Story
Hypertension
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In one pass The cruelest thing about high blood pressure is that it doesn't hurt.
Educational content, not medical advice — consult a clinician.
Story path
Chapter 1
What high blood pressure is
The cruelest thing about high blood pressure is that it doesn't hurt. Year after year the pressure scours the vessel walls, wearing the inner lining and thickening and stiffening the wall; the heart muscle grows thicker to push against it; and the finest vessels in the kidneys and the back of the eye are damaged one by one, all without you feeling anything. By the time you do feel something, it is often already a heart attack, a stroke, heart failure or kidney failure. That is why it is called the silent killer.
Blood pressure is the force of blood pushing on the vessel walls. Only three things push it up:
1. The heart pumps too hard: under stress or when the sympathetic nervous system is fired up, heart rate and the amount pumped per beat both rise
2. The vessels are held too tight: the smooth muscle clamps down, the lining won't relax, the walls stiffen, and blood needs more force to squeeze through
3. There is too much water in the blood: sodium is held in the body, water follows sodium into the vessels, and blood volume swells
Two systems mainly control these three: , which tightens the vessels and holds on to sodium, and the endothelium, which lets them relax. Blood pressure of 180/120 or higher together with chest pain, shortness of breath, a severe headache, slurred speech or weakness on one side of the body is an emergency: get medical help immediately.
Blood pressure is the force of blood pushing on the vessel walls. Only three things push it up:
1. The heart pumps too hard: under stress or when the sympathetic nervous system is fired up, heart rate and the amount pumped per beat both rise
2. The vessels are held too tight: the smooth muscle clamps down, the lining won't relax, the walls stiffen, and blood needs more force to squeeze through
3. There is too much water in the blood: sodium is held in the body, water follows sodium into the vessels, and blood volume swells
Two systems mainly control these three: , which tightens the vessels and holds on to sodium, and the endothelium, which lets them relax. Blood pressure of 180/120 or higher together with chest pain, shortness of breath, a severe headache, slurred speech or weakness on one side of the body is an emergency: get medical help immediately.
Clinical · Where the diagnostic line is drawn
Hypertension means blood pressure that stays high. Over the years it damages the blood vessels of the heart, brain and kidneys, ending in heart attack, stroke, heart failure and kidney failure.Diagnostic cut-points (the 2017 update of the US ACC/AHA guideline); guidelines differ from country to country, and many still use 140/90 as the line for diagnosing hypertension:
Normal: < 120 / 80 mmHgElevated: 120–129 / < 80Stage 1 hypertension: 130–139 / 80–89Stage 2 hypertension: ≥ 140 / 90Hypertensive emergency: ≥ 180 / 120 together with organ damage
The SPRINT trial (2015, NEJM) compared intensive lowering (systolic < 120) with standard lowering (< 140) in people at high cardiovascular risk who did not have diabetes. Death from any cause fell by 27% in relative terms in the intensive group. Note: < 130/80 is the 2017 ACC/AHA cut-point for diagnosis and treatment, not SPRINT's target. It was SPRINT's result that pushed the 2017 ACC/AHA guideline to move the line from 140/90 down to 130/80, a paradigm shift in clinical guidelines.
