Is something dark happening right under our noses?
There’s a change that’s quietly crept up on us for the past few decades, and it’s been so slow that we’ve barely noticed.
Since the 1970s, doctors have slowly lowered blood pressure targets. That’s provided justification to prescribe more and more blood pressure pills to an ever-increasing percentage of the population.
Is there some grand conspiracy going on here to push ‘big pharma’ drugs onto people? Or is there genuine evidence to adopt more aggressive blood pressure targets? Particularly since the new blood pressure guidelines published in August of this year have changed their wording on what levels we should target.
Table of Contents
The Narrative
Let’s take a careful look at what’s going on. Because if the medical community is pushing certain blood pressure targets just to line the pockets of drug companies, that’s a huge problem.
And we need to start by asking: Why might someone think that’s what’s going on?
On the surface, there’s some data that could look suspicious. Each time we move the threshold of what counts as “high blood pressure” lower, we’re expanding the number of people who will be diagnosed with a medical problem that needs attention. If someone was sitting at a blood pressure of, say, 140 in 1980, their doctor would say, “No problem. You’re healthy.”
But now, they’ll be diagnosed with stage 2 hypertension — which sounds pretty bad. And, wouldn’t you know it, Big Pharma sells pills that can take that blood pressure level down.
So as the thresholds have changed, we’ve gone from a place where hypertension — the medical term for high blood pressure — was relatively rare to where nearly half the adult population in the U.S. has this condition. And that number reaches almost 72% for those 60 and older [1].
That’s potentially a huge number of prescriptions for anti-hypertensive medications. And it has translated into equally huge sums of money. In 2025, the global market for these medicines is estimated to be over $22 billion. And the demand is rising [2].
So the worry you’ll see on social media is this. It’s Big Pharma that’s really driving the changes in blood pressure targets [3].
A Look at the History
But your doctor is going to tell you, “Nope, it’s about the research. Our blood pressure targets are driven by evidence from compelling studies. They’re changing because our understanding is getting better.”
Who’s right? To sort this out, we need to look at how we got here.
Let’s back up to the 1940s. At the time, the idea of what counted as high blood pressure was… well, high. In a cardiology textbook published in 1948, the author said high blood pressure was above 180/110 [4].
But there was another key aspect of how they thought about blood pressure at the time. They didn’t think high blood pressure — all by itself — was necessarily something to worry about. It was only a problem if it caused problems — if, for example, the heart muscle was swelling [4].
And this was a strange attitude to have, even back then. Because we already had evidence several decades earlier that elevated blood pressure was linked to a greater risk of early death.
The year was 1925. One of the most important medical discoveries ever was just published. And it wasn’t by a group of doctors. Or scientists. Instead, it came from a group of mathematicians.
They were the people who crunched the numbers for life insurance companies to figure out who was at the greatest risk of dying young. And their data was telling an unmistakable story. There was one basic health indicator that was strongly linked to eventually having heart attacks and strokes and suffering an early death. The indicator? Blood pressure [5].
Blood pressure measurements were relatively recent at that time. Life insurance companies had started checking this metric when people applied for new policies only in the decade before. But by 1925, they had enough data that the trend was abundantly clear.
And that simple link wasn’t all they discovered. They also uncovered a dose-response relationship. The higher the blood pressure, the greater the risk [5].
This conclusion was based on the records from over 700,000 individuals. It was incredibly suggestive data. But it was largely ignored by the medical community. Which is why that medical textbook from 1948 wasn’t too worried about high blood pressure in most cases.
But this was all going to change in 1957 when early results from a groundbreaking study were published.
That study was the Framingham Heart Study. It started in 1948 to investigate the causes of heart disease. The goal was to analyze a large group of people over the long term. Researchers wanted to see which factors were linked to those who developed heart disease [6].
So they recruited over 5,000 adults between 30 and 62 from the town of Framingham, Massachusetts [6].
Only 4 years into the study, something jumped out from the data. It was clear there was a significant association between high blood pressure and the development of heart disease [7].
