Turn Down the Pressure

As society increasingly measures blood pressure, it is increasingly important to have perspective on what high blood pressure means.

Hypertension (or high blood pressure) is one of the most important risk factors for cardiovascular disease. Recognition and treatment of chronic HTN have surely extended life and prevented much suffering. But blood pressure is a dynamic, complex number to interpret and treat. Here, we feature the voice of Josh Lieberman, a practicing clinician, who provides nuanced insights regarding blood pressure. As we amble into the digital era, the definition of normal and abnormal will need to be clarified — lest we harm people in our enthusiasm to help. JMM

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Every medical professional knows that controlling blood pressure saves lives. High blood pressure killed nearly 686,000 Americans in 2022. For every 10 point drop in systolic pressure, we lower our patients’ risk of stroke by 27%, heart failure by 29%, CAD by 17% and all-cause mortality by 13%.

But here's where we've gone wrong: In our crusade against chronic hypertension, we've started treating every blood pressure spike like a medical emergency. We're so terrified of high numbers that we've forgotten a basic truth — blood pressure is supposed to fluctuate.

The Insurance Companies Knew First

The medical profession's relationship with hypertension has an embarrassing history. It was insurance companies, not doctors, who first identified the dangers of high blood pressure. In the early 1900s, actuarial analyses showed that applicants with elevated BP died younger from stroke and heart disease. Insurers were already raising premiums and denying coverage, while physicians still dismissed hypertension as harmless, referring to it as "benign essential hypertension."

The medical establishment fought this idea for decades. Throughout the 1940s and into the 1950s, doctors believed that high blood pressure was a normal part of aging, and treating it might actually cause harm.

The Framingham Heart Study, conducted in the 1950s and 1960s, finally provided epidemiological proof, and randomized trials in the 1960s and 1970s demonstrated that lowering blood pressure saved lives. Medical opinion shifted overnight, and we became evangelical about blood pressure control.

The Overreaction Issue

The greater availability of home monitoring has now set us up to overtreat hypertension. Patients often call because their blood pressure was high "for a few hours". Knowing their blood pressure is high often makes it higher. Doctors sometimes respond to these spikes by escalating medical therapy because we have taught generations of doctors that all high blood pressure needs instant correction.

During residency, I would get urgent calls from nurses about elevated readings and I was taught to order IV medications immediately. But does this actually help patients?

According to the evidence, the answer is a clear “No”.

A 2020 study of nearly 23,000 adults found that treating high blood pressure in the hospital with oral or IV medications actually increased rates of kidney and heart injury. A 2023 VA study confirmed the same disturbing pattern—aggressive inpatient blood pressure treatment led to more adverse events, not fewer.

Not only do we overtreat inpatient blood pressure, but we also do it in the outpatient setting. We continue sending patients from clinic visits straight to the ER simply because of a high reading, even when they feel fine. A 2016 study proved this doesn't work. Researchers compared patients in the office with systolic pressure over 180 mmHg who were sent home with those who were rushed to the ER. The results? No difference in outcomes over six months.

How High Can You Go?

So what's the real danger of intermittent high blood pressure? We actually have data on this question.

In 1985, researchers wanted to know how high blood pressure could spike during exercise. They inserted catheters directly into weightlifters' arteries and measured their blood pressure during maximum lifts.

The results were staggering. During double-leg presses, average blood pressure hit 320/250 mmHg, with one subject reaching 480/350 mmHg. Even single-arm curls pushed pressures to an average of 255/190 mmHg.

A follow-up study confirmed these extreme elevations, documenting pressures up to 345/245 mmHg during heavy lifts.

These studies proved something crucial: The human body can handle intermittent extreme blood pressure elevations just fine.

The Real Distinction

The key tension is that chronic high blood pressure will kill you. Intermittent high blood pressure won't — even when it's very high.

When a patient calls panicked about their blood pressure, don't reach for the prescription pad. Ask what might have contributed to the reading. Did they just have an argument? Eat restaurant food the night before? (Any restaurant meal contains enough sodium to spike your pressure.)

Instead of medication adjustments, patients can try these immediate interventions:

• Mindfulness exercise

• Brief meditation

• Light activity like walking or cycling

• Simply waiting

Tell them to recheck tomorrow. If their pressure is elevated day after day, then we might have a problem worth treating.

And that treatment doesn't have to mean pills. Reducing salt intake, improving sleep quality, engaging in regular exercise, and limiting alcohol consumption can all provide significant blood pressure benefits without adverse side effects.

The Bottom Line

We've created a generation of patients (and doctors) terrified of normal physiological variation. Blood pressure spikes helped our ancestors survive — it's a feature, not a bug.

The irony is rich: In our zeal to prevent the real dangers of chronic hypertension, we're causing actual harm by overtreating normal fluctuations. We're giving medications that can cause kidney damage or falls to prevent theoretical cardiovascular events that won't happen from temporary blood pressure elevations. Reserve aggressive treatment for patients who truly require it: those with persistently elevated readings over time.

If your patient's blood pressure hits 200 for an hour after a stressful day? That doesn’t call for treatment. That's not an emergency — that's being human.

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The author is an independent cardiologist in Milwaukee and has spent too many sleepless nights ordering unnecessary blood pressure medications.