Stage 2 Hypertension Management

Blood Pressure Classification

The American College of Cardiology defines Stage 2 hypertension as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, based on an average of at least 2 readings obtained on at least 2 separate occasions 1, 2, 3
The American College of Cardiology recommends classifying blood pressure into categories, including Normal BP: <120/<80 mm Hg, Elevated BP: 120-129/<80 mm Hg, Stage 1 Hypertension: 130-139/80-89 mm Hg, and Stage 2 Hypertension: ≥140/≥90 mm Hg 1, 2

The American College of Cardiology recommends that blood pressure diagnosis be based on proper measurement technique, including patient seated quietly for at least 5 minutes with back supported, feet flat on floor, and arm at heart level 5
The American College of Cardiology suggests using an average of at least 2 readings, 1 minute apart, on at least 2 separate occasions, and confirming diagnosis with out-of-office monitoring (home or ambulatory BP monitoring) to exclude white coat hypertension 1, 6, 5

The American Heart Association recommends immediate initiation of both nonpharmacological therapy and antihypertensive medications, typically starting with 2 agents of different classes, for all patients with Stage 2 hypertension 7
The American Heart Association suggests evaluating patients within 1 month of initial diagnosis, initiating combination therapy immediately with 2 antihypertensive agents of different classes, and titrating treatment according to both office and home BP measurements 7

The American Heart Association recommends reassessing BP in 1 month after initiating treatment to evaluate response and adjust therapy as needed 7
The American Heart Association suggests assessing electrolytes and renal function 2-4 weeks after initiating therapy in patients on renin-angiotensin system inhibitors or diuretics 7
Home BP monitoring should be performed daily, ideally for at least 1 week, beginning 2 weeks after treatment changes, as recommended by the American College of Cardiology 5

The American Heart Association recommends particularly aggressive management with prompt treatment and careful upward dose titration for patients with Stage 2 hypertension and BP ≥160/100 mm Hg 7
The American Heart Association suggests that the absolute CVD risk reduction from BP lowering is greater in patients at higher baseline risk, making aggressive treatment even more critical in these populations 7