This had profound significance. It raised the possibility that high blood pressure, all by itself, was a health risk.
But we needed data from clinical trials to confirm these findings.
One of the most important early trials was completed by the U.S. Veterans Administration and published in 1967. It included a group of 143 men with severe hypertension. There was a group taking blood pressure medications and a placebo group. Over the study period, there were 27 severe blood-pressure-related health problems in the placebo group. In the treatment group, there were just 2. The researchers concluded that getting blood pressure under control provided a significant benefit [8].
As evidence from studies like this and the Framingham study began to mount in the 1970s, the first set of authoritative guidelines for blood pressure were published.
They came from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in the U.S. It’s a bit of a mouthful, so it goes by JNC for short. Their 1977 report included 2 important things. First, it suggested blood pressure levels that called for monitoring. Basically, doctors were told to keep a close eye on anything over 160/95. Levels over 140/90 should also be monitored to see if they were getting any higher over time [4].
No treatment was called for until the diastolic number hit 105. That’s the second, lower number in a blood pressure reading. 105 is relatively high. These days, that would land you in stage 2 hypertension. In the 1977 report, however, there were no recommendations based on the systolic number [4].
So we can see the beginnings of a progression. The textbook we looked at from 1948 used a threshold of 180 as a level of concern. And the JNC 1977 report moves that down to 160. Again, the reason for the change was a mixture of observational studies and clinical trials establishing an important link between elevated blood pressure and heart-related problems.
Then the JNC report in 1984 was the first to define hypertension based on systolic blood pressure — the higher number in a blood pressure reading. They placed the threshold at 140 [9].
But what was the justification for setting it at this level? At this point, much of the existing evidence centered on diastolic blood pressure levels. The 1984 report cites a number of clinical trials showing benefits from treating people with what was considered mild hypertension. That meant a diastolic blood pressure of at least 90 [9].
And the idea was that the systolic number of 140 roughly corresponded to the same risk profile as a diastolic level of 90. You can see that they are still paired today on a standard blood pressure chart [10].
But, overall, they took a more aggressive approach in setting the level at 140 because this much was clear: The lower our blood pressure, even within normal range, the better our health outcomes [9].
And that level of 140 for hypertension was the standard in clinical practice for a while. But, beginning in the early 2000s, there was a series of startling new discoveries that would change our understanding again.
The first landed in the prestigious journal The Lancet in 2003. It was a massive analysis of data from one million adults contained in 61 separate studies. The researchers looked at the relationship between blood pressure and death, especially from heart attacks and strokes [11].
Now at this point, we already had plenty of data showing a continuous link between elevated blood pressure and risks for things like heart attacks. As we brought blood pressure down, risks fell, too. But what we didn’t realize is how low we could take our blood pressure and still see improvements in outcomes. Remember, the standard recommendation was to try to keep it below 140.
But the researchers behind this huge new analysis found the benefits kept coming even below 140. In fact, they found the relationship between lower blood pressure and better outcomes continued all the way down to at least 115 [11].
The implications were huge. At 140, we’re leaving significant potential health gains on the table. We’re still at an elevated risk compared to lower levels.
And it was on the strength of evidence like this that the official guidelines made a major change in 2017. They recommended considering normal blood pressure as under 120. Between 120 and 129 was elevated. 130 to 139 was stage 1 hypertension, and 140 and above was stage 2 [12].
In other words, the implication here is that we ideally want to be under 120. The authors note the evidence is substantial that our risks for heart-related problems go up even as our blood pressure rises above that level [12].
There was good evidence for these recommendations at the time. But since 2017, there have been 3 additional studies that have strengthened these conclusions.
The first, called the SPRINT trial, was published in 2021. The people in this study were at high risk for heart disease, but they didn’t have diabetes or a history of stroke. They were split into two groups: One aimed for a blood pressure below 140, and the other aimed for less than 120.
Now, here’s where it gets really interesting — the results were so clear that they had to stop the study early!
The study was supposed to last 4–6 years, but after just 3.3 years, it was obvious that lowering blood pressure to below 120 made a huge difference. There was a 27% lower risk of having a heart attack, stroke, or dying from these causes each year [13].