Numbers · How many people in China are on this boat
Epidemiology in China (Wang 2018, Circulation, the China Hypertension Survey):Prevalence 27.9% (crude; 23.2% after standardization, about 245 million people)Awareness 46.9%, treatment 40.7%, control 15.3%The silent killer: most people have no symptoms until a complication arrivesSeparately, dietary surveys put average salt intake in China at about 11 g a day (the WHO recommends < 5 g), among the highest in the world
Why these numbers matter
In China, cardiovascular disease accounts for 40%+ of all deaths (GBD 2019)The leading modifiable risk factor for cardiovascular disease is high blood pressureA rough order-of-magnitude estimate: raising control from about 15% to 50% (close to US and Japanese levels) would mean roughly 700,000–1,000,000 fewer deaths a year; this is an estimate, not the result of a particular study
In practice · How to measure blood pressure
Measuring at homeHome readings are more informative than clinic readings: they avoid white-coat hypertension (high only in the clinic) and masked hypertension (normal in the clinic, high at home)Take 2 readings within 1 hour of getting up and 2 before bed, and average themUpper-arm electronic monitors are accurate; wrist and finger monitors are not reliableA diagnosis needs many readings, not one
Related stories: how the vessel wall is damaged step by step is in Cardiovascular System; snoring, collapse of the upper airway and high blood pressure are in Obstructive Sleep Apnea; high blood pressure is also one of the markers of metabolic syndrome, see Endocrine System; magnesium and blood pressure are in Magnesium; the basics of the sodium-potassium balance are in Potassium & Sodium.
Chapter 2
Two systems that set blood pressure
Blood pressure is run by two systems: one tightens, the other relaxes.
The tightening system is called (the renin-angiotensin-aldosterone system). The liver makes the raw material, renin released by the kidney makes the first cut, and ACE in the lungs makes the second, producing angiotensin II, a powerful signal to constrict. Once it arrives it does four things at once: it clamps the blood vessels, driving resistance up; it has the adrenal glands release aldosterone, which makes the kidney tubules hold on to sodium and let go of potassium, swelling blood volume; it has the brain release vasopressin, so water is held too; and on top of that it raises sympathetic drive. The first-line ACE inhibitors (ACEi, such as enalapril) and angiotensin receptor blockers (, such as losartan) each cut this chain at one point.
The relaxing system lives in the endothelium: the cells of the vessel's innermost layer release nitric oxide () toward the muscle layer, the smooth muscle relaxes as soon as it receives it, the vessel widens and the pressure falls. Smoking, high blood sugar, high blood lipids and aging increase the oxidants in the vessels, which grab and destroy NO, so the vessel cannot relax when it should. That is endothelial dysfunction.
The tightening system is called (the renin-angiotensin-aldosterone system). The liver makes the raw material, renin released by the kidney makes the first cut, and ACE in the lungs makes the second, producing angiotensin II, a powerful signal to constrict. Once it arrives it does four things at once: it clamps the blood vessels, driving resistance up; it has the adrenal glands release aldosterone, which makes the kidney tubules hold on to sodium and let go of potassium, swelling blood volume; it has the brain release vasopressin, so water is held too; and on top of that it raises sympathetic drive. The first-line ACE inhibitors (ACEi, such as enalapril) and angiotensin receptor blockers (, such as losartan) each cut this chain at one point.
The relaxing system lives in the endothelium: the cells of the vessel's innermost layer release nitric oxide () toward the muscle layer, the smooth muscle relaxes as soon as it receives it, the vessel widens and the pressure falls. Smoking, high blood sugar, high blood lipids and aging increase the oxidants in the vessels, which grab and destroy NO, so the vessel cannot relax when it should. That is endothelial dysfunction.
Mechanism · The sodium–potassium tug of war
Sodium pulls water into the blood vessels with it; potassium stands on the other side. The typical Chinese table has this ratio backwards: too much from the salt jar, too little from vegetables and beans.The sodium-potassium balance (more in Potassium & Sodium):
High sodium with low potassium is the pair that pushes blood pressure upDoing both, less sodium and more potassium (a daily sodium < 2300 mg and potassium ≥ 3500 mg, commonly used targets), can be expected to lower blood pressure by about 5–10 mmHg. That is a rough sum of the effects seen across several kinds of trials; the Aburto 2013 (BMJ) looked only at potassium, and found that in people with high blood pressure, eating more potassium alone lowered systolic pressure by a few mmHgTypical Chinese intake is roughly sodium 4500 mg+, potassium 1500 mg, the complete reverse
Leafy greens and beetroot also carry nitrate, which bacteria in the mouth turn into nitrite; this tops up the body's nitric oxide and helps vessels relax, and may be one reason eating more vegetables lowers blood pressure (more in L-Citrulline).
