Blood pressure in focus: what it reveals about our vascular health

Blood pressure is one of the health measurements that many people only pay attention to when it is abnormal. Yet it changes long before symptoms occur. A single high reading does not mean hypertension. However, if pressure in the blood vessels remains elevated over a longer period, the cardiovascular system can come under increasing strain.

Particularly with healthy ageing in mind, it is therefore worth taking a closer look at blood pressure. It is not just a number on a blood pressure monitor, but a marker of strain on the vascular system and part of a complex interaction between the heart, blood vessels, kidneys, hormones and nervous system.

Modern blood pressure research reveals an important detail: risk does not begin to rise only at a single magic threshold. Rather, there is a continuous association between blood pressure and cardiovascular events across a wide range. At the same time, individual treatment targets differ according to age, coexisting diseases, overall risk and tolerability.

Anyone wishing to understand their blood pressure should therefore distinguish between three questions: what exactly is being measured? Why does blood pressure change as we get older? And what can actually be influenced in everyday life?

Contents

1. How blood pressure arises
2. Why high readings matter in the long term
3. What happens to blood vessels as we age
4. Which blood pressure levels are now considered elevated
5. Why a single measurement is not enough
6. What influences blood pressure in everyday life
7. Movement, diet and salt as factors you can adjust
8. What medicines achieve and when they become important
9. Blood pressure and the brain: what research shows
10. How to monitor your own blood pressure sensibly
11. What really matters for healthy ageing
12. References

How blood pressure arises

With every heartbeat, blood is pumped into the arteries. This creates pressure on the vessel walls. This pressure can be measured as blood pressure.

Two values are distinguished: the systolic blood pressure and the diastolic blood pressure.

The systolic value describes the pressure that arises when the heart muscle contracts and ejects blood into the arteries. The diastolic value refers to the pressure during the heart's relaxation phase.

A blood pressure of, for example, 120 over 80 mmHg therefore does not mean that blood constantly flows through the body at precisely this pressure. The two numbers represent different phases of the cardiac cycle.

The heart alone does not determine blood pressure

The pressure in the blood vessels does not depend solely on how forcefully the heart pumps. The vascular resistance also plays a central role.

Arteries and smaller vessels can change their diameter. When the muscles in the vessel walls contract, resistance to blood flow rises. When the vessels dilate, resistance can fall.

Other factors include the amount of blood in the circulation, the elasticity of the large arteries and regulation by the kidneys, hormones and autonomic nervous system.

The kidneys are particularly important here. Among other things, they influence how much sodium and water the body retains or excretes. Through the renin–angiotensin–aldosterone system they can also activate a hormonal cascade that influences vessel diameter and fluid balance.

Blood pressure is therefore not a static value. It constantly responds to physical activity, stress, sleep, temperature, posture and numerous other stimuli.

This also explains why a blood pressure of 135 over 85 after quickly climbing the stairs means something different from the same reading after several minutes of rest.

Why high readings matter in the long term

Blood vessels are not rigid pipes. Their walls consist of different cell types and structures that can respond to mechanical stimuli.

If blood pressure is elevated over a longer period, correspondingly greater forces act on the vessel wall. This can be accompanied by structural changes. The vessel wall can thicken, and the vessels can lose elasticity.

At the same time, the function of the endothelium, the thin layer of cells lining the inside of blood vessels, changes. Among other things, the endothelium regulates vessel diameter, blood clotting and various signalling pathways.

Chronically elevated blood pressure therefore does not represent an isolated problem of blood pressure measurement. It is associated with changes that can affect several organ systems.

The WHO describes hypertension as an important risk factor for cardiovascular disease, stroke and kidney disease. Particularly relevant is the fact that many people with elevated blood pressure initially have no symptoms.

Why the body can initially tolerate high readings

The insidious aspect of elevated blood pressure is that the body can partly adapt to altered pressure conditions.

However, this does not mean that persistently high blood pressure has no consequences.

The vascular system can function for a long time despite increased strain. At the same time, changes may develop that are initially imperceptible. This is why how you feel cannot reliably tell you whether your blood pressure is normal.

High blood pressure often causes no typical symptoms.

This is precisely why measurement is more important than how you feel.

What happens to blood vessels as we age

Blood vessels change as we get older. One major process affects the large arteries, particularly the aorta.

Young, elastic vessels can expand during a heartbeat and absorb part of the pressure wave generated by the heart. The term arterial compliance is often used for this property.

