Demystifying Hypertension, Part I: Throw Out Your Hypertension Playbook

It’s Not 1999 Anymore

Today’s post marks a return to clinical medicine. It begins a three-part series on what good hypertension care should look like in 2025. It’s meant for clinicians and for anyone who wants to feel more informed and empowered about their own blood pressure.

Introduction

This is the first essay in a three-part series on hypertension (“high blood pressure”), a highly modifiable risk factor for many diseases, most notably heart attacks, heart failure, stroke, kidney disease, and cognitive decline. Hypertension affects more than 122 million Americans. After age 45, well over half of U.S. adults carry the diagnosis.

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My interest in hypertension began at Yale University School of Medicine in 1988 and it ultimately shaped my career path into cardiology and preventive cardiology. Hypertension captured my attention because it blends rigorous clinical-trial evidence with fascinating physiology and highly personalized care. Managing it well requires getting several things right, including accurate identification, proper measurement, thoughtful medication selection, attention to lifestyle, and careful follow-up over time.

Yet after more than thirty-five years in practice, I have watched hypertension in the United States remain persistently underdiagnosed, undertreated, and poorly controlled. Nearly half of adults with hypertension are untreated, and control remains below 30 percent nationally. These patterns reflect, in part, outdated diagnostic and management practices, but they also arise from broader forces such as cost, access, and social determinants of health that strongly influence diagnosis, treatment, and control.

This series is an effort to clarify what modern, evidence-based hypertension care should look like. It draws heavily on the 2017 and 2025 hypertension guidelines from the American Heart Association, American College of Cardiology, and other contributing organizations.

Part I is for clinicians and patients. It addresses the most common misconceptions and the essential first steps: making the correct diagnosis and using out-of-office blood pressure measurements as the foundation of treatment. Part II is geared toward clinicians, but very relevant to patients. It follows a representative real-world case to show how hypertension management can drift off course and how to choose medications when they are needed. Part III is clinical and explores the physiology and pharmacology that explain why some medications work better than others, particularly as people age. Detail-oriented or science-minded patients also may find that discussion helpful.

My goal is to make hypertension care more accurate, more rational, and more effective for clinicians and patients.

What We Were Taught and Why It Doesn’t Hold Up

Most clinicians over age forty years were trained with a hypertension playbook that reflected the best thinking of the 1980s and 1990s, yet these myths persist:

• Diagnose hypertension if the office blood pressure is 140/90 mmHg or higher → WRONG.

• Manual blood pressure readings are more accurate than automated readings→ WRONG.

• Office readings are more reliable than home readings → WRONG.

• Blood pressure control and medication assessment should be guided by the blood pressures recorded in the clinic → WRONG.

• Diastolic blood pressure (the bottom number) matters more than systolic blood pressure (the top number) → WRONG.

• Hydrochlorothiazide or a beta blocker are the best first-line medications → WRONG.

Many patients believe these myths too: almost every week, a patient is focused on their diastolic blood pressure and comes to me for better hypertension control but does not measure it at home. That framework was the consensus over wo decades ago and was shaped by the tools available, the trials then completed, the technology that was feasible, and cost constraints. But none of those assumptions have survived careful re-examination. Modern hypertension management requires letting go of old rules and outdated treatment strategies.

Why Correct Diagnosis Begins with Correct Measurement

Clinicians would not diagnose any other chronic disease based on one or two in-office measurement taken under poorly controlled conditions, yet that is still how many patients are diagnosed with hypertension. Patients walk in after parking in a crowded lot, hurrying down a hallway, feeling late, flustered, or anxious. They sit down, a cuff is wrapped on the arm over a coat or sleeve, someone hits a button, and the number that appears becomes the foundation of their diagnosis. Can you imagine diagnosing diabetes based on a blood sugar measured this way? Of course not.

Blood pressure is dynamic. It fluctuates minute to minute with posture, talking, background noise, caffeine, anxiety, pain, and also is influenced by the white coat effect, seen in about 20% of people, where blood pressures in the office are notably higher than at home. Blood pressure can vary by 10 to 20 mmHg in a matter of minutes. There even is a phenomenon that affects about 10 percent of people called “masked hypertension,” where their blood pressure is normal in the office and high at home – essentially, the opposite of the white coat effect. When clinicians rely on rushed office values as the “real” number, misdiagnosis follows. When measured properly, the “true” blood pressure is often very different from the hurried clinic reading.