Clinical · Not every high reading is primary
Secondary versus primary hypertensionPrimary (about 90–95%): many factors together, genes plus lifestyleSecondary (about 5–10%): there is a specific cause that can be foundNarrowing of a kidney artery ( switched on abnormally)GlomerulonephritisPheochromocytoma (an adrenal tumor releasing too much adrenaline-type hormone)Cushing's syndrome (too much cortisol)Primary aldosteronism (formerly Conn's syndrome): it may be an adenoma on one adrenal gland or overgrowth of both; it is badly underdiagnosed. Estimates of its share among people with resistant hypertension range from 10–20% to more than 20%, depending on the studyObstructive sleep apnea (): the upper airway repeatedly collapses during sleep (see Obstructive Sleep Apnea)The contraceptive pill, long-term steroids or non-steroidal anti-inflammatory drugs, and decongestantsResistant hypertension (not at target on 3 drugs, one of them a diuretic; the older definition was still > 140/90) must be checked for a secondary cause
In practice
High blood pressure that is severe in someone young (< 40): always look for a secondary causeHigh blood pressure plus low potassium: test for primary aldosteronism (often missed)High blood pressure plus snoring and daytime sleepiness: test for obstructive sleep apnea
Clinical · Why primary aldosteronism gets missed
The cause of high blood pressure that clinics miss most easily, and that can genuinely be cured, is primary aldosteronism (PA, formerly called Conn's syndrome). One sentence is enough to remember: if your blood pressure still won't come down on three drugs, or you have high blood pressure and a low potassium result, it is time to have your aldosterone-to-renin ratio (ARR) checked once.It is far more common than was once thought. The old view put it at only 1–2% of hypertension, but modern studies (Funder 2016, Brown 2020) find far more. When Brown 2020 screened US adults systematically, about 16% of people with stage 1 hypertension, about 22% with stage 2, and about 22% with resistant hypertension showed aldosterone being made out of control, and so did about 11% of people with normal blood pressure. Scaled to China's roughly 250 million people with hypertension, that means more than ten million potential PA patients, of whom only a small share are diagnosed.
The mechanism is simple. The adrenal glands release too much aldosterone without control (it may be an adenoma on one side, or both sides may be overgrown), so the body keeps more and more sodium, loses more and more potassium, blood volume is pushed up, and blood pressure will not come down. Aldosterone also damages blood vessels and the heart on its own, so this is not only a matter of high blood pressure.
When should you think of it and get screened? Remember a few signals: blood pressure not controlled on three drugs (one of them a diuretic); low potassium, either on its own or after starting a drug; severe hypertension at a young age (< 40); a growth on an adrenal gland found at a check-up; or a first-degree relative with PA. Any one of these is worth an ARR test.
Screening and confirmation have a trap that belongs with the specialist: many blood-pressure drugs (ACEi, , diuretics and others) interfere with the ARR result, so before the test the drugs often need to be switched or paused for a while under a doctor's guidance; do not change them on your own. If the ARR comes back abnormal, endocrinology runs a confirmatory test and an adrenal CT, and if needed adrenal venous sampling (AVS, drawing blood from each adrenal vein to compare the two sides), to tell whether one side or both are involved, because the two are treated completely differently.
The treatment is exactly why it is worth pursuing. If it is an adenoma on one side, removing that adrenal gland by minimally invasive surgery brings blood pressure back to normal in about 30–60% of people, sometimes off medication altogether, and most of the rest improve clearly; if both sides are overgrown, the answer is a long-term aldosterone blocker such as spironolactone plus salt restriction. A cause of hypertension that can be removed at the root was overlooked for decades. So if you fall into the resistant or low-potassium group, ask for the test yourself, and don't let it keep being treated as ordinary hypertension.
funder-2016-endocrine-primary-aldosteronismbrown-2020-primary-aldosteronism-prevalence
Chapter 3
How the DASH diet lowers pressure
DASH is not a magic diet. It simply pushes the plate in one direction: more vegetables, fruit and whole grains, with low-fat dairy and nuts, and less processed meat, sugary drinks and red meat. Eating this way brings more potassium, magnesium, calcium and fiber, and less saturated fat.
