A new analysis of hypertension guidelines suggests some older adults — mostly women — with slightly high blood pressure could safely hold off on medications if they’re otherwise in relatively good health.
That is, age alone shouldn’t always be a deciding factor in being prescribed blood pressure pills.
“In the past, many people over 65 with mildly elevated blood pressure might have been started on medication fairly quickly,” said Dr. Michael Nanna, an interventional cardiologist and assistant professor of internal medicine at Yale School of Medicine.
The latest guidance, he said, “recognizes that if someone has otherwise low cardiovascular risk, it can be reasonable to start with lifestyle strategies and careful monitoring before one adds medication.” Nanna co-authored the new report published Monday in the Annals of Internal Medicine.
Who could hold off on blood pressure medications?
Normal blood pressure is considered anything under 120/80. People with blood pressure readings between 130-139 over 80-89 have Stage 1 hypertension, according to guidelines published jointly last year by the American Heart Association and the American College of Cardiology.
For most people, that’s cause to start on medicines meant to drive down blood pressure. Hypertension is a major risk factor for heart disease, the nation's No. 1 killer.
But Nanna’s report suggests that about 11% of people with Stage 1 hypertension could hold off on those medications because they don’t have any other risk factors for heart disease. They don’t smoke, don’t have diabetes, and they’re on the younger side of older adulthood: mid-to late 60s.
“The recommendation for lower risk patients is to focus first on lifestyle changes,” Nanna said. “It’s less about reducing medications overall and more about tailoring treatment so that medication is started when the expected benefit is the clearest.”
People most likely to be affected by these changes are women, because men in general are more likely to carry other risks associated with heart disease.
“It would be extremely rare for a man who is 65 whose blood pressure is at Stage 1 to not have other risk factors that would push them over in their risk calculation,” said Dr. Daniel Jones, a former president of the American Heart Association and chair of the committee that wrote the 2025 hypertension guidelines.
Those guidelines rely in part on a risk calculator called PREVENT. It’s free and available to the public here. It analyzes information like body mass index, smoking status and results from routine blood work, such as total cholesterol levels and a measure of how well the kidneys filter waste (eGFR).
Lifestyle plays a big role. People with Stage 1 hypertension who would qualify to hold off on medications, Jones said, are also generally physically fit, are at a normal weight and consume a diet high in fruits and vegetables and low in sodium and alcohol.
Those are changes people can adopt early in adulthood so they reach 65 as healthy as possible. “If you’re over 65 and you don’t yet have a high risk for cardiovascular disease, chances are something else will kill you before cardiovascular disease does,” Jones said.
That doesn’t mean even slightly elevated blood pressure — readings in the 120-129 and 80-89 range — should be ignored at any stage of life.
“That’s when you have to get serious,” said Dr. Karol Watson, co-director of the UCLA Program in Preventive Cardiology and a professor of medicine at UCLA’s David Geffen School of Medicine said. She was not involved with the new report, but was on the committee that wrote the 2025 hypertension guidelines.
“If your blood pressure is between 120 and 129, get to the gym, lose weight, eat lots of fruits and vegetables, lower your sodium,” Watson said. “All those things can keep you from ever having to go on medication.”