And correct technique matters more than most clinicians realize. The following steps are essential:

• Use a validated upper-arm automatic blood pressure system

• Ensure the cuff fits properly and is placed on the bare upper arm

• The patient should be seated quietly for at least five minutes with feet on the floor, back supported, and arm supported at heart level.

• No talking, multitasking, or dangling legs.

• Multiple readings should be obtained and averaged.

Now consider the mayhem of a busy health clinic or doctor’s office. How likely is it that blood pressure will be measured accurately? And even when it is, white coat and masked hypertension still affect up to one-third of people. The solution is simple: home blood pressure monitoring, using the technique above and validated upper-arm systems (Omron and A&D Medical are reliable options; see the full list here).

Why Home Blood Pressure Readings Are Mandatory

The biggest shift in modern hypertension care is the central role of out-of-office measurement. Home blood pressure monitoring no longer is optional. It is the most reliable way to confirm the diagnosis and titrate therapy.

This matters not just because of white-coat and masked hypertension, but because home readings capture the lived experience of blood pressure, not the snapshot created by an anxious morning. They also can help identify blood pressure patterns that would otherwise go unnoticed.

Guidelines moved toward home readings as a core requirement for diagnosis and treatment nearly a decade ago for good reason: when home readings guide therapy, control rates rise, medication selection improves, and adverse effects decrease. It only makes sense that the numbers that shape treatment and risk should come from the environment where people live their lives.

This might seem more cumbersome than the traditional approach, but it protects patients from overdiagnosis and undertreatment. It also helps align treatment with the patient’s unique physiology and circumstances. Finally, skip cuffless monitors. They are not accurate enough for clinical use. They are toys, not clinical tools.

The Six Steps to Modern Hypertension Care

1. Make the correct diagnosis

2. Use out-of-office blood pressure measurements

3. Identify secondary and contributing causes

4. Choose the right initial medication(s)

5. Use the right medication combinations

6. Lifestyle, lifestyle, lifestyle

Step 1: Make the Correct Diagnosis. This is the foundation for everything else. When diagnoses are rushed, medication algorithms become guesswork, create unnecessary side effects, and lead to under- or over-treatment. When diagnoses are careful, treatment plans become precise.

Step 2: Use Out-of-Office Blood Pressure Measurements for Diagnosis and Management. Hypertension cannot be understood by a few clinic readings every six months. The rhythms of daily life shape blood pressure in ways that clinic measurements simply cannot capture. Home monitoring closes that gap.

Once clinicians fully integrate Steps 1 and 2 into their practice, the rest of hypertension management becomes far less complicated. The remaining questions - which drugs to start, how to combine them, and when to look for secondary causes - fall into place naturally once the diagnosis is correct.

What Comes Next

Part II will review secondary and contributing causes of hypertension, explain how to get off on the right foot by choosing the correct initial medication and combinations, and outline the core lifestyle elements that matter most. I also will follow a typical patient whose case reflects how hypertension care goes off the rails when old habits drive decisions. The missteps are familiar, and their cumulative effect contributes to the epidemic of uncontrolled blood pressure despite multiple medications.

Part III will explain key nuances of medication classes and agents, such as which angiotensin receptor blockers (ARBs) are most effective, why they may outperform angiotensin-converting enzyme (ACE) inhibitors, why beta blockers underperform, why chlorthalidone is superior to hydrochlorothiazide, and how the biology of aging fundamentally changes pressure-wave propagation in the arterial system.

Hypertension management is not complicated, but it is misunderstood. Once the misconceptions fall away, the path to effective care becomes much more straightforward.

References:

· Martin SS. et al. 2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2025;151:e4–e660. DOI: 10.1161/CIR.0000000000001303https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001303

· Whelton PK, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:1269-1324. doi: 10.1161/HYP.0000000000000066

· Jones DW, et al. AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension 2025; 82:e212-e316. doi: 10.1161/HYP.0000000000000249.