What makes it remarkable is that it was tested in real , not inferred from correlations seen in populations. People were randomly assigned to different ways of eating for 8 weeks, and changing the food alone lowered systolic pressure noticeably in people with hypertension, by about as much as a single blood-pressure drug. In that first trial every group ate the same amount of salt, so this drop did not come from eating less salt. A later follow-up trial then lowered sodium on its own and showed that less salt and DASH add up: doing both lowers pressure the most.
For Chinese households there is one more opportunity. Most of our salt comes not from packaged food but from the salt jar and the soy-sauce bottle on the stove, so the switch for cutting salt is in your own hands.
What makes it remarkable is that it was tested in real , not inferred from correlations seen in populations. People were randomly assigned to different ways of eating for 8 weeks, and changing the food alone lowered systolic pressure noticeably in people with hypertension, by about as much as a single blood-pressure drug. In that first trial every group ate the same amount of salt, so this drop did not come from eating less salt. A later follow-up trial then lowered sodium on its own and showed that less salt and DASH add up: doing both lowers pressure the most.
For Chinese households there is one more opportunity. Most of our salt comes not from packaged food but from the salt jar and the soy-sauce bottle on the stove, so the switch for cutting salt is in your own hands.
Evidence · How the DASH trial was run
DASH (Dietary Approaches to Stop Hypertension) is one of the classic of diet in nutrition science.The DASH randomized controlled trial (Appel 1997, NEJM, funded by the US National Heart, Lung, and Blood Institute)
N = 459 adults with high or elevated blood pressure3 ways of eating for 8 weeks, with sodium intake held the same across groups:Control: a typical American dietFruit-and-vegetable group: more fruit and vegetablesDASH group: more fruit, vegetables, whole grains, low-fat dairy, lean meat and nuts; less processed meat, soft drinks and red meat
Results (8 weeks)
In people with hypertension, the DASH group's systolic pressure fell by 11.4 mmHg and diastolic by 5.5 mmHgAbout as much as a single blood-pressure drugThe fruit-and-vegetable group landed in between; the control group did not change
The follow-up: DASH-Sodium (Sacks 2001, NEJM)
Within both the control diet and the DASH diet, sodium was set at high, medium and low levelsOn both diets, lower sodium meant lower blood pressure, and the effects of less salt and DASH added upCompared with the typical diet at high sodium, low-sodium DASH lowered systolic pressure by about 12 mmHg in people with hypertension
In practice · What a day of eating looks like
A DASH day (at 2000 kcal a day)Vegetables: 4–5 servings (1 serving = 1 cup raw or 0.5 cup cooked)Fruit: 4–5 servingsWhole grains: 6–8 servingsLow-fat milk or yogurt: 2–3 servingsLean meat, fish or eggs: ≤ 6 servings a dayNuts, beans and seeds: 4–5 servings a weekLimits: added sugar, processed meat and soft drinks, and sodium < 2300 mg
DASH and the Mediterranean diet
The Mediterranean diet puts more weight on olive oil, fish and whole grains; the traditional version includes red wine, but alcohol raises blood pressure and is no reason to drinkDASH puts more weight on low-fat dairy, and on potassium and magnesiumBoth have evidence for lowering blood pressure and both are livable for the long term, but few trials have compared them head to headIn practice in China: whole grains, plenty of vegetables, less salt, more fish and less red meat is a DASH that fits the Chinese table
In practice · The salt jar and the soy-sauce bottle
Less salt, and in China that starts at the stoveAmong Chinese residents, more than 75% of dietary sodium comes from salt used in home cooking, followed by high-salt condiments (the national dietary-guideline figure); in Europe and the US, about 70% comes from processed foodWhat to do: halve the soy sauce, keep dipping sauces on the side, add salt at the end of cooking, and choose sodium-free or low-sodium saltLow-sodium salt (a salt substitute): sodium chloride with some potassium chloride mixed in. The China Salt Substitute and Stroke Study (2021, NEJM) saw 12% fewer deaths and 14% fewer strokes; it was a randomized trial of about 21K people carried out in China, with meaning well beyond China
