High blood pressure - Causes and Dietary Management

High blood pressure, or the “silent killer,” is a leading driver of most cardiovascular diseases, such as a heart attack or stroke. 

But often hypertension has no symptoms, and the only way to detect it is to regularly measure blood pressure.

And according to the leading cardiology organization in Europe, blood pressure is elevated even above 120/70!

Therefore, in the following lines we will consider:

• What are the symptoms of high blood pressure?
• What are the most common causes of high blood pressure?
• What actually lowers blood pressure?

If you want a lifestyle change that will help you control your blood pressure and help you reduce or even stop taking daily medications, book a consultation with a specialist.

What is blood pressure and when is it high?

Blood pressure is the force with which blood presses against the walls of the arteries. It is recorded as two numbers:

• Systolic (upper limit) – the pressure at the moment the heart contracts, with which it pushes the blood out.
• Diastolic (lower limit) – the pressure between two contractions when the heart relaxes and fills with blood.

It is measured in millimeters of mercury (mmHg) – a unit left over from the first mercury gauges.

When blood pressure is high, it is called hypertension. Hypertension is the most common chronic condition in the world.

The criteria for diagnosis are determined by the latest recommendations of The European Society of Cardiology (ESC), which came out in 2024, and for the USA = from the American Heart Association and the American College of Cardiology (AHA/ACC), which came out in August 2025. 

The definition of hypertension in Europe has not changed, remaining ≥140/90 mmHg when measured in the office. [1]. But ESC 2024 eliminated the previous grading (grade 1, 2 and 3) and introduced three categories:

The point of the new category of "high blood pressure" is that it includes millions of people who are not hypertensive by definition, but who already probably have an increased cardiovascular risk. 

In these cases, an assessment of the overall risk is recommended and if it is high enough, it is recommended to begin lifestyle changes as a form of treatment, rather than just observation [2],[3].

AHA/ACC Recommendations

According to AHA/ACC 2025 The classification is unchanged from 2017, i.e. hypertension starts at 130/80 mmHg:

The goal of treatment according to both organizations is similar – below 130/80 mmHg, and the American authors add the recommendation to aim for <120/80 mmHg when this is achieved safely and is well tolerated. [4].

The summarized data in the new American guideline show that at values above 120/80, each decrease in systolic pressure by 10 mmHg reduces the risk of:

• coronary heart disease – with about 17%;
• stroke – with about 27%;
• heart failure – with about 28%;
• major cardiovascular events – with about 20%;
• death from any cause – with about 13% [5].

Types of arterial hypertension

Classification by value is not the only one:

• Systolic-diastolic hypertension – the classic version.
• Systolic hypertension – elevated only the upper limit. It is typical of older people and is due to lost elasticity of the large arteries. For a long time it was considered a normal part of aging, but today it is clear that it carries an independent risk of stroke.
• Diastolic hypertension – only the lower limit is elevated. It is more common in younger people, in obesity, and in cases of increased sympathetic tone.
• White coat hypertension – the pressure is high only in the doctor's office and normal at home. It is not harmless, because some of these people develop true hypertension after years.
• Masked hypertension – the opposite. In the office, the values are normal, but outside of it – high. That is why home measurement is part of the standard diagnostics.

Two measurements in the morning and two in the evening at home for a week provide much more useful information than one measurement in the office.

How to measure your blood pressure correctly

It is important that blood pressure is measured correctly:

• No coffee, cigarettes and physical exertion at least 30 minutes before measurement.
• Sit quietly for 5 minutes – with your back flat, feet on the floor, legs uncrossed.
• The arm – bare and supported at heart level, not sagging and not lifted/tightened.
• Correct cuff size. A cuff that is too small and tight will increase the values.
• No calls or phone calls during the measurement – neither by the patient nor by the measurer.
• At least two measurements with a minute break in between, using the average.
• The first time, measure on both arms. A persistent difference of more than 10 mmHg between the two arms is a signal of vascular disease and is associated with higher cardiovascular risk. [6]. 
• Use a validated device. Automatic devices for above the elbow are reliable, while those for the wrist – not so much.