And when it came to death rates alone, there was a 25% lower risk of dying in the group that aimed for 120 [13].
Let that sink in for a moment — a 25% reduction in the risk of death just by lowering blood pressure more aggressively. This isn’t a small improvement; it’s a game-changer.
But the story doesn’t stop there. Recently, another study in China tested these findings on an even larger and more diverse group — over 11,000 people. And it included those with diabetes and those who had already had a stroke.
Think of this study as a sequel to the SPRINT study but with an even bigger cast. And guess what? The results were just as powerful.
Lowering systolic blood pressure to less than 120 reduced the risk of heart attacks, strokes, and death from cardiovascular causes by 12% [14].
Plus, it cut the overall risk of death from any cause by 21% over three and a half years [14].
And the data keeps coming in. A new analysis of the SPRINT study data focusing on dementia just came out earlier this year. The same pattern we’ve been seeing in other areas holds when it comes to brain health, too. Those who were given the lower blood pressure target had a 14% lower chance of developing dementia during the follow-up period [15].
The takeaway is clear. The blood pressure thresholds have followed the data. The levels we used to think were safe in the past, we now know are dangerous. Most of us should aim for a systolic blood pressure of less than 120 to really protect our health.
And this is a conclusion that rests on a mountain of observational and clinical data.
The caveat here though is that for some older adults who I see in the clinic, we may need to have their blood pressure slightly higher to balance the risks vs benefits.
The real culprit in this story isn’t Big Pharma. It’s the health influencers who spread confusion and encourage people at high risk to ignore the chance to do something about their blood pressure before it’s too late.
New Guidelines Released
I mentioned at the outset that new guidelines were just published. So how do they change the picture? Have they lowered the thresholds yet again?
No. The levels for elevated (or prehypertension) and hypertension haven’t changed. But there is an important shift in approach that reflects growing urgency.
They recommend that those with hypertension and elevated cardiovascular risk shoot for at least under 130. But 120 or below is preferable [16].
The guidelines also recommend starting treatment for elevated blood pressure earlier. In lower risk categories, this starts with lifestyle changes. But medications are appropriate if patients haven’t reached their goals in 3 to 6 months [16].
Part of the reason for a more aggressive approach is that the evidence keeps getting striking about the link with dementia [16].
When it comes to keeping blood pressure under control, the guidelines now recommend lowering salt intake, even if our blood pressure is currently normal [16].
And they emphasize the potential role of salt substitutes. These are typically a mixture of ordinary salt plus a salt made with potassium. This lowers sodium intake and boosts potassium at the same time. Both help reduce blood pressure, which is why I also include potassium in MicroVitamin [16].
The guidelines also set a weight-loss target of 5% as a way to lower blood pressure effectively if we’re overweight or obese [16].
References
1. https://www.cdc.gov/nchs/products/databriefs/db511.htm
2. https://www.statista.com/outlook/hmo/pharmaceuticals/anti-hypertensive-drugs/worldwide
3. https://rxbalance.org/whos-setting-your-health-goals-your-doctor-or-big-pharma/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC8109518/
5. https://www.google.com/books/edition/Blood_Pressure/PjvQAAAAMAAJ?hl=en&gbpv=1
6. https://www.framinghamheartstudy.org/fhs-about/history/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC1550985
8. https://jamanetwork.com/journals/jama/article-abstract/336799
9. https://ostemed-dr.contentdm.oclc.org/digital/api/collection/myfirst/id/3922/download
10. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
11. https://pubmed.ncbi.nlm.nih.gov/12493255/
12. https://www.ahajournals.org/doi/10.1161/hyp.0000000000000065
13. https://www.nejm.org/doi/10.1056/NEJMoa1901281
14. https://pubmed.ncbi.nlm.nih.gov/38945140/
15. https://www.neurology.org/doi/abs/10.1212/WNL.0000000000213334
16. https://jamanetwork.com/journals/jama/fullarticle/2841006