Eating more potassium, in practice
Dark leafy greens, bananas, avocados, sweet potatoes, legumes and dried fruitTake care if you have chronic kidney disease: the ability to get rid of potassium is impaired
In practice · China's official targets
The DASH and salt-substitute trials describe mechanisms and effects; this page gives the numbers you will actually be measured against in China, from the National Health Commission's *Dietary Guidelines for Adults with Hypertension (2023 edition)*.Bring salt down, step by step, to under 5 g a day. Note the wording, *step by step*: taste buds take weeks to adapt, and cutting all at once rarely sticksThe sources of sodium are the reverse of the Western pattern: more than 75% of dietary sodium among Chinese residents comes from salt used in home cooking, followed by high-salt condiments, with processed food only a growing third route. So in China the switch for cutting salt sits on your own stove, not on food labelsGet more potassium from food, not pills. The guideline is explicit: eat more potassium-rich foods (fresh vegetables, fruit, beans); potassium supplements, including drugs, are not recommended for lowering blood pressure; people with good kidney function may use potassium-enriched low-sodium salt, and anyone with impaired kidney function must consult a doctor before taking in more potassiumKeep an eye on calcium too: the guideline names low dietary calcium as a widespread problem among Chinese residentsWhole grains or mixed beans should make up 1/4 to 1/2 of the staple food
⚠️ The guideline also has a full section on traditional-medicine syndrome typing and food-medicine substances. This story does not cite that part and takes only its nutritional targets.
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Evidence · The salt-substitute trial, and how to switch
The China Salt Substitute and Stroke Study (SSaSS, Neal 2021, NEJM) is one of the most important cardiovascular randomized trials carried out in China, and it carries weight for guidelines everywhere.Why this trial matters so much for China
Average salt intake in China is about 11 g a day, among the highest in the world (the WHO recommends < 5 g)More than 75% comes from salt used in home cooking, followed by high-salt condiments (in the West about 70% comes from processed food), so there is room to change things at the level of the person and the householdCardiovascular disease accounts for 40%+ of all deaths in China, and high blood pressure is the leading modifiable risk factorEating less salt overall is hard (taste habits), so switching to a different salt becomes a smart middle path
How the trial was designed
N = 20,995, from 600 rural communities in 5 provinces of northern China, randomized by community, and participants knew which group they were inEligibility: a previous stroke, or age 60 or older with high blood pressure (either one; 88% of those enrolled had hypertension)Intervention group: low-sodium salt (75% sodium chloride + 25% potassium chloride), replacing the household's cooking saltControl group: regular salt (100% sodium chloride)Average follow-up of about 5 years
Results
Strokes fell by 14% (rate ratio 0.86, 95% 0.77–0.96, P = 0.006)Major cardiovascular events (heart attack, stroke, cardiovascular death) fell by 13%Deaths from any cause fell by 12%Safety: clinically serious high potassium did not increase. But read it carefully: the trial excluded people taking potassium-sparing diuretics or potassium supplements and people with serious kidney disease, so this holds only for people like those in the trial
Where its weight comes from
About 21,000 ordinary people in China, not patients selected in big hospitalsA simple intervention: change the bag of salt, with no drugs and no equipmentLarge public-health meaning: a modeling estimate (Marklund 2020) suggests nationwide adoption could prevent about 450,000 cardiovascular deaths a yearLike SPRINT (2015, NEJM, intensive blood-pressure lowering), it is one of the trials most often cited in the field
How to switch