When is 24-hour monitoring necessary?

Ambulatory blood pressure monitoring (ABPM) is performed with a device that measures blood pressure automatically throughout the day. This is the gold standard for suspected white coat hypertension or masked hypertension. 

An important clarification is that ABPM it is not Holter. A Holter records an electrocardiogram, i.e. the rhythm and electrical activity of the heart, not blood pressure. The two tests answer different questions and are sometimes done together.

The specific advantage of ABPM is that it shows the night profile. It is normal for blood pressure to drop by 10-20% at night. If the drop is below 10% (so-called non-dipper) or the pressure even rises at night, the risk of cardiovascular events is higher, and obstructive sleep apnea is often detected.

Causes of hypertension and high blood pressure 

In about 90% of the cases we are talking about essential (primary) hypertension – a condition in which there is not just one cause, but multiple factors that accumulate play a role.

Heredity and age

Heredity is among the strongest factors. Dozens of genetic variants have been identified related to sodium regulation, vascular tone, and the renin-angiotensin system. [7]. 

If both of your parents have high blood pressure, your risk is several times higher than average. This is a good reason to start monitoring your blood pressure after age 30, not after age 50.

As we age, arteries lose their elasticity and systolic blood pressure increases almost linearly. In African Americans in particular, hypertension appears earlier and is more aggressive.

Sodium, potassium and the ratio between them

The problem is not just the salt – the problem is the the balance between sodium and potassium. 

Dietary sodium/potassium ratio predicts cardiovascular risk better than intake of either alone [8].

The modern diet skews this ratio in a negative direction, as it contains too much sodium from processed foods, bread, sausages and ready meals and too little potassium because people do not consume enough fruits, vegetables and legumes. 

The main sources of sodium in the diet are prepared foods, not the salt shaker on the table. [9].

Practical goals for most people are sodium about 2-3 g daily (about 5-6 g salt) and potassium at least 3.5 g daily, except in advanced kidney disease.

These sodium intake recommendations apply primarily to those 25-30% of the population who are “sodium sensitive,” the so-called “hyperresponders.”.

It is important to note that these recommendations do not apply and salt needs increase dramatically in people who sweat profusely, for example during prolonged exercise or working in high temperatures.

Obesity and insulin resistance

Obesity is one of the main factors leading to high blood pressure. There are several mechanisms that work simultaneously. [10]:

• activation of the sympathetic nervous system
• sodium retention by the kidneys
• activation of the renin-angiotensin-aldosterone system by visceral adipose tissue
• endothelial dysfunction 

Therefore, in a patient with overweight and high blood pressure, we almost always look for insulin resistance – the two conditions move together and are influenced by the same measures – most notably the waist/height ratio.

Smoking, alcohol and stress

Nicotine increases blood pressure sharply with each cigarette and accelerates the loss of elasticity of the vessels. 

Alcohol also has a clear dose-dependent relationship with the risk of hypertension, which is why the American recommendations are categorical – no alcohol is best, and if it is still taken – no more than one standard unit per day for women and two for men [4].

Chronic stress and lack of sleep have negative effects through sympathetic activation and increased cortisol. For this reason, stress management is also part of the recommendations.

Pregnancy and postpartum period

High blood pressure during pregnancy, which is often associated with preeclampsia, is a risk factor not only for the pregnancy itself, but also for the woman's entire later life. 

The new American Heart Association guideline expands recommendations regarding pregnancy, and recommends active monitoring of blood pressure even after delivery in women who had high blood pressure during pregnancy itself [5].

When is hypertension secondary?

