High blood pressure damages the heart, kidneys, brain, and eyes for years before it produces a single symptom. Nearly half of American adults have it. Most of them are not at goal.
The numbers
- Normal: under 120/80
- Elevated: 120–129 systolic, under 80 diastolic
- Stage 1: 130–139 systolic or 80–89 diastolic
- Stage 2: 140 or higher, or 90 or higher
- Hypertensive crisis: above 180/120 — seek care immediately
The treatment target is below 130/80 for nearly everyone. Not a lower target for the young and a looser one for the old. The 2025 guideline made this universal, with narrow exceptions for people who are institutionalized, have limited life expectancy, or are pregnant.
| Blood pressure (mmHg) | Category |
|---|---|
| Below 120 / 80 | Normal |
| 120–129 / under 80 | Elevated |
| 130–139 / 80–89 | Stage 1 hypertension |
| 140+ / 90+ | Stage 2 hypertension |
| Over 180 / over 120 | Hypertensive crisis — seek care now |
What changed, and why it matters to you
The guideline that governed blood pressure care from 2017 was replaced in 2025. Three changes are worth knowing about, because they alter what should happen at your visit.
Risk is calculated differently. The PREVENT equation replaced the older Pooled Cohort Equation. It estimates ten-year cardiovascular risk more accurately, and it drives the decision about when to start medication in the 130–139 range.
Medication is not a last resort. At 140/90 or above, drug therapy starts alongside lifestyle change, not after it fails. At 130–139/80–89, medication is recommended if three to six months of lifestyle change has not brought you to goal, or immediately if your cardiovascular risk is elevated or you already have kidney disease, diabetes, or established heart disease.
First-line drug selection is race-neutral. Thiazide diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers, chosen on the basis of your other conditions rather than your race. For stage 2, a single-pill combination of two classes is preferred, because it works faster and people actually take it.
Beta blockers are not first-line for uncomplicated hypertension. They are excellent drugs for other indications and they are still prescribed for blood pressure alone more often than they should be.
Why a nephrologist
The kidney sets long-term blood pressure. It is also the organ most reliably destroyed by the failure to control it.
Kidney disease causes hypertension, hypertension causes kidney disease, and the loop tightens. Roughly one in five people with high blood pressure has an identifiable secondary cause, and most of those causes are renal, endocrine, or vascular — primary aldosteronism, renal artery stenosis, obstructive sleep apnea, thyroid disease.
Primary aldosteronism alone accounts for somewhere between five and ten percent of all hypertension, and the overwhelming majority of cases are never diagnosed. It is curable in some patients and specifically treatable in the rest. Finding it requires knowing to look.
If your blood pressure is not controlled on three drugs including a diuretic, or if it appeared suddenly, or before age thirty, or with low potassium, the question is not which drug to add. The question is what is actually causing it.
What we do
Confirm the diagnosis with out-of-office measurement, because roughly one in five people diagnosed with hypertension in a clinic does not have it, and another substantial group has masked hypertension that only shows up at home. Ambulatory monitoring settles both.
Screen for secondary causes when the pattern warrants it, rather than adding a fifth medication to an undiagnosed adrenal adenoma.
Protect the kidney — albumin-to-creatinine ratio, eGFR, and the drugs that slow progression rather than merely lower a number.
And use home blood pressure monitoring to guide titration, because what your pressure does across a week matters more than what it did in our exam room.
When to come in
If your blood pressure is above 130/80 on repeated readings. If you take three medications and remain above goal. If it rose abruptly, or began before thirty, or comes with low potassium, episodic sweating, or snoring with daytime somnolence.
And if you have kidney disease of any stage, because the target, the drug selection, and the monitoring all change.