Almost Half of Hypertension Patients Don’t Know They Have It

FLORENCE, Italy — During the 23rd European Congress of Internal Medicine 2025, held from March 5 to 8, the scientific program featured a special session in collaboration with the European Society of Hypertension (ESH). In addition to discussions on hypertension in specific patient populations, this session provided an update on current guidelines and the global prevalence of hypertension.

Despite the well-established link between hypertension and mortality, updated data on its prevalence, diagnosis, and treatment suggest that current efforts to control high blood pressure have been largely ineffective, according to Dragan Lovic, MD, PhD, professor of internal medicine at Singidunum University Medical School in Nis, Serbia, and member of the Scientific Council of the ESH. Speaking at the session, Lovic highlighted the trends concerning hypertension management worldwide.

The World Health Organization estimates that 1.3 billion people globally have hypertension. Alarmingly, 46% of hypertensive individuals are unaware of their condition, whereas only 42% receive a diagnosis and treatment. Even among those treated, only 21% achieved adequate blood pressure control. Hypertension remains a leading global cause of mortality, with its prevalence steadily increasing over decades without significant sex disparities.

Although a variety of pharmacological options and combination therapies are available, treatment success remains suboptimal. In Europe, approximately 78% of hypertensive patients receive treatment, yet blood pressure control is achieved in only 49% of cases, with significant variations between countries. Further disparities exist in the choice of drug combinations most frequently prescribed by general practitioners and cardiologists.

“This is a highly complex issue. A multidisciplinary approach is an ideal solution for managing hypertension effectively, but we face a fundamental practical problem: General practitioners do not only treat hypertension but many other conditions, making it difficult to stay up-to-date and adjust prescriptions accordingly,” Lovic said in an interview with Univadis Italy, a Medscape Network platform. Despite these challenges, Lovic emphasized that education and training remain key to improving hypertension management worldwide.

What is the reason for such low hypertension control rates? There are likely multiple contributing factors, but patient compliance plays a significant role. It is no coincidence that clinical guidelines include dedicated sections addressing adherence issues, along with recommendations on how to mitigate their impact. The more medications a patient needs to take, the lower the adherence rate. Personalized treatment — tailored beyond the technical recommendations in guidelines — can make a substantial difference in improving outcomes.

Role of Guidelines

Clinical guidelines are essential resources for physicians aiming to manage hypertension effectively. During the session, experts presented both the ESH 2023 guidelines and their summary, the 2024 clinical practice guidelines.

Leading this discussion was Thomas Weber, MD, deputy director of the Department of Cardiology at Klinikum Wels-Grieskirchen in Wels, Austria, current ESH President, co-author of the ESH 2023 hypertension guidelines, and co-author of the ESH 2024 clinical practice guidelines.Unlike previous years, the European Society of Cardiology (ESC) and ESH no longer publish joint guidelines on hypertension management. Weber’s presentation compared key differences between the ESH 2023 and ESC 2024 guidelines.

One of the key topics addressed was blood pressure measurement. The ESH guidelines recommend electronic upper arm monitors for blood pressure assessment both in the clinic and at home. In contrast, cuffless devices are not recommended, as there is insufficient reliability data despite ongoing research in this area.

Regarding measurement methods — which are generally performed in a doctor’s office — the guidelines introduce no major changes. They reaffirm that hypertension diagnosis should be based on in-office measurements, as current studies rely on this approach.

“This does not eliminate the importance of home measurements, from which important additional information can be derived,” said Weber.

Experts emphasized that the relationship between cardiovascular risk and hypertension exists along a continuum, rather than having a sharp threshold where risk suddenly escalates. However, for practical purposes, it is necessary to define a threshold for diagnosing hypertension. Both the ESH and ESC maintain the current diagnostic threshold at 140/90 mm Hg.

Below the 140/90 mm Hg hypertension threshold, the ESH defines three categories: Optimal, normal, and normal-high blood pressure. In contrast, the ESC has adopted a simplified classification, distinguishing only between “not elevated“ and “elevated“ blood pressure. With this new classification, the concept of “optimal” blood pressure is no longer included, and only 16% of the population would fall into the “not elevated” category.

When Should Treatment Begin?

For patients with hypertension, defined as blood pressure ≥ 140/90 mm Hg, treatment is generally indicated. However, in individuals with very low cardiovascular risk, initial management may focus on lifestyle modifications before considering pharmacological intervention. The decision to start treatment in patients who do not meet the classic hypertension definition is more complex and requires an individualized assessment.

Regarding treatment targets, both the ESH and ESC guidelines agree on a systolic blood pressure goal of 120-129 mm Hg.

The guidelines provide recommendations on pharmacological and lifestyle interventions, but their effectiveness remains in question, given the persistently low rates of blood pressure control. “Guidelines are just one piece of the puzzle and only a small part of the solution. Their implementation is essential for keeping pace with scientific advancements, but success also depends on collaboration with key stakeholders, particularly general practitioners,” said Weber, speaking to Univadis Italy.

Weber emphasized that managing a chronic condition like hypertension differs significantly from treating acute illnesses and requires consideration of multiple factors to achieve therapeutic success.

Lovic declared no conflicts of interest.

Cristina Ferrario, a molecular biologist by training, holds a master’s degree in communication and health from the University of Milan, Milan and in cancer genetics from the University of Pavia, Pavia, Italy. After conducting research in molecular oncology, she has been involved in scientific journalism and medical writing for over 20 years.

This story was translated from Univadis Italy using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.