Hypertension – a major modifiable and undertreated risk factor

Hypertension remains one of the most prevalent and modifiable risk factors for preventable deaths in Australia.¹ Yet effective management continues to face significant challenges, including inconsistent blood pressure measurement practices, therapeutic inertia in relation to treatment targets, and limited use of team-based approaches involving general practitioners (GPs) and other medical practitioners, nurses, nurse practitioners, and allied health professionals. Since the last national guideline update in 2016,² multiple international guidelines have been released that do not align with some of Australia's current recommendations. An updated national guideline is needed to ensure that practitioners in Australia are supported by evidence-based, internationally consistent best practice.³

This editorial highlights current gaps in hypertension care and anticipates key changes in the forthcoming 2026 Australian hypertension guideline,⁴ including improved blood pressure measurement standards, lower treatment targets, and greater use of combination therapy. These changes, guided by the National Hypertension Taskforce, aim to improve blood pressure control and reduce cardiovascular morbidity and mortality across Australia.³

Hypertension screening in the general community is suboptimal, despite consistent guidance for primary care clinicians to measure blood pressure opportunistically.^5-7 Only a small fraction of the people predicted to have hypertension are identified, and inaccurate measurement practices further undermine detection.⁸ It has been demonstrated for many years that out-of-clinic measurements, including home blood pressure monitoring (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM), are superior to in-clinic readings for predicting adverse cardiovascular events.^9-11 These methods improve detection of clinically relevant issues such as postural (orthostatic) drop, autonomic neuropathy and diurnal variation, which may be missed with standard in-clinic assessments. These methods also minimise white coat (elevated in-clinic but normal out-of-clinic) and masked (normal in-clinic but elevated out-of-clinic) hypertension, and more accurately reflect actual blood pressure.

Effective implementation requires education, support (including financial incentives), use of validated devices, and, preferably, digital integration with electronic medical records. Where out-of-clinic methods are unavailable, automated office blood pressure (AOBP) is recommended for clinic measurements as it closely reflects the resting daytime blood pressure values typically observed with ABPM.¹²

Pharmacological treatment decisions need to be guided by both cardiovascular disease (CVD) risk stratification and blood pressure levels. The 2023 Australian CVD Risk Calculator provides a valuable tool for assessing individual risk and informing pharmacological and healthy behavioural and lifestyle management strategies. This dual approach, which considers both blood pressure and overall risk, is consistent with international best practice¹³ and supports more targeted, evidence-based care.

Lower treatment targets reflect and support a more ambitious approach to preventing cardiovascular events. International guidelines recommend targets of less than 130/80 mmHg for a broader range of patients, reflecting evidence from trials such as SPRINT.^13-15 While the 2016 Australian guideline included lower targets for specific high-risk groups (e.g. those with an estimated glomerular filtration rate of less than 45 mL/min/1.73 m²), these thresholds are not yet applied universally. Updating national guidance offers an opportunity to align with evolving international standards while also addressing concerns about over-medicalisation, individualised care needs, and the risk of adverse events in older and frail populations.¹⁵ While there is reluctance to treat hypertension in older and very old adults, or not treat to recommended targets, limited existing evidence supports treating to targets with careful, individualised assessment of frailty and risk of falls, and close monitoring of response.¹³

Starting treatment with dual therapy is more effective than monotherapy for most individuals with hypertension greater than 140/90 mmHg¹³ and will likely in the future be strongly recommended for those with blood pressure greater than 160/95 mmHg. Use of more than one drug compounds the antihypertensive effect of individual drugs through targeting different pathophysiological pathways, thereby achieving more rapid blood pressure control and subsequent lower risk of cardiovascular events.^16,17 Single-pill combinations improve adherence and accelerate blood pressure control, and align with global evidence-based best practice.¹³ Initiating treatment with a dual combination – ideally one that can be escalated to a triple-drug regimen if needed – can help to achieve these therapeutic advantages.

Nonpharmacological strategies remain central to hypertension care. Interventions such as salt reduction or substitution,¹⁸ dietary modification such as the dietary-approaches-to-stop-hypertension (DASH) diet,¹⁹ increased physical activity,²⁰ alcohol moderation²¹ and smoking cessation²² can have significant impacts on blood pressure and general health. Structured, culturally appropriate behavioural support integrated into routine care, rather than relying solely on verbal advice, is recommended.

Causes of secondary hypertension should be considered at initial diagnosis, particularly primary aldosteronism. Targeted screening – especially in individuals with early-onset hypertension, hypokalaemia, or resistant hypertension – can facilitate early diagnosis and improve patient outcomes.²³ Screening for primary aldosteronism is complex and may require biochemical testing beyond routine clinical indicators. A recent prospective study in Melbourne general practices found primary aldosteronism in 14% of newly diagnosed, treatment-naive hypertensive patients, with hypokalaemia present in only 30% of cases.²⁴ This highlights the risk of underdiagnosis when relying solely on traditional markers. Primary aldosteronism, either undiagnosed or poorly treated, can lead to persistent high blood pressure, cardiovascular inflammation and fibrosis, and increase the risk of cardiometabolic disease.²³

The 2026 Australian hypertension guideline will offer a major opportunity to improve detection, management and outcomes for hypertension in Australia. In the interim, there is a call to action to improve standards of measurement, to better target and intensify drug treatment (including the use of combination therapies), to strengthen promotion of healthy behavioural and lifestyle factors, supported by digital tools and quality improvement frameworks. Using these approaches, we can shift the dial on high blood pressure control and improve cardiovascular health in Australia.

This article was finalised on 28 October 2025.

Conflicts of interest: All authors are current members of the Australian hypertension guidelines committee and the National Hypertension Task Force Steering Committee.

Charlotte Hespe has been on COVID- and CVD-related advisory boards for AstraZeneca, Amgen, GSK, Moderna, Novartis, Pfizer, MSD, Lundbeck and Novo Nordisk Collaboration Diabetes CVD research project.

This article is peer reviewed.

 

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