High Blood Pressure (Hypertension)
High blood pressure means the force of blood pushing against the artery walls stays too high — in practice, a clinic reading of 140/90 mmHg or above on at least two separate visits. It almost never causes symptoms, which is why surveys here suggest somewhere between a quarter and a third of Pakistani adults have it and around half of them do not know. Left untreated it slowly damages the heart, brain, kidneys and eyes, and it is the single largest preventable cause of stroke. Treatment is a combination of less salt, weight loss, regular walking and, for most people, one or more daily tablets taken for life rather than only on days the reading is high. Most people reach a safe reading — usually below 140/90, and below 130/80 if they also have diabetes or kidney disease — within two to three months of starting, using medicines that cost a few hundred rupees a month.
Diabetologist & General Physician · MBBS
What blood pressure actually measures
Every time the heart beats it pushes blood into the arteries, and the arteries push back. is a measure of that push, written as two numbers. The first, the pressure, is the peak as the heart squeezes. The second, the pressure, is the resting level between beats. Both are given in millimetres of mercury, written mmHg, which is why a reading is read aloud as "one twenty over eighty".
Pressure rises and falls all day. It is lowest in sleep, highest in the first hours after waking, and goes up with a cup of tea, a flight of stairs, a full bladder or an argument. That normal variation is exactly why a diagnosis of is never made on a single reading. What matters is the level it sits at when you are rested — and whether that level stays high week after week.
What the numbers mean
| Category | Systolic (top number) | Diastolic (bottom number) |
|---|---|---|
| Normal | Under 130 | Under 85 |
| High-normal | 130-139 | 85-89 |
| Grade 1 hypertension | 140-159 | 90-99 |
| Grade 2 hypertension | 160 or more | 100 or more |
| Needs same-day medical review | 180 or more | 110 or more |
Only one of the two numbers has to be in a band for the reading to sit in that band. A pressure of 145/82 is grade 1 hypertension even though the lower number is fine. In people over about 60 it is common for the top number alone to be raised, because the large arteries stiffen with age — that still counts, and still needs treating.
How the reading was taken matters as much as the reading. The cuff must be the right size for the arm, wrapped over bare skin, with the arm supported at the level of the heart and the back and feet supported. Five minutes of quiet sitting first, no tea, cigarette or naswar for half an hour before, and no talking during. A cuff that is too small for a heavy arm will over-read by 10 mmHg or more, which is enough to start someone on a lifetime of tablets they never needed.
Why it happens
In about nine people out of ten no single cause is found. This is called primary or essential hypertension, and it is the accumulated result of genetics, diet, weight and age rather than one thing that went wrong. The factors that push it up are well established:
- Salt. The strongest dietary factor by a distance, and the hardest one here, because most of it is not the salt in the shaker — it is in pickles, papar, chutneys, packet masalas, stock cubes, namkeen, bakery rusk and restaurant food.
- Weight around the middle. Every 5 kg lost lowers the top number by roughly 4 mmHg on average.
- Sitting still. Thirty minutes of brisk walking on most days lowers it by about 5 mmHg, and the benefit disappears within weeks of stopping.
- Family history. A parent with hypertension roughly doubles the risk, and it tends to appear a decade earlier in each generation.
- Tobacco in every form — cigarettes, huqqa, naswar, gutka. Each use raises the pressure sharply for around half an hour and damages the artery lining permanently.
- and kidney disease, each of which both raises blood pressure and is worsened by it.
- Some medicines, including taken regularly, oral steroids, some cold remedies containing pseudoephedrine, and combined oral contraceptives.
- Untreated sleep apnoea — loud snoring with pauses in breathing, and daytime sleepiness.
In the remaining tenth there is a specific cause — a kidney problem, a narrowed kidney artery, a disorder, or a rare hormone-producing tumour. Your doctor will look for one if the pressure appears before the age of 30, if it is very high from the start, if it suddenly worsens after years of good control, or if it does not respond to three medicines taken properly.
Does it cause symptoms?
Usually not, and this is the single most dangerous thing about it. Hypertension is often called a silent condition because the first sign in many people is the event it causes — a , a heart attack, or kidney failure found on a routine blood test. Headache, dizziness, nosebleeds and a flushed face are commonly blamed on blood pressure, but studies of people wearing 24-hour monitors have found no reliable link between those symptoms and the actual reading. Waiting to "feel" high blood pressure is waiting for damage.
How it is diagnosed
Diagnosis needs raised readings on at least two occasions, usually a week or more apart, taken properly. Where there is doubt — and particularly where the reading is high in the clinic but the patient insists it is normal at home — a doctor may ask for a week of home readings taken twice a day, or a 24-hour ambulatory monitor. Home readings run about 5 mmHg lower than clinic ones, so the home threshold for hypertension is 135/85 rather than 140/90.
