Blood Pressure Classification and Immediate Management of Stage 2 Hypertension

1. Classification Thresholds

ACC/AHA (American College of Cardiology/American Heart Association) defines Stage 1 hypertension as systolic 130–139 mmHg or diastolic 80–89 mmHg. 1
ACC/AHA defines Stage 2 hypertension as systolic ≥140 mmHg or diastolic ≥90 mmHg. 1
According to ACC/AHA, an adult with a systolic pressure of 150 mmHg (≥140 mmHg) meets Stage 2 criteria. 1
International Society of Hypertension (ISH) defines Grade 1 (Stage 1) hypertension as systolic 140–159 mmHg and diastolic 90–99 mmHg. 5
ISH defines Grade 2 hypertension as systolic ≥160 mmHg or diastolic ≥100 mmHg. 5
An adult with a blood pressure of 150/88 mmHg falls within the ISH Grade 1 range. 5
JNC 7 (historical) defined Stage 1 hypertension as systolic 140–159 mmHg or diastolic 90–99 mmHg, and Stage 2 as ≥160/100 mmHg. 7

ACC/AHA guidelines state that Stage 2 hypertension requires immediate initiation of antihypertensive medication together with lifestyle interventions. 1
The 2025 ACC/AHA update specifically recommends starting therapy with two first‑line agents from different classes in a single‑pill, fixed‑dose combination for all patients with Stage 2 hypertension. 3
ISH guidelines mandate immediate drug treatment (plus lifestyle measures) for any adult with office blood pressure ≥140/90 mmHg. 5

Do not postpone treatment while awaiting multiple confirmatory visits when office blood pressure is ≥140/90 mmHg; prompt pharmacologic therapy is indicated. 5
Avoid using outdated terminology (e.g., JNC 7) because ACC/AHA has lowered diagnostic thresholds and altered management algorithms. 1
Do not rely on monotherapy for Stage 2 hypertension; combination therapy with two agents is preferred to achieve faster control and improve adherence. 3
When feasible, confirm the diagnosis with out‑of‑office monitoring (home BP ≥135/85 mmHg or 24‑hour ambulatory BP ≥130/80 mmHg), but do not delay treatment if office readings are markedly elevated. 5