As we get older, the elasticity of the large arteries decreases. Among other things, components of the vessel wall such as elastin and collagen change. Long-term metabolic and inflammatory processes can also contribute to structural changes in the vessels.

A stiffer aorta can transmit the pulse wave more quickly through the vascular system. This changes the pressure load reaching different organs.

This is particularly relevant for organs with a sensitive microcirculation, including the brain and kidneys.

Age and blood pressure influence each other

The association between age and blood pressure is therefore not simply linear.

On the one hand, blood vessels change throughout life. On the other, vascular ageing can itself be promoted by blood pressure elevated over decades.

This creates a cycle: less elastic vessels can make blood pressure regulation more difficult, while persistently high pressure loads are in turn associated with structural changes in the vessel wall.

This is one reason why blood pressure is of interest to preventive medicine. It does not just reflect the current state. Long-term blood pressure readings can tell us something about the mechanical strain to which the vascular system has been exposed over the years.

However, this should not create the impression that blood pressure is the sole “measure of ageing”. Vascular health depends on numerous factors, including genetic predisposition, smoking, physical activity, metabolic health, diet and existing diseases.

Which blood pressure levels are now considered elevated

It is worth looking closely at the thresholds, because different guidelines have used different categories in the past.

The 2024 ESC guideline distinguishes three ranges in its blood pressure classification.

The classification initially describes the blood pressure measured in the clinic. It does not alone determine whether treatment is necessary. Overall cardiovascular risk, existing diseases, age and the individual situation are also taken into account.

The distinction between elevated blood pressure and diagnosed hypertension is important here. A reading of, for example, 135/85 mmHg falls within the elevated blood pressure range under the new ESC classification, but does not automatically mean that treatment with medication is required.

The ESC guideline emphasises that cardiovascular risk increases continuously with rising blood pressure levels. The categories therefore primarily serve to structure further assessment and possible treatment. They are not sharp biological boundaries at which health risk suddenly changes.

Blood pressure category and treatment are not the same

With elevated blood pressure, the overall cardiovascular risk is considered first. This includes, for example, existing cardiovascular disease, diabetes, chronic kidney disease and other risk factors.

For people with clinic blood pressure of 120 to 139/70 to 89 mmHg, the ESC therefore recommends an additional risk assessment. For people at lower cardiovascular risk, lifestyle measures are the initial priority. At higher risk, however, treatment with medication may also be considered.

For confirmed hypertension from 140/90 mmHg the ESC recommends treatment with lifestyle measures and, depending on the individual situation, blood pressure-lowering medicines. For diagnosis, the elevated reading should, where possible, be confirmed by a measurement outside the clinic or a repeat standardised clinic measurement.

This is crucial for interpreting readings in everyday life: a single reading on a blood pressure monitor is not yet a diagnosis. Conversely, repeatedly elevated blood pressure should not be ignored simply because there are no symptoms.

Why a single measurement is not enough

Blood pressure is surprisingly sensitive to external conditions.

Coffee, nicotine, physical activity, excitement, a full bladder or simply the situation in a doctor's surgery can influence the reading. Posture and the cuff used also play a role.

The 2024 ESC guideline therefore recommends standardised measurement. Before measuring, you should sit quietly for a few minutes. Your back and arm should be supported, and your legs uncrossed. Physical activity, caffeine and nicotine should be avoided in the preceding half-hour.

Clinic readings and blood pressure at home

Another distinctive feature is the so-called white-coat effect. Some people have higher readings in medical settings than in their normal daily life.

Conversely, so-called masked hypertension can also occur. In this case, readings in the clinic are normal, while those outside the clinic are elevated.

This is why measurements outside the doctor's surgery are gaining importance.

The ESC guideline recommends a standardised approach to home measurement. Usually, two measurements are taken in the morning and two in the evening, one to two minutes apart, over at least three days and ideally up to seven days. The average is then considered.

A single measurement is therefore more of a snapshot. Several readings obtained under standardised conditions provide a much more informative picture.

What influences blood pressure in everyday life

Blood pressure does not arise independently of lifestyle. Sleep, movement, body weight, diet, alcohol, nicotine and stress can influence blood pressure regulation. At the same time, it is important not to turn this into a simple equation. Not every case of elevated blood pressure can be normalised through a single change.

Factors that can be influenced include, above all, physical activity, diet and body weight. Salt consumption also plays a role. The WHO also identifies tobacco use and high alcohol consumption as modifiable risk factors for elevated blood pressure.

