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High blood pressure, or hypertension, is one of the most common conditions we treat in internal medicine, and one of the most consequential. Blood pressure reflects two things: how much blood your heart pumps and how much resistance that blood meets in the arteries. When the pressure stays high for years, it strains the heart, stiffens and damages arteries, and raises the risk of stroke, heart attack, heart failure, kidney disease and aneurysm.
The difficulty is that high blood pressure is usually silent. According to the National Heart, Lung, and Blood Institute, symptoms usually do not appear until the condition has already caused serious problems. Headaches or nosebleeds are not reliable warning signs. The only way to know is to measure, which is why we check blood pressure at every visit and take abnormal readings seriously.
The good news is that hypertension is very treatable. Caught early, it can often be controlled with lifestyle changes alone, and when medication is needed, well-chosen drugs with regular follow-up bring most people into a healthy range.
What counts as high blood pressure
We use the categories from the 2017 American College of Cardiology and American Heart Association guideline, summarized by the American Heart Association. Normal is below 120/80. Elevated is a top number of 120 to 129 with a bottom number under 80. Stage 1 hypertension is 130 to 139 on top or 80 to 89 on the bottom, and stage 2 is 140 or higher on top or 90 or higher on the bottom. A reading above 180/120 is severe and needs prompt attention.
A single high reading in the office does not make the diagnosis. Some people run high only in the doctor's office, called white-coat hypertension, and others are normal in the office but high at home or at work, called masked hypertension. Both are common, and both are found only by measuring outside the office.
How we evaluate high blood pressure at NYMD Center
We start by making sure the numbers are right. Office readings are taken seated after rest, with your back supported, feet flat and arm at heart level, using a cuff sized to your arm; a cuff that is too small reads falsely high. We usually ask you to confirm with home readings. The AHA recommends an automatic upper-arm monitor rather than a wrist or finger device, no caffeine, smoking or exercise for 30 minutes beforehand, five minutes of quiet rest, and two readings a minute apart. Bring your monitor to a visit so we can check it against ours. When home readings are unclear, we can arrange 24-hour ambulatory monitoring.
Once hypertension is confirmed, we look for its effects and for other risk factors. Blood tests check kidney function, potassium and sodium, blood sugar and cholesterol, and a urine test looks for protein. An in-office ECG shows rhythm and signs of heart muscle thickening. When the ECG or exam raises questions, an echocardiogram shows whether the heart wall has thickened or its pumping has changed.
In younger patients, in people whose pressure is hard to control despite several medications, and when potassium is unexpectedly low, we look for secondary causes. The most common are obstructive sleep apnea, kidney disease and excess aldosterone from the adrenal glands. Certain medications and supplements, including decongestants and regular anti-inflammatory painkillers, can also raise pressure.
Treatment options, least invasive first
Lifestyle changes
For elevated readings and many cases of stage 1 hypertension, lifestyle is the first treatment, and it remains the foundation for everyone. Cutting salt, much of which comes from restaurant and packaged food, has a real effect on pressure. So do losing excess weight, regular aerobic activity, limiting alcohol, stopping smoking and sleeping enough. A diet rich in vegetables, fruit, whole grains and low-fat dairy, such as the DASH eating plan, lowers pressure on its own. These changes take time and persistence, but they cost nothing in side effects and they improve cholesterol and blood sugar at the same time.
Medication
When lifestyle changes are not enough, or when pressure is in stage 2 or your overall cardiovascular risk is high, we add medication. The main first-line classes are thiazide-type diuretics, ACE inhibitors or angiotensin receptor blockers (ARBs), and calcium channel blockers. The choice depends on your other conditions: ACE inhibitors and ARBs are often preferred with diabetes or kidney disease, for example. Many people need two drugs, sometimes combined in one pill. Each class has possible side effects, such as cough with ACE inhibitors, ankle swelling with some calcium channel blockers, and changes in potassium or sodium with diuretics, so we check labs after starting or changing doses.
Follow-up
We see you back within weeks of any change until your pressure is controlled, then at regular intervals. Home readings between visits make adjustments faster and more accurate. Because high blood pressure rarely travels alone, we also manage cholesterol and blood sugar and review your overall picture through heart and stroke risk screening.
What to expect at your visit
Bring your medication list, including over-the-counter products and supplements, and any home readings you have, along with your monitor. Expect careful blood pressure measurement, an exam, an ECG, and a blood and urine sample if these have not been done recently. You will leave with a plan for home monitoring, lifestyle changes, and medication if needed, and a date to come back.
When to seek care urgently
Call 911 if your blood pressure is above 180/120 and you have chest pain, shortness of breath, back pain, numbness or weakness, a change in vision, or difficulty speaking. These can signal a hypertensive emergency, stroke or heart attack. If your reading is that high without symptoms, rest for a few minutes and measure again; if it stays that high, call us the same day.
Questions patients ask
What blood pressure is considered high?
Under the American Heart Association and American College of Cardiology categories, a reading consistently at or above 130 on top or 80 on the bottom is hypertension. Readings from 120 to 129 on top with a bottom number below 80 are called elevated. The diagnosis should rest on several readings, ideally including home measurements, not one visit.
Can I have high blood pressure without symptoms?
Yes, and most people do. High blood pressure usually causes no symptoms until it has damaged the heart, brain, kidneys or blood vessels. Headaches and nosebleeds are not reliable signs. Regular measurement, in the office and at home, is the only way to know your numbers.
What is white-coat hypertension?
It is blood pressure that is high in the doctor's office but normal at home. The opposite, masked hypertension, is normal in the office but high elsewhere. Both are found by comparing office readings with home or 24-hour ambulatory readings, which is why we ask many patients to monitor at home before we decide on treatment.
Will I have to take blood pressure medicine for life?
Not necessarily. Some people with mild hypertension control it with weight loss, less salt, exercise and less alcohol. Others need medication, and for most of them it is long term. If lifestyle changes bring your pressure down substantially, we can sometimes reduce or stop a medication under close monitoring.
Which home blood pressure monitor should I buy?
Choose an automatic monitor with an upper-arm cuff that fits your arm, rather than a wrist or finger device. Measure seated after five minutes of rest, with your arm supported at heart level, and take two readings a minute apart. Bring the monitor to your visit so we can check its accuracy against ours.