Where to buy it: common in Chinese supermarkets, with low-sodium salt on the pack; major producers such as China National Salt make itPrice (in China): a little more than regular salt (¥3–5 a pack against ¥2–3), but far cheaper than blood-pressure drugsThe same 1 g of salt, with a quarter swapped for potassium chloride: 25% less sodium and 25% more potassium, helping in both directions at onceUse it like regular salt; it tastes much the same (a slight metallic bitterness most people don't notice)
Who should not switch (important)
Chronic kidney disease stage 3–5 ( < 60), with risk rising at later stages; with eGFR < 30 especially, do not switch on your own: the body cannot clear potassium well, so high potassium is a riskPeople taking ACEi, , spironolactone or eplerenone without regular checks of kidney function and blood potassium: risk of high potassiumChronic kidney disease together with an ACEi or ARB: do not switch on your own; ask your doctor firstNormal kidney function and no drugs that raise potassium: safe in people like those in the trial
Really eating less salt (the end goal)
Target: the WHO recommends < 5 g a day (about one teaspoon)How:Halve the soy sauce, or try a concentrated low-sodium soy sauceKeep dipping sauces on the side (dip before eating rather than mixing in)Add salt at the end of cooking, and don't salt meat in advanceEat fewer pickled and salted vegetables, or noneRead the sodium on food labels: pick the lower-sodium option within a type of food, and rely on a low-sodium claim on the pack to tell you whether it counts as low-sodiumAdjustment period: taste buds adapt in about 3–4 weeks, after which your old amount of salt tastes too salty
Potassium-rich foods (to use alongside low-sodium salt)
1 banana (about 400 mg)1 large mango (about 320 mg)1/2 avocado (about 480 mg)1 medium cooked sweet potato (about 540 mg)1 cup cooked spinach (about 840 mg)1 cup cooked legumes (about 700 mg)Target: 3500 mg a day; as noted above, typical intake in China is only about 1500 mg
For Chinese households, switching to low-sodium salt, at about ¥5 a month, is one of the highest-return things to do. It is not a perfect solution, but it is a realistic path to clearly better blood pressure and cardiovascular outcomes.
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In practice · Three switches besides food
Exercise150 minutes a week of moderate aerobic exercise lowers systolic pressure by about 5–7 mmHgStrength training adds to the effectHigh-intensity interval training () may do more, but safety has to be assessed first
Quitting smoking
Smoking raises systolic pressure by 5–10 mmHg in the short term and damages the vessel lining over the long termThe payoff of quitting: cardiovascular risk falls clearly after 1 year and is close to a never-smoker's after 5 years
Limiting alcohol
There is no amount of alcohol that is safe for health; less is better, and none is bestMore than 20–30 g of alcohol a day raises systolic pressureAfter stopping, systolic pressure can fall by 3–5 mmHg within weeksThe old J-shaped curve, which said a little alcohol protects the heart, no longer holds up (see Alcohol Metabolism)
Chapter 4
BP meds · 5 classes
Blood-pressure drugs are not a matter of picking one at random: the five common classes each clamp down on a different part of how pressure rises. Go back to the three sources of high pressure: the heart pumping too hard, the vessels held too tight, and too much water in the blood.
ACE inhibitors and angiotensin receptor blockers (ACEi / ) act on the axis: they make less angiotensin II or block it, so the vessels relax and sodium is no longer held so tightly, bringing down both resistance and blood volume. Most people start here.
Calcium channel blockers (CCB) relax the smooth muscle of the vessels directly. They deal with the vessels held too tight part and work especially well in older people.
Diuretics flush extra sodium and water out through the kidneys. They deal with the too much water in the blood part.
Beta-blockers slow the heart. They deal with the heart pumping too hard part; but for high blood pressure without other heart problems, they are no longer a first choice.
The real clinical point is less about which class to pick than two other things: most people should start with two drugs at low doses together, and keep taking them, because the benefit of these drugs comes entirely over the long term.