Stress is not just a matter of wellbeing

Acute stress activates the sympathetic nervous system, among other things. Heart rate and vascular tone can increase, temporarily raising blood pressure.

Initially, this is a normal physical response. It becomes more problematic when strain, lack of sleep and insufficient recovery periods persist together.

A distinction should be made between acute blood pressure spikes and persistently elevated blood pressure. A stressful working day can influence an individual reading without automatically resulting in hypertension.

This is another reason why blood pressure should always be assessed over several measurements and under conditions that are as comparable as possible.

Body weight and blood pressure

As body weight increases, various mechanisms that influence blood pressure may come together. These include changes in metabolism, the sympathetic nervous system, kidney function and the renin–angiotensin–aldosterone system.

For people who are overweight or have obesity, weight loss may therefore be accompanied by a reduction in blood pressure. The size of this effect varies from person to person.

This does not mean that body weight alone determines blood pressure health. People of normal body weight can also develop hypertension, for example because of genetic factors, age or certain diseases.

Movement, diet and salt as factors you can adjust

Among modifiable factors, regular movement is one of the best-studied ways of favourably influencing blood pressure.

Physical activity does not only have an effect during training. Regular movement can influence vascular function, physical fitness and various metabolic processes over the long term.

The WHO recommends that adults undertake at least 150 minutes of moderate physical activity per week or 75 minutes of vigorous activity. Muscle-strengthening activities on at least two days a week are also recommended.

This does not have to mean completing structured endurance training five days a week. Brisk walking, cycling, swimming or other activities can also contribute.

Salt is only one part of diet

Sodium influences the body's fluid balance. With high sodium intake, more water may be retained in the body, which can change blood volume and thus blood pressure, among other things.

The WHO recommends less than 5 grams of salt per day for adults, corresponding to less than 2 grams of sodium. Particularly relevant here is that a large proportion of salt intake does not necessarily come from the salt shaker. Processed foods, bread, cheese, processed meats, ready meals and salty snacks can contribute significantly.

The ESC guideline also describes an association between salt reduction and blood pressure. It points out that people with a high baseline intake in particular may benefit from a reduction.

At the same time, diet should not be reduced to a single nutrient.

An overall balanced diet with plenty of vegetables and fruit, sufficient fibre and a choice of foods that are as minimally processed as possible is more relevant to cardiometabolic health than whether an individual meal was a little too salty.

Potassium as a counterbalance

Potassium is also relevant to blood pressure regulation. Among other things, it influences sodium excretion through the kidneys and vascular function.

A diet with sufficient potassium-rich foods such as vegetables, fruit, pulses and potatoes can therefore form part of a blood pressure-conscious diet.

However, with certain kidney diseases or when taking certain medicines, high potassium intake can be problematic. Blanket supplementation is therefore not useful.

What medicines achieve and when they become important

Lifestyle measures are an important part of blood pressure treatment. However, with diagnosed hypertension, they are not always sufficient.

Antihypertensive medicines act at different points in blood pressure regulation. ACE inhibitors and angiotensin receptor blockers influence the renin–angiotensin–aldosterone system. Calcium channel blockers reduce vascular resistance, among other things. Diuretics influence fluid and sodium balance.

Which medicine is used depends on the individual situation.

The decision to treat is also not based exclusively on a single blood pressure number. Relevant factors include overall cardiovascular risk, existing diseases, kidney function, age and the tolerability of treatment.

Why “the lower, the better” falls short

Research in recent years has shown that more intensive blood pressure reduction can benefit certain people.

One central investigation was the SPRINT study. It included 9,361 people at increased cardiovascular risk, but without diabetes. Intensive treatment with a systolic target below 120 mmHg was compared with standard treatment with a target below 140 mmHg.

After a median follow-up of 3.26 years, the combined cardiovascular endpoint occurred less frequently in the intensively treated group. All-cause mortality was also lower. At the same time, certain adverse effects such as hypotension and acute kidney injury occurred more frequently.

The results were scientifically important, but cannot be applied to everyone. People with diabetes or certain other diseases, for example, were not part of the group studied.

The question of the optimal blood pressure target has also been studied in older people.

In the STEP study, 8,511 people aged 60 to 80 with hypertension were randomised. Intensive treatment with a systolic target range of 110 to below 130 mmHg was compared with a target range of 130 to below 150 mmHg. After a median of 3.34 years, cardiovascular events occurred less frequently in the intensively treated group. However, hypotension was more common there.

The studies therefore show one thing above all: The optimal treatment target is an individual medical decision.

