Hypertension Diagnosis and Management

Blood Pressure Classification

The American College of Cardiology and American Heart Association recommend classifying blood pressure into four categories: Normal (<120/<80 mm Hg), Elevated (120-129/<80 mm Hg), Stage 1 Hypertension (130-139/80-89 mm Hg), and Stage 2 Hypertension (≥140/≥90 mm Hg), with classification based on the higher category when systolic and diastolic readings differ 1, 2
The American College of Cardiology and American Heart Association define Normal BP as <120 mm Hg systolic AND <80 mm Hg diastolic 1, 2, 3
The American College of Cardiology and American Heart Association define Elevated BP as 120-129 mm Hg systolic AND <80 mm Hg diastolic 1, 2
The American College of Cardiology and American Heart Association define Stage 1 Hypertension as 130-139 mm Hg systolic OR 80-89 mm Hg diastolic 1, 2
The American College of Cardiology and American Heart Association define Stage 2 Hypertension as ≥140 mm Hg systolic OR ≥90 mm Hg diastolic 1, 2

The relationship between BP and cardiovascular disease is continuous and progressive, with risk doubling for every 20 mm Hg systolic or 10 mm Hg diastolic increase 3
At the elevated BP range (120-129/<80 mm Hg), hazard ratios for coronary heart disease and stroke are 1.1-1.5 times higher compared to normal BP 1, 2
At Stage 1 hypertension levels (130-139/80-89 mm Hg), this risk increases to 1.5-2.0 times baseline 1, 2

For patients with Stage 1 Hypertension (130-139/80-89 mm Hg) who are low-risk, lifestyle modifications alone are recommended initially, with drug therapy only if BP remains ≥140/90 mm Hg after 3-6 months 4
For patients with Stage 1 Hypertension (130-139/80-89 mm Hg) who are high-risk, start lifestyle modifications PLUS single antihypertensive agent immediately 4
For patients with Stage 2 Hypertension (≥140/≥90 mm Hg), immediately initiate both nonpharmacologic therapy AND antihypertensive medications, typically starting with 2 agents of different classes 5

The target BP for most patients is <130/80 mm Hg, with a minimum acceptable control of <150/90 mm Hg 4
For patients ≥65 years, target systolic BP <130 mm Hg with no specific diastolic target 4

Accurate BP measurement requires: patient seated quietly for ≥5 minutes with back supported, feet flat on floor, arm at heart level, using proper cuff size on bare arm, with no conversation and empty bladder 6, 5
The 2017 ACC/AHA guidelines represent a significant departure from JNC 7 (2003), which defined hypertension as ≥140/90 mm Hg and included a "prehypertension" category (120-139/80-89 mm Hg) 3

The American College of Cardiology recommends that blood pressure diagnosis be based on an average of at least 2 readings obtained on at least 2 separate occasions, with the patient seated quietly for ≥5 minutes with back supported, feet flat on floor, arm at heart level, using proper cuff size on bare arm, with no conversation and empty bladder 7, 8

The American College of Cardiology recommends a blood pressure target of <130/80 mm Hg for high-risk patients, which is a Class I recommendation 9
The American College of Cardiology recommends a blood pressure target of <130/80 mm Hg for lower-risk patients, which is a Class IIb recommendation 9
For patients ≥85 years with symptomatic orthostatic hypotension, the American Heart Association considers a more lenient target of <140/90 mm Hg 10

For patients with stage 2 hypertension, the American College of Cardiology recommends initiating therapy with 2 first-line agents of different classes, which is a Class I recommendation 9
For patients with stage 1 hypertension, the American College of Cardiology recommends initiating therapy with a single antihypertensive drug, with dosage titration and sequential addition of other agents, which is a Class IIa recommendation 9

Spironolactone is favored as the first-line agent for resistant hypertension, if not contraindicated 11, 12

The American College of Cardiology recommends home BP monitoring and ambulatory BP monitoring to confirm diagnosis and detect white coat hypertension, masked hypertension, white coat effect, and masked uncontrolled hypertension 7, 8
The American College of Cardiology recommends follow-up strategies to improve BP control, including systematic use of HBPM, team-based care, and telehealth strategies, which is a Class I, Level A recommendation 9

The American College of Cardiology recommends a blood pressure target of <130/80 mm Hg for adults with confirmed hypertension and known cardiovascular disease or 10-year ASCVD risk ≥10% (Class I recommendation) 13
For adults with confirmed hypertension without additional cardiovascular disease risk markers, a blood pressure target of <130/80 mm Hg may be reasonable but carries a lower strength of recommendation (Class IIa) 13
The American College of Cardiology recommends initiating treatment at blood pressure ≥130/80 mm Hg with a target <130/80 mm Hg for patients with diabetes or chronic kidney disease, as they are considered high-risk 14

Out-of-office blood pressure measurements using ambulatory blood pressure monitoring or home blood pressure monitoring should be used to confirm the diagnosis before initiating treatment, to detect white coat hypertension or masked hypertension 14
The American College of Cardiology recommends monthly follow-up for adults initiating new or adjusted antihypertensive therapy until blood pressure control is achieved (Class I, Level B-R recommendation) 13

Systematic use of home blood pressure monitoring is recommended as a useful adjunct to improve blood pressure control 14