Why is the bottom number of blood pressure high

Ask the doctor

A. This question comes up often, perhaps because doctors and patients alike tend to pay more attention to the top (first) number, known as systolic pressure. It reflects the amount of pressure inside the arteries as the heart contracts. The bottom (second) number, diastolic pressure, is always lower since it reflects the pressure inside the arteries during the resting phase between heartbeats.

As it turns out, both systolic and diastolic blood pressure are important. Per the most recent guidelines, you have what's called elevated blood pressure if your systolic blood pressure reading is 120 to 129 mm Hg (which stands for millimeters of mercury). Once your systolic reading reaches 130 or higher or your diastolic reading is 80 or higher, you're considered to have high blood pressure, or hypertension.

Most people have what's known as essential or primary hypertension, which means it's not caused by a medical condition, medication, or substance. Primary hypertension can affect both systolic and diastolic pressure to a similar degree. But sometimes, especially in older people, it affects mainly the systolic pressure; this is called isolated systolic hypertension.

Why does this happen? As you age, your arteries tend to become less elastic and less able to accommodate surges of blood. Blood flowing through your arteries at high pressure can damage the inner lining of these vessels, accelerating the buildup of cholesterol-laden plaque. This further stiffens and narrows the arteries, a condition known as atherosclerosis. Because the same volume of blood has to pass through a smaller area, the systolic pressure tends to rise, while the diastolic pressure remains the same or gradually falls over time. In some people with isolated systolic hypertension, the diastolic pressure reading may drop into the 50s or even the 40s.

Most studies show a greater risk of cardiovascular disease (especially strokes) related to high systolic pressure as opposed to elevated diastolic pressure. But in 2019, an eight-year-long study involving more than 1.3 million adults found that while elevated systolic pressure had a greater effect on cardiac outcomes, high diastolic readings also affected a person's risk, regardless of the systolic reading.

To ensure accurate readings when you're checking your blood pressure at home, be sure to sit comfortably with your back supported, your feet flat on the floor, and your arm resting on a table with your palm facing up. If needed, support your arm with a pillow so that your elbow is at the level of your heart.

— Deepak L. Bhatt, M.D., M.P.H.
Editor in Chief, Harvard Heart Letter

Image: © Vadim Zhakupov/Getty Images

What do your blood pressure numbers mean?

The only way to know if you have high blood pressure (HBP, or hypertension) is to have your blood pressure tested. Understanding your results is key to controlling high blood pressure.

Healthy and unhealthy blood pressure ranges

Learn what’s considered normal, as recommended by the American Heart Association.

Note: A diagnosis of high blood pressure must be confirmed with a medical professional. A doctor should also evaluate any unusually low blood pressure readings.

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Blood pressure categories

The five blood pressure ranges as recognized by the American Heart Association are:

Normal

Blood pressure numbers of less than 120/80 mm Hg are considered within the normal range. If your results fall into this category, stick with heart-healthy habits like following a balanced diet and getting regular exercise.

Elevated

Elevated blood pressure is when readings consistently range from 120-129 systolic and less than 80 mm Hg diastolic. People with elevated blood pressure are likely to develop high blood pressure unless steps are taken to control the condition.

Hypertension Stage 1

Hypertension Stage 1 is when blood pressure consistently ranges from 130-139 systolic or 80-89 mm Hg diastolic. At this stage of high blood pressure, doctors are likely to prescribe lifestyle changes and may consider adding blood pressure medication based on your risk of atherosclerotic cardiovascular disease (ASCVD), such as heart attack or stroke.

Hypertension Stage 2

Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes.

Hypertensive crisis

This stage of high blood pressure requires medical attention. If your blood pressure readings suddenly exceed 180/120 mm Hg, wait five minutes and then test your blood pressure again. If your readings are still unusually high, contact your doctor immediately. You could be experiencing a hypertensive crisis.

If your blood pressure is higher than 180/120 mm Hg and you are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, do not wait to see if your pressure comes down on its own. Call 911.

Your blood pressure numbers and what they mean

Your blood pressure is recorded as two numbers:

• Systolic blood pressure (the first number) – indicates how much pressure your blood is exerting against your artery walls when the heart beats.
• Diastolic blood pressure (the second number) – indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats.

Which number is more important?

Typically, more attention is given to systolic blood pressure (the first number) as a major risk factor for cardiovascular disease for people over 50. In most people, systolic blood pressure rises steadily with age due to the increasing stiffness of large arteries, long-term buildup of plaque and an increased incidence of cardiac and vascular disease.

However, either an elevated systolic or an elevated diastolic blood pressure reading may be used to make a diagnosis of high blood pressure. According to recent studies, the risk of death from ischemic heart disease and stroke doubles with every 20 mm Hg systolic or 10 mm Hg diastolic increase among people from age 40 to 89.

Why blood pressure is measured in mm Hg

The abbreviation mm Hg means millimeters of mercury. Mercury was used in the first accurate pressure gauges and is still used in medicine today as the standard unit of measurement for pressure.

Taking your pulse versus checking your blood pressure

While both are indications of health, blood pressure and heart rate (pulse) are two separate measurements. Learn more about the difference between blood pressure and heart rate.

Written by American Heart Association editorial staff and reviewed by science and medicine advisers. See our editorial policies and staff.

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