In about 101% of patients, high blood pressure is not essential hypertension, but is a consequence of another disease:

• Primary aldosteronism – screening is recommended for all patients with resistant hypertension, regardless of whether they have low blood potassium levels. For many years, the condition was only looked for in hypokalemia and often went undiagnosed.
• Kidney diseases – chronic glomerulonephritis, polycystic disease, renal artery stenosis. The new guideline recommends testing the ratio albumin/creatinine in urine in all hypertensive patients.
• Obstructive sleep apnea – snoring, stopping breathing during sleep, daytime sleepiness and high nocturnal blood pressure.
• Thyroid diseases – both hyper- and hypothyroidism.
• Systemic autoimmune diseases – for example, lupus with kidney involvement.
• Medications and substances – with regular use of nonsteroidal anti-inflammatory drugs, corticosteroids, oral contraceptives, decongestants, stimulants, some antidepressants.
• After COVID-19 – an increase in blood pressure and worsening of control were observed in some of the patients, probably through endothelial and autonomic involvement [11].

Symptoms of high blood pressure

The most important thing you need to know is that Uncomplicated hypertension usually has no symptoms and a person does not feel it. 

Many people say, “I can feel when my blood pressure is high.“ Unfortunately, this is an illusion – perception does not reliably correlate with actual values.

Symptoms appear either at very high levels or when there is already organ damage:

• headache, typically occipital and morning;
• tinnitus, dizziness, "fly"-like spots before the eyes;
• palpitations, shortness of breath on exertion;
• nosebleed;
• facial flushing, sweating;
• nighttime urination;
• easy fatigue and reduced work capacity.

When is it an emergency?

Emergency medical attention is needed immediately if: hypertensive crisis with signs of organ damage, which include:

• severe chest pain;
• severe shortness of breath;
• weakness in one half of the body, facial distortion, speech disorders;
• visual disturbances or sudden loss of vision;
• confusion, severe headache with vomiting, seizure.

How to lower high blood pressure – hypertension treatment

Lifestyle change – the first step

Lifestyle changes can lead to significant benefits, with combining several interventions mutually reinforcing the effect.

Potassium-enriched salt substitute is now an official recommendation (grade 2a) in AHA/ACC 2025. 

The basis is the SSaSS study, conducted with nearly 21,000 participants with a history of stroke or hypertension over 60 years of age. The intervention was the replacement of regular salt with a product containing 75% sodium chloride and 25% potassium chloride, with a mean follow-up period of 4.74 years. 

The result is 14% fewer strokes, 13% fewer major cardiovascular events, and 12% fewer deaths., without a significant increase in serious adverse events of hyperkalemia [12],[13]. 

Interestingly, most of the effect was due to the added potassium, not the reduced sodium. [14].

Contraindicated or requiring careful monitoring are in chronic kidney disease, hyperkalemia and when taking potassium-retaining medications – ACE inhibitors, angiotensin receptor blockers, spironolactone, etc. potassium-sparing diuretics (triamterene, eplerenone, amiloride).

Isometric exercises are the other new recommendation. A large network meta-analysis of 270 randomized trials with nearly 16,000 participants ranked isometric training as the most effective in reducing systolic blood pressure, with a reduction of about 8 mmHg, ahead of combination training, strength training, aerobic activity, and interval training. [15],[16]. 

The best-researched options are wall squats and isometric hand grips, about three times a week, for several sets of 2 minutes each.

IMPORTANT! During the isometric effort itself, the pressure rises significantly, in some participants over 170/115 mmHg [17]. 

In cases of uncontrolled severe hypertension, aneurysm, recent cardiovascular event (last 6 months) or proliferative retinopathy, this type of training is introduced. only after medical advice!

Effectiveness of dietary supplements

There are few supplements that have a measurable positive effect on blood pressure.

IMPORTANT! Supplements are not harmless and pose serious risks, such as the use of potassium supplements for kidney disease, garlic for anticoagulant therapy, high doses of omega-3 for increased risk of atrial fibrillation, etc.

