Laura Cowen interviewed Teresa Castiello, MD, a cardiologist and healthcare prevention advocate, to discuss her insights on hypertension management in the era of precision medicine. Castiello shared her perspectives on the need for a proactive approach to hypertension care, the role of precision medicine and pharmacogenomics, and the potential impact of digital health Hilo in transforming how hypertension is diagnosed, monitored, and treated.
Q: Do you think there needs to be a shift in how hypertension is diagnosed and treated?
Teresa Castiello, MD: Without a doubt. We must move from reactive medicine—treating damage once it has occurred—to proactive medicine. Hypertension is frequently underdiagnosed because it often remains asymptomatic until organ damage is already underway. Furthermore, traditional office readings are often biased by the “white coat” effect, which is why clinical guidelines, including those from the ESC (European Society of Cardiology), are moving away from them. Current monitoring also has limitations; nocturnal readings from standard cuffs often wake the patient, and sporadic readings fail to reflect the true, dynamic daily blood pressure response.
Q: Are there any “uncomfortable truths” about hypertension care that we don’t talk about enough?
Castiello: A significant “uncomfortable truth” is the lingering bias that considers a rising blood pressure to be a normal part of aging. It isn’t. Data from the Yanomami population in the Amazon shows that systolic blood pressure can remain constant at approximately 100 mmHg throughout life. In our Westernized society, blood pressure increases as a response to environmental and stressful “insults” rather than as a physiological necessity. Unfortunately, current clinical practice in the U.K. has not yet fully implemented recent ESC changes. We still see values defined as “normal” when guidelines now identify them as elevated (anything above 120/70 mmHg). Cardiovascular risk actually begins to climb much sooner than most realize, often at systolic levels as low as 110–115 mmHg.
Q: Is there a risk of current treatment strategies controlling blood pressure numbers without addressing underlying mechanisms?
Castiello: Yes. Labeling most cases as “essential hypertension” is essentially admitting we are treating a multifactorial condition of unknown cause. We often fail to assess the individual holistically. Stress, hormonal shifts, poor work-life balance, diet, and physical inactivity are profound drivers of blood pressure increases. While medical therapy is a vital tool, we must not forget that humans are multifaceted and complex. We need a healthcare approach that treats the person, not just the metric.
Q: Is there a need for increased precision medicine in hypertension, e.g., with the use of pharmacogenomics? Could this information redefine high-risk?
Castiello: We are in an era where precision medicine is the only way to deliver effective care. The power of data is enabling us to target prevention and early diagnosis like never before. Pharmacogenomics is a key part of this; by understanding how a patient’s genetic profile influences their metabolism of a drug, we can move away from “trial and error.” This information redefines “high-risk” from a generic population score to an individual biological reality. It allows us to define optimal doses that maximize efficacy while minimizing the toxicity that often leads to treatment non-compliance.
Q: Are healthcare systems ready to integrate continuous blood pressure monitoring into routine care?
Castiello: Probably not yet, but they will be forced to be. COVID-19 showed that we can adapt to global interconnection and remote monitoring in a very short time when we have no choice. Prevention is the only way for healthcare systems to survive the rising burden of chronic disease. Philosophically, if we wait until we feel “ready” to take action, we will never act. The time to implement these preventive strategies is now.
Q: In ten years’ time, how do you hope hypertension will be managed differently?
Castiello: I hope every individual has access to a medical-grade wearable—whether a band, ring, or chip—empowered by AI to feed data into a proactive health system. This data will be filtered to flag those requiring care at a pre-pathological stage. We can no longer afford to wait for a crisis to occur before we treat it; global healthcare systems cannot handle that burden. We must prevent what is possible and focus our hospital resources on the conditions that occur despite our best preventive strategies
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