Once the diagnosis is made, the tests that follow are not about confirming it. They are about finding out whether damage has already begun, and what else needs treating alongside it:
- with an eGFR, to check how the kidneys are working.
- A for , which is often the earliest sign of kidney damage from pressure.
- or , because diabetes and hypertension travel together.
- A , since the overall risk to the heart depends on as well as pressure.
- An , to look for thickening of the heart muscle or an .
- An eye examination, because the small vessels at the back of the eye show pressure damage before anything else does.
- , both as a baseline and because an unexplained low potassium points to a hormonal cause.
How it is treated
Changes that work without a tablet
These are not an alternative to medicine for someone whose pressure is already high — they are what allows the medicine to work on a lower dose, and for some people with grade 1 hypertension and no other risk they genuinely are the whole treatment. Give them three to six months and measure the result.
- Cut salt to under 5 g a day, which is about one level teaspoon in total, from everything. Cook without adding salt at the table, drop pickles and papar to an occasional item rather than a daily one, and read the sodium on any packet: 2 g of sodium is 5 g of salt.
- Lose weight if the waist is over 90 cm in men or 80 cm in women. These cut-offs are lower for South Asians than the European ones, and deliberately so.
- Walk briskly for 30 minutes on five days a week, or any activity that leaves you slightly breathless but still able to talk.
- Eat more potassium — banana, orange, tomato, spinach, lentils, yoghurt — unless your kidneys are impaired, in which case ask first.
- Stop all tobacco. It does less for the reading itself than the other measures, and more than any of them for the heart attack and stroke risk that is the whole reason for treating.
- Treat the snoring if there are witnessed pauses in breathing at night.
The medicines
Most people need medicine, and most eventually need two. That is not a failure; the guidelines expect it, because two medicines at low dose control pressure better and with fewer than one at maximum dose. All the classes below are available in Pakistan as inexpensive generics.
| Class | Common examples | What it does | What to watch for |
|---|---|---|---|
| ACE inhibitors | Enalapril, lisinopril, ramipril | Blocks a hormone that narrows arteries, so they relax | A persistent dry cough in some people; never used in pregnancy |
| Angiotensin receptor blockers (ARBs) | Losartan, valsartan, telmisartan | The same effect by a different route | No cough; also never used in pregnancy |
| Calcium channel blockers | Amlodipine, nifedipine | Widens the arteries directly | Ankle is common, harmless, and often improves on a lower dose |
| Thiazide-type | Indapamide, hydrochlorothiazide | Removes salt and water through the kidneys | Can lower potassium and raise blood sugar; needs a blood test after starting |
| Beta blockers | Bisoprolol, atenolol, carvedilol | Slows the heart and reduces its workload | Not a first choice for pressure alone; used when there is also angina, a fast rhythm or heart failure |
Two things about these tablets are worth stating plainly. The first is that they do not cure anything: they hold the pressure down while they are in the body, and it climbs back within days of stopping. The second is that they are not painkillers — there is nothing to feel, so there is no moment at which you can tell they are working. That is why a home monitor is worth more than any sensation.
Measuring at home
A home monitor is one of the few pieces of medical equipment genuinely worth owning. Buy a digital machine with an upper-arm cuff — wrist and finger devices are far less reliable — and take it to your next appointment so the reading can be checked against the clinic's.
- Sit for five minutes first, back supported, feet flat, legs uncrossed, in a quiet room.
- Rest the arm on a table so the cuff is level with the heart. Bare skin, not over a sleeve.
- Take two readings a minute apart and write down the second, or the average of the two.
- Measure twice a day — morning before breakfast and medicine, and evening — for seven days before an appointment.
- Bring the whole week of numbers. Not the highest one, and not the best one.
- Ignore any single high reading. A pattern over a week is the only thing that means anything.
Living with it
Hypertension is a lifelong condition managed rather than cured, and after the first few months it should take up very little of your attention: one tablet with breakfast, a week of home readings before each review, and a blood test once or twice a year. The follow-up your doctor will arrange is usually every three to six months while the dose is being settled, then once or twice a year with a blood test and a urine check. Ramadan needs one specific conversation — most once-daily medicines can simply be moved to sehri or iftar, but a in summer heat may need adjusting, so ask before the month begins rather than during it.
When to see a doctor
Book an appointment if a home or pharmacy reading is 140/90 or higher on more than one occasion, if you have never had your pressure checked and are over 40, or if you are on treatment and your readings have drifted upwards. Come sooner if you have developed a new symptom on a blood-pressure medicine — a cough that will not clear, dizziness on standing, swelling, or a rash. And come the same day, rather than waiting for an appointment, for a reading of 180/110 or more, for a pressure of 140/90 or above in pregnancy, or for any of the warning symptoms listed at the top of this page.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