The current ESC guideline recommends a systolic target range of 120 to 129 mmHg for most treated adults, provided treatment is well tolerated. For certain groups, such as people with pronounced frailty, symptomatic orthostatic hypotension or very advanced age, other target ranges may be appropriate.

Blood pressure and the brain: what research shows

The brain is among the organs that respond particularly sensitively to long-term changes in vascular function.

One reason for this is its complex microcirculation. Small vessels must reliably regulate blood flow while also preventing pressure fluctuations from being transmitted unchecked to sensitive brain structures.

Chronically elevated blood pressure can influence this vascular regulation. Over time, structural changes in small cerebral vessels may develop. Imaging in people with long-standing hypertension, for example, more often shows changes in the white matter.

This makes it clear why blood pressure is not solely a matter for the heart and arteries.

What does this mean for cognitive health?

Observational studies show associations between elevated blood pressure in middle age and later cognitive impairment. However, the relationship is complex and is influenced by age, vascular health and other risk factors, among other things.

Interventional studies also provide important indications. SPRINT-MIND investigated whether intensive blood pressure treatment affects cognitive endpoints. In the primary analysis, intensive treatment did not lead to a statistically significant reduction in probable dementia, but a lower rate of newly developing mild cognitive impairment was observed.

The result is therefore interesting, but does not prove that a particular blood pressure number can prevent dementia.

For healthy ageing, this means above all: Vascular health and brain health are closely connected.

How to monitor your own blood pressure sensibly

Anyone wishing to understand their blood pressure better does not necessarily need to measure it every day.

What matters initially is to use a validated upper-arm monitor and take the measurement correctly. Wrist monitors can also be used depending on the situation, but are more dependent on positioning.

For structured home measurement, the ESC recommends two measurements in the morning and two in the evening, each one to two minutes apart, over at least three and up to seven days. The individual readings are then averaged.

How to make measurement more informative

Before measuring:

• sit quietly for a few minutes
• support your back
• place your feet on the floor
• do not cross your legs
• rest your arm comfortably at heart level
• where possible, do not smoke, drink coffee or exercise in the preceding 30 minutes
• empty your bladder beforehand if needed

These seemingly small details matter. The measurement situation itself can influence blood pressure.

A single unusual reading is therefore initially no reason to panic. Repeatedly and clearly elevated readings, however, should be assessed by a doctor.

Very high blood pressure readings together with acute symptoms such as chest pain, shortness of breath, neurological deficits or other severe symptoms require immediate medical assessment.

What really matters for healthy ageing

Blood pressure is not an isolated health measurement. It sits at the centre of a network of blood vessels, heart, kidneys, metabolism, nervous system and lifestyle.

This network does not automatically become diseased as we get older. But the vessels change, and the ability to compensate for blood pressure fluctuations may change. At the same time, risk factors can accumulate over decades.

This is why it makes sense not to take blood pressure seriously only once it is clearly elevated.

This does not mean scrutinising every measurement or chasing the lowest possible reading. Far more important is appropriate blood pressure over the long term, suited to the individual's health situation.

This includes regular movement, a balanced diet, a conscious approach to salt and alcohol, not smoking and a body weight suited to the personal situation. With diagnosed hypertension, medicines may be added where necessary.

For healthy ageing, the long-term perspective matters more than a single perfect reading.

A blood pressure monitor can only capture one moment. Many years of good blood pressure control, however, tell a much more interesting story.

References

1. McEvoy JW et al. 2024. „2024 ESC Guidelines for the management of elevated blood pressure and hypertension.“ European Heart Journal 45(38): 3912-4018. DOI: 10.1093/eurheartj/ehae178.
2. The SPRINT Research Group. 2015. „A Randomized Trial of Intensive versus Standard Blood-Pressure Control.“ New England Journal of Medicine 373: 2103-2116. DOI: 10.1056/NEJMoa1511939.
3. Zhang W et al. 2021. „Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension.“ New England Journal of Medicine 385: 1268-1279. DOI: 10.1056/NEJMoa2111437.
4. The SPRINT MIND Investigators for the SPRINT Research Group. 2019. „Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial.“ JAMA 321(6): 553-561. DOI: 10.1001/jama.2018.21442.
5. World Health Organization. 2025. „Hypertension.“ WHO.
6. World Health Organization. 2020. „WHO Guidelines on Physical Activity and Sedentary Behaviour.“ Geneva: World Health Organization.
7. World Health Organization. 2020. „Healthy diet.“ WHO.