Email 1, May 8, 2025
Imagine this scenario:
You visit your doctor, and for the first time, your blood pressure reads 140/90 mm Hg. You’re not on any medication. This is new, and you’re not quite sure what it means or what to do next.
If your doctor follows current hypertension guidelines, you will be prescribed a blood pressure-lowering medication and encouraged to begin lifestyle changes, such as reducing salt intake, cutting back on alcohol, and increasing physical activity. A blood pressure of 140/90 mm Hg or higher is Stage 2 hypertension.
But the question many patients ask is:
Should I wait and see if lifestyle changes alone work? Do I really need medication now?
The answer is no.
Waiting may feel reasonable, but it can be risky.
What Research Tells Us
A 2025 study published in the journal Hypertension followed over 15,000 newly diagnosed adults with high blood pressure to evaluate how the timing of treatment affected outcomes. The findings were clear:
- Starting medication within the first month of diagnosis of Stage 2 hypertension was linked to better blood pressure control at both 6 and 30 months.
- Monotherapy—using only one drug—often fails to bring blood pressure under control. (This is consistent with clinical evidence showing that most people require two or three medications to achieve the target blood pressure.)
This study adds to the growing body of research highlighting the risks of therapeutic inertia, which occurs when treatment is delayed or not intensified even when it’s clearly needed.
What’s at Risk When Blood Pressure Is Left Uncontrolled?
Even if you feel perfectly well, elevated blood pressure silently damages critical organs. Over time, it increases the risk of:
- Heart disease
- Stroke
- Chronic kidney disease
- Sexual dysfunction
- Vision loss
- Cognitive decline and dementia
High blood pressure is often called the “silent killer” because these complications can develop with no symptoms, and sometimes the first sign is a life-altering event like a stroke or heart attack.
Confirming the Diagnosis
Before starting medication, it’s ideal to confirm the diagnosis:
- Home blood pressure monitoring can provide more accurate readings than a single visit.
- Even better is a 24-hour ambulatory blood pressure test, which captures variations throughout the day and night.
- You have to advocate for yourself.
However, once a diagnosis is made, the best course of action is early action, using both medication and lifestyle.
What Else Can You Do?
Blood pressure control isn’t only about medication. Lifestyle changes make a real difference when done consistently. I’ve created a video playlist with practical tools and tips to help you lower your blood pressure.
If you—or someone you care about—has been told they have high blood pressure, the time to act is now, not later. The damage caused by untreated hypertension is real, but with the right plan, it’s also preventable.
Reference
Barrett RB, Riesser B, Martin B, et al.
Treatment in the First Month After Hypertension Diagnosis Improves Blood Pressure Control.
Hypertension. Published online April 21, 2025.
Best regards,
Shabnam
Email 2, May
Hi
After my last email on the early treatment of newly diagnosed high blood pressure, I received a thoughtful response from a physician. Thank you, Dr. R!
He reminded me that while guidelines often focus on the 140/90 mm Hg threshold, this isn’t appropriate for everyone. For example, in an 80-year-old with poor balance or a history of falls, aggressively lowering blood pressure to 120/70 mm Hg may increase the risk of falls and serious injury.
This is why individualized care matters.
In my last email, I forgot to mention that the study I referenced (Barrett et al., Hypertension, 2025) involved much younger adults—the average age was 56.0 ± 14.8 years. That age group doesn’t represent many of our older or frailer patients.
🩺 A Call for Individualized Care
When considering whether and how to treat high blood pressure in older adults, a 2019 review in Circulation Research suggests that rather than using age as the main guide, we should tailor treatment based on function and independence. Here’s a simple way to think about it:
- What is this person’s functional status?
- Are they at risk of falls or postural hypotension?
- Are they independent in daily activities?
- Would treatment improve or worsen their quality of life?
🚶♀️ Functional Status–Based Treatment Profiles
1. Preserved Function Profile
These are older adults who are physically active, mentally sharp, and fully independent. Their blood pressure can usually be managed using the same approach as younger adults between 65 and 75.
2. Some Loss of Function, Still Independent in Daily Tasks
These people may move more slowly or feel a bit more tired, but they can still manage everyday tasks like dressing, bathing, and eating independently.
A more detailed health review can help decide whether starting or adjusting medication is a good idea.
3. Significant Loss of Function and Daily Independence
These people often need help with daily activities and may have memory problems or other serious health issues.
In these cases, the focus may shift to comfort and safety. It may be better to reduce or stop some medications rather than add more.
🔄 What Is Orthostatic Hypotension—and Why Does It Matter?
Orthostatic hypotension is when your blood pressure drops significantly when you stand up. It’s defined as a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.
This can lead to dizziness, lightheadedness, or even fainting. It’s especially important in older adults who are on blood pressure medication.
Many clinics don’t routinely check for it, but you can easily do it yourself at home.
👉 How To Test For Orthostatic Hypotension
If you notice a significant drop, it’s worth discussing with your healthcare provider.
🌿 It’s Not Always About More Medications
While medications are necessary to control blood pressure, better blood pressure doesn’t always require more pills. Several effective strategies can help naturally improve blood pressure:
- Getting better sleep, especially the deeper stages of sleep
- Low-carbohydrate food
- Adjust salt intake with guidance—some people are more salt-sensitive than others.
- Review your current medications—are any raising your BP or causing side effects? Some cold and flu over-the-counter medications and pain medications can increase BP.
- Isometric exercises such as wall sits or handgrip training
- Adding key nutrients like magnesium and omega-3 fatty acids, CoQ10
- Maintaining healthy vitamin D levels
When used together, these strategies can support blood pressure control and overall vascular health, often reducing the need for additional medications.
Final Thoughts
Good medicine isn’t just about following protocols and treating numbers—it is about providing individualized care. What matters most is safety, functional independence, quality of life, and what truly matters to the person.
Best regards,
Shabnam
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Reference
Benetos, Athanase, Mirko Petrovic, and Timo Strandberg. “Hypertension management in older and frail older patients.” Circulation research 124.7 (2019): 1045-1060.