ACE inhibitors and angiotensin receptor blockers (ACEi / ) act on the axis: they make less angiotensin II or block it, so the vessels relax and sodium is no longer held so tightly, bringing down both resistance and blood volume. Most people start here.
Calcium channel blockers (CCB) relax the smooth muscle of the vessels directly. They deal with the vessels held too tight part and work especially well in older people.
Diuretics flush extra sodium and water out through the kidneys. They deal with the too much water in the blood part.
Beta-blockers slow the heart. They deal with the heart pumping too hard part; but for high blood pressure without other heart problems, they are no longer a first choice.
The real clinical point is less about which class to pick than two other things: most people should start with two drugs at low doses together, and keep taking them, because the benefit of these drugs comes entirely over the long term.
Clinical · The trap in each class
ACEi / : first line for most people, and they also protect the kidneys when heart failure or diabetic kidney disease is present. The common trap is a dry cough from ACE inhibitors in a minority of people (about 10–20%), which usually goes away after switching to an ARB. Both can raise blood potassium, and both must not be used in pregnancy.CCB (amlodipine and similar drugs): especially good for older people; the cost is ankle swelling in some.
Diuretics (hydrochlorothiazide and similar drugs): cheap, with a long track record, and they combine well with the first two classes. Potassium-sparing diuretics such as spironolactone are the add-on choice for resistant hypertension.
Beta-blockers (bisoprolol and similar drugs): no longer a first choice for uncomplicated high blood pressure, unless there is an extra reason such as angina, an irregular heartbeat or a previous heart attack.
In practice · Combine, stay on it, and what is coming
Combining: most people should start on two drugs at low doses, often in a single combination pill, which is easier to remember and easier to stay on. The different mechanisms cover for each other, and side effects partly cancel out.Staying on it: about half of people miss doses or stop on their own within a year, yet the benefit of these drugs comes entirely over the long term. Whether it has to be for life is not absolute: people at an early stage who lose a lot of weight, stop smoking and limit alcohol may be able to reduce the dose under a doctor's guidance, but must never stop suddenly on their own.
New drugs on the way: a liver-targeted RNA interference drug that works for months after one injection (zilebesiran, still in clinical trials), an endothelin receptor antagonist for resistant hypertension (aprocitentan, already approved), and weight-loss drugs that lower blood pressure as a side benefit.
Chapter 5
Whether to start meds, and where
Blood pressure stuck at 130–140, or already at 150: should you take a drug? This chapter is a triage table: match your number first, then check for extra risk, then start with the easiest levers to pull. The bands below are from the 2017 US ACC/AHA guideline; the lines differ between countries.
Q1: What range is your blood pressure in?
120–129 / < 80 (elevated): lifestyle changes are enough130–139 / 80–89 (stage 1 hypertension): for people at low cardiovascular risk, change lifestyle for 3–6 months first and add a drug if the target is not reached; for people who already have cardiovascular disease, diabetes or chronic kidney disease, or who are at higher risk, a drug should be considered alongside at this stage140–159 / 90–99 (stage 2 hypertension): start lifestyle changes and medication together≥ 160 / 100: start medication right away, along with lifestyle changes≥ 180 / 120: an emergency; seek medical care immediately
Q1: What range is your blood pressure in?
