High blood pressure, or hypertension, is a common condition where the force of blood against the artery walls is consistently too high. This sustained pressure can quietly damage blood vessels and is the most prevalent modifiable risk factor for developing serious conditions like heart attack, stroke, and kidney disease. For decades, the standards for defining and treating this condition were set by the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Clinicians today rely on a newer, evidence-based standard to guide diagnosis and treatment protocols for adults.
Why the Guidelines Changed
The standards for blood pressure evolved after the last report from the Joint National Committee (JNC 8). The JNC ceased issuing subsequent updates, leading to a transition in clinical practice. The widely accepted current standards are the 2017 guidelines released by the American College of Cardiology and the American Heart Association (ACC/AHA).
This shift was driven by large-scale clinical trial data supporting the benefits of a lower blood pressure target. A landmark study, the Systolic Blood Pressure Intervention Trial (SPRINT), was particularly influential. SPRINT demonstrated that aggressively treating systolic blood pressure to a target below 120 mm Hg, compared to the previous standard of 140 mm Hg, significantly reduced the rates of cardiovascular events and overall mortality in high-risk adults.
The Current Blood Pressure Categories
The ACC/AHA guidelines established a new framework for classifying blood pressure readings. Blood pressure is measured using two numbers: systolic pressure (the upper number) and diastolic pressure (the lower number). The new system defines four distinct categories to help determine a patient’s risk and the appropriate course of action.
A reading of Normal blood pressure is now defined as a systolic pressure less than 120 mm Hg AND a diastolic pressure less than 80 mm Hg. The next category, Elevated blood pressure, occurs when systolic pressure is between 120 and 129 mm Hg AND diastolic pressure remains less than 80 mm Hg. Lifestyle changes are necessary at this stage to prevent progression to hypertension.
Stage 1 Hypertension is diagnosed when systolic pressure is between 130 and 139 mm Hg OR diastolic pressure is between 80 and 89 mm Hg. This stage represents a significant increase in cardiovascular risk. Finally, Stage 2 Hypertension is defined by a systolic pressure of 140 mm Hg or higher OR a diastolic pressure of 90 mm Hg or higher. This classification indicates a clear need for a combination of lifestyle changes and medication.
Foundational Lifestyle Recommendations
Lifestyle recommendations are a foundational component of treatment for all stages of hypertension. Dietary adjustments focus on adopting the Dietary Approaches to Stop Hypertension (DASH) eating plan. This diet emphasizes vegetables, fruits, and whole grains while including low-fat dairy products, poultry, fish, and nuts. The DASH plan works by boosting minerals like potassium and magnesium, which help regulate blood pressure.
A major focus is the reduction of sodium intake. The guidelines recommend limiting daily sodium consumption to less than 2,300 milligrams, with an ideal target of less than 1,500 milligrams per day for most adults with hypertension. Increasing potassium intake through diet, often achieved by consuming more fruits and vegetables, is also recommended to help counteract the effects of sodium.
Physical activity plays a significant role in lowering blood pressure. Adults should aim for at least 90 to 150 minutes per week of moderate-intensity aerobic physical activity, such as brisk walking. Regular dynamic resistance exercise may also contribute to blood pressure reduction. Limiting alcohol consumption is another important lifestyle modification, with men advised to have no more than two standard drinks per day and women no more than one.
Treatment Goals and Medication Strategy
The goal for pharmacological treatment in most adults with confirmed hypertension is to achieve a blood pressure reading below 130/80 mm Hg. This target applies particularly to those with existing cardiovascular disease or a high estimated 10-year risk of heart disease or stroke.
Medication is generally initiated immediately for all patients diagnosed with Stage 2 Hypertension. For individuals with Stage 1 Hypertension, medication is recommended only if they have a high 10-year cardiovascular risk, or existing conditions like diabetes or chronic kidney disease. Those with Stage 1 hypertension and a low cardiovascular risk are first advised to pursue lifestyle changes for three to six months before considering drug therapy.
The strategy for medication often involves combination therapy, especially for those with Stage 2 Hypertension. This approach uses two different classes of anti-hypertensive drugs, sometimes combined into a single pill, to achieve control more effectively and quickly. For those with Stage 1 Hypertension who require drug therapy, starting with a single agent may be reasonable. Medication decisions are individualized based on a patient’s specific health profile and should be made in consultation with a healthcare provider.