What is Your Blood Pressure Telling You?

Maybe it’s too much salt, alcohol, or political news? Maybe it’s time for medication? Let’s move beyond 120/80 🩺

Apr 08, 2025

ICYMI 👉

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I recently saw a patient, a 58-year-old executive who arrived with a notebook filled with meticulous blood pressure readings from home. He'd been tracking his numbers twice daily for months as I had suggested, his jaw tightening as he showed me the data.

“I can't seem to get below 124/78,” he said. Despite cutting out salt, increasing his exercise to four times a week, and losing eight pounds, he couldn’t get his numbers down to the holy grail of 120/80. For decades, this threshold has defined the boundary between "normal" and "concerning" blood pressure.

“Should we try a different medication?” he asked.

I had diagnosed him with elevated blood pressure two years prior when his “top” number (i.e., the systolic blood pressure readings) was running in 138-142 range, and when his “bottom” number (i.e., the diastolic blood pressure readings) ranged from 86-90. These readings were recorded on repeated visits over time and were confirmed with his home blood pressure device. I started him on a low-dose angiotensin receptor blocker (Losartan) and instructed him to aim for readings in the 120s/70-80s.

But somewhere along the way, he had fixated on the textbook 120/80. Despite the dramatic improvements in his blood pressure as a result of medication plus lifestyle, he still felt like he was failing because he couldn't reach this target.

I get it. The American medical system has conditioned patients to view metrics like blood pressure, BMI, and cholesterol as "good" or "bad.” The wellness industry suggests that certain health problems (such as high blood pressure or obesity) signal a lack of adequate willpower.

Of course, clinical guidelines and standard definitions are crucial in healthcare. Personal responsibility is part of everyone’s bigger health picture. But human physiology isn’t always under our personal control. It also isn’t black or white.

When Guidelines Shift

In 2017, the American College of Cardiology and American Heart Association made waves by redefining hypertension. Suddenly, the threshold dropped from 140/90 to 130/80. Overnight, millions of Americans "became hypertensive" without any change in their actual condition.

The American Heart Association has defined the following blood pressure categories:

Optimal: Less than 120/80 mmHg
Normal: 120-129/80-84 mmHg
Elevated: 130-139/80-89 mmHg
Stage 1 Hypertension: 140-159/90-99 mmHg
Stage 2 Hypertension: 160 or higher/100 or higher

These shifts in definitions weren’t arbitrary—they were based on studies suggesting cardiovascular risk begins to increase at lower readings than previously thought. But it created confusion, anxiety, and led many to wonder: am I sick now when I was healthy yesterday?

The reality is that blood pressure, like blood sugar, cholesterol, and weight, exists on a spectrum. Your cardiovascular risk doesn't magically jump when you cross from 129 to 130 systolic. It's a gradual, continuous increase that depends on numerous factors beyond just the numbers.

What Your Blood Pressure Really Means

When I talk with patients about blood pressure, I encourage them to think of it less as a diagnosis and more as one vital sign among many that tells us something about their cardiovascular health.

A blood pressure reading is a snapshot—influenced by your stress level, what you ate, how well you slept, whether you exercised that day, and even how the measurement was taken. One elevated reading doesn't define you, just as one normal reading doesn't guarantee cardiovascular health.

What matters more is:

Your pattern over time: Consistent elevations mean more than a single high reading
Your overall cardiovascular risk profile: Family history, cholesterol levels, smoking status, diabetes, etc.
How your blood pressure affects you: Are you experiencing symptoms? Is it causing organ damage?
Your personal context: Age, other health conditions, medications, stress level, sleep patterns, and other lifestyle factors all matter

For an anxious patient with a one-off reading of 128/82, for example, I will explain that this doesn’t mean she suddenly has a disease. It is a signal to pay attention, monitor regularly, and consider lifestyle modifications—not a reason for medication or panic (at least not yet!)

For an unbothered patient with repeated readings of 142/88, I will take time to explain that consistently elevated readings increase the risk of heart attack, stroke, and kidney disease over time. I will formulate a plan to address any reversible root causes of high blood pressure (such as alcohol use, Ibuprofen use, sleep apnea) and recommend medication and lifestyle changes as needed.

The Gray Zone (Where Most People Actually Live)

Most of my patients don't have perfectly normal blood pressure all the time, nor do they have severe, unmitigated hypertension; they live somewhere in the middle. Maybe their systolic pressure hovers between 125-138, or their diastolic fluctuates between 82-88. They're in what I call the "gray zone."

This gray zone is exactly the space where the medical system often fails people. This is no one’s fault in particular; it’s our clunky medical system doing the best it can. But living in this gray zone requires a different approach—one that acknowledges gradients of risk and embraces personalized decision-making.

If you fall into this blood pressure gray zone, here's how you might approach it:

See your doctor to contextualize the numbers: I might tell a patient something like this: “Your reading of 135/84 puts you at somewhat increased risk compared to someone at 118/76, but it doesn't mean you have a disease. Let's look at your overall picture."
Assess total cardiovascular risk: Age, sex, cholesterol, smoking status, diabetes, family history, and other factors all influence how concerned we should be about borderline blood pressure.
Discuss personal preferences and values: Some patients are medication-averse and highly motivated to make lifestyle changes. Others prefer a pill if it means less lifestyle disruption. Neither approach is wrong—it's about finding what works for each individual.
Set personalized targets: For some patients (like those with diabetes or kidney disease), we aim for lower numbers. For others, slightly higher targets may be appropriate. Blood pressure goals are not one-size-fits-all.
Create a home monitoring plan: Regular readings at home often tell us more than sporadic office visits. Patterns matter more than individual readings. A study from 2024 reminds us that the best way to get an accurate reading is to:
- Sit in a comfortable chair, placing both of your feet flat on the floor.
- Place your arm supported on a table.
- Position the middle of the blood pressure cuff at heart level
- Take some slow, deep breaths to relax (and don't talk about politics!)

Reclaiming Agency over Your Blood Pressure

In my experience, when patients are labeled "hypertensive," they often view it as something that happens to them—a condition that always requires medical intervention rather than a process they can influence.

The truth is, blood pressure is one of the most modifiable aspects of cardiovascular health. Even small changes can make significant differences:

Regular physical activity can lower systolic blood pressure by 5-8 mmHg
Reducing sodium intake can drop it by 2-8 mmHg
The DASH diet (rich in fruits, vegetables, whole grains, and low-fat dairy) can reduce it by up to 11 mmHg
Limiting alcohol to moderate levels can lower it by about 4 mmHg
Stress management techniques like meditation can help by 2-10 mmHg

For many in the "gray zone," these approaches—alone or in combination—can move blood pressure into a healthier range without medication. And even for those who do need medication, these lifestyle modifications can reduce the number or dosage of drugs required.

Instead of asking "Do I have hypertension?" you might consider asking:

"What's my cardiovascular risk profile?"
"How does my blood pressure contribute to that risk?"
"What approaches (lifestyle, medication, or both) make the most sense for my situation?"
"What can I do to improve my vascular health overall?"

The Upshot

I hope by understanding the nuances of blood pressure management, you feel empowered to take an even more active role in your cardiovascular health. After all, the goal isn't just to have a number below a certain threshold. It's to live well, with the energy and health to do the things that matter to you. And that's something worth measuring!

QUESTIONS 🙋🏻‍♀️

What approaches have you found most effective for managing your blood pressure?
Do you find health "thresholds" (for blood pressure or any other health metrics) helpful or anxiety-inducing?

I'm all ears!

If you want to hear more about the nuance around the numbers of cholesterol, check out my recent Q&A where I break down this question around high blood pressure.