120–129 / < 80 (elevated): lifestyle changes are enough130–139 / 80–89 (stage 1 hypertension): for people at low cardiovascular risk, change lifestyle for 3–6 months first and add a drug if the target is not reached; for people who already have cardiovascular disease, diabetes or chronic kidney disease, or who are at higher risk, a drug should be considered alongside at this stage140–159 / 90–99 (stage 2 hypertension): start lifestyle changes and medication together≥ 160 / 100: start medication right away, along with lifestyle changes≥ 180 / 120: an emergency; seek medical care immediately
In practice · Extra risk, and five lifestyle levers
Q2: Do you have extra risk?Existing cardiovascular disease, diabetes or chronic kidney disease, or age ≥ 65: a stricter target (< 130/80)Smoking, high (the so-called bad cholesterol), high , a family history: treatment should be more activePregnancy: managed separately (there is a risk of preeclampsia, and ACE inhibitors and must not be used)
Q3: The 5 lifestyle levers (roughly how much each lowers pressure; this is not a ranking)
Losing weight (when BMI > 25): each 1 kg lost lowers systolic pressure by about 1 mmHgCutting salt (in China, mostly cooking salt): going from 6 g to 3 g a day lowers systolic pressure by 5–8 mmHgEating more potassium (leafy greens, bananas, sweet potatoes, beans): lowers systolic pressure by 4–5 mmHgExercise (150 minutes a week of moderate aerobic activity): lowers systolic pressure by 5–7 mmHgLimiting alcohol: less is better and none is best; if you already drink, at least keep it to < 1 drink a day, which lowers systolic pressure by 3–5 mmHg
Clinical · Monitoring, and what often gets missed
Q4: How to monitorUse an upper-arm monitor at home and have it calibrated once a yearTake 2 readings on getting up and 2 before bed, and average themMissing the target means a 3-month average still ≥ 130/80, not a single readingWhite-coat hypertension (high in the clinic, normal at home): usually no drug at first, but with regular rechecksMasked hypertension (normal in the clinic, high at home): needs treatment; it is a high-risk type, with no fewer cardiovascular events than sustained hypertension
Q5: Checking for complications
Heart: an ECG and an echocardiogram (to see whether the left ventricle has thickened)Kidneys: urine albumin, creatinine and the filtration rate ()Eyes: an eye-fundus exam (hypertensive retinopathy)Brain: only if there are symptoms
Q6: Causes that are often overlooked
Obstructive sleep apnea () (see Obstructive Sleep Apnea): snoring and daytime sleepiness with high blood pressure call for a sleep study ()Primary aldosteronism (formerly Conn's syndrome): resistant hypertension with low potassium, or an adrenal adenoma found on a scan, calls for renin and aldosterone testsOveractive or underactive thyroid, and Hashimoto's thyroiditis (see Hashimoto's Thyroiditis)Depression, anxiety and chronic stress: linked to the stress-hormone axis and sympathetic activation, and associated with high blood pressure
Important reminders
"Once you start blood-pressure drugs, it's for life" is not absolute: some people at an early stage can reduce their drugs after losing weight and quitting smoking (discuss it with your doctor; do not stop on your own)Stopping blood-pressure drugs suddenly on your own can make pressure rebound and raises the risk of cardiovascular events; don't do itLong-term non-steroidal anti-inflammatory drugs, decongestants, some traditional Chinese medicines (such as licorice) and some supplements can all raise blood pressure; watch for them
Self-check list
Every year: measure your blood pressure at home and have a check-upEspecially from age 35Any elevated reading or stage 1 hypertension: 6 months of lifestyle change first, then measure againStill not at target: see an internal-medicine doctor
Related stories: dietary drivers are in Alcohol Metabolism and Ultra-processed Foods, as well as Fructose vs Glucose Metabolism; sleep drivers in Obstructive Sleep Apnea and Insomnia; metabolic syndrome in Endocrine System; how complications develop in Cardiovascular System; nutritional tools in L-Citrulline and Magnesium, as well as Potassium & Sodium.
High blood pressure is China's leading modifiable risk for cardiovascular disease. Measuring early, acting early and managing it over the long term pays off handsomely for both the health system and the individual. It is not a disease of old age but a state of the whole metabolic and vascular system that begins around age 35.
References · 6
- SPRINT Research Group. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103-2116. 10.1056/NEJMoa1511939
- Wang, Z., Chen, Z., Zhang, L., Wang, X., Hao, G., Zhang, Z., et al. (2018). Status of hypertension in China: results from the China Hypertension Survey, 2012-2015. Circulation, 137(22), 2344-2356. 10.1161/CIRCULATIONAHA.117.032380
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