Reducing high blood pressure through medication

Regarding drug treatment, the two guidelines diverge:

• ESC 2024 – if hypertension ≥140/90 mmHg is confirmed, treatment is initiated. In the case of „high blood pressure“ (120-139/70-89 mmHg), lifestyle measures are first implemented for about 3 months, and medication is discussed if the pressure remains ≥130/80 mmHg and the 10-year cardiovascular risk is high enough (≥10%), calculated using SCORE2 / SCORE2-OP / SCORE2-Diabetes.
• AHA/ACC 2025 – medication is started at stage 1 (≥130/80 mmHg) in the presence of cardiovascular disease, diabetes, chronic kidney disease, or estimated 10-year risk ≥7.5%. The threshold for „high risk“ has been lowered from 10% to 7.5%, and the old Pooled Cohort Equations calculator has been replaced by the new one PREVENT, which includes body mass index and kidney function and gives both 10-year and 30-year risk. At low risk – medication after 3-6 months if lifestyle changes fail.

The main drug classes remain four:

1. ACE inhibitors (perindopril, ramipril, lisinopril) – block the conversion of angiotensin I to angiotensin II. A typical side effect is a dry, irritating cough.
2. Angiotensin receptor blockers (losartan, valsartan, telmisartan) – act on the same system, but lower; cough is practically absent.
3. Calcium antagonists (amlodipine, lercanidipine) – relax the vascular wall. The most common problem is ankle swelling.
4. Diuretics – thiazide-like (indapamide, chlorthalidone) are preferred over classic hydrochlorothiazide. They require monitoring of potassium, sodium, and urine.

Beta-blockers (bisoprolol, metoprolol, nebivolol) are no longer first-line in uncomplicated hypertension, but remain mandatory in concomitant ischemic disease, heart failure, tachyarrhythmias or after myocardial infarction.

Two principles that changed practice more than the emergence of new molecules:

• It starts with a combination of two medications in one pill, rather than with monotherapy and gradual addition. The effect is better, and adherence to therapy is significantly higher.
• One dose daily is preferable whenever possible.

In addition, three other possible interventions to affect high blood pressure are being worked on:

• Aldosterone synthase inhibitors. Baxdrostat is the first registered representative of this new class – approved in the US in May 2026 under the name Baxfendy, for use in combination with other antihypertensive agents in poorly controlled blood pressure. In the phase 3 study BaxHTN, the 2 mg dose lowered systolic blood pressure by 15.7 mmHg, which was 9.8 mmHg above placebo, in patients already taking two or more medications. Lorundrostat and vicadrostat are in development in the same class [24].
• Zilbesiran is a drug containing small interfering RNA that suppresses the production of angiotensinogen in the liver. The effect is long-lasting, and the application – once every 3 or 6 months.
• Renal denervation – a catheter procedure that cuts off the sympathetic nerves around the renal arteries – entered the AHA/ACC 2025 as an option for resistant hypertension in specialized centers after earlier conflicting results were followed by more convincing studies.

How to lower high blood pressure at home?

Unfortunately, there is advice circulating on the internet that can be harmful, the most popular of which is perhaps that about massaging the carotid sinuses.

Don't massage your neck. 

The so-called carotid sinus massage is recommended in many popular, but non-medical materials as a way to relieve pressure in minutes. This is a manipulation that in medicine is only applied by a doctor, under certain indications and with readiness for resuscitation. 

Cases have been described of ischemic stroke after self-massage of the neck, including in people without known vascular disease, as well as severe bradyarrhythmias and syncope [25],[26]. If there is plaque in the carotid artery, which is relatively common in hypertensive patients over 60 years of age, there is a serious risk of stroke.

Additionally, do not take an extra dose of your medication as needed unless your doctor has given you an explicit schedule. Rapidly lowering your blood pressure can cause cerebral and myocardial hypoperfusion.

High blood pressure relief

What can to do at high value without symptoms of organ damage:

• Contact your GP or a specialist who is familiar with your medical history.
• Sit still, breathe slowly for 5-10 minutes and measure again. A lot of high readings are anxiety plus poor technique.
• Practice slow, controlled breathing – about 6 breaths per minute for 10-15 minutes. The effect is modest, but real and safe.
• Don't drink coffee, smoke, or exercise for the next hour.
• If the values remain very high or any of the symptoms of organ involvement appear – seek medical attention. emergency medical care (tel. 112) instead of experimenting.