lowered the threshold for diagnosing hypertension. Treatment advice in this field keeps moving, which is exactly why his closing suggestion still holds - physicians need to keep pace with the evidence, and patients lose nothing by asking why a specific drug, dose or target was chosen for them.*

Attribution/Source(s): This quality-reviewed publication was selected for publishing by the editors of Disabled World (DW) due to its relevance to the disability community. Originally authored by Wake Forest Baptist Medical Center and published on 14 Dec 2014, this content may have been edited for style, clarity, or brevity.

* Editorial additions by Ian C. Langtree.