Hypertension Diagnosis and Management

Diagnostic Criteria and Blood Pressure Measurement

The Canadian Hypertension Education Program recommends blood pressure measurements on 4-5 separate office visits before diagnosing hypertension when systolic BP is 140-160 mmHg or diastolic BP is 90-100 mmHg, or alternatively, diagnosis can be confirmed using ambulatory or home blood pressure monitoring 1
Office BP threshold: Hypertension is defined as seated BP ≥140/90 mmHg based on multiple measurements 1
Stage 1 hypertension: 140-159/90-99 mmHg 1
Stage 2 hypertension: ≥160/100 mmHg 1
Obtain BP readings with the patient seated quietly for >5 minutes, feet flat on floor, back supported, arm at heart level 2
Use validated devices with appropriate cuff size that encircles 80% of the arm 2
Base diagnosis on average of ≥2 readings obtained on ≥2 separate occasions 3, 4

Use ABPM or HBPM to detect white coat hypertension and masked hypertension 3, 4
ABPM/HBPM thresholds for hypertension are lower than office measurements 1
White coat hypertension carries cardiovascular risk similar to normal BP, while masked hypertension carries risk equivalent to sustained hypertension 3, 4
Screen for secondary causes when patients present with early onset hypertension, resistant hypertension, sudden deterioration in BP control, or BP lability with episodic symptoms 5
Basic screening includes thorough history, physical examination, serum sodium, potassium, eGFR, TSH, and dipstick urinalysis 5

Target BP <140/90 mmHg for all hypertensive patients, except those with diabetes mellitus or chronic kidney disease, where target BP <130/80 mmHg 5
Consider lifestyle modifications alone for 3-6 months before starting medications in patients with Stage 1 hypertension and low cardiovascular risk 2
For high-risk patients, initiate therapy at BP ≥130/80 mmHg 5

Dietary sodium restriction: <2300 mg (100 mmol)/day; ideally 1500-2300 mg (65-100 mmol)/day for hypertensive patients 6
DASH diet: Emphasize fruits, vegetables, low-fat dairy, whole grains, dietary fiber, and plant-based protein while reducing saturated fat and cholesterol 2

First-line antihypertensive agents include thiazide diuretics, ACE inhibitors, long-acting calcium channel blockers, angiotensin receptor blockers, and beta-blockers 6
Consider starting with two first-line agents if systolic BP is 20 mmHg above target or diastolic BP is 10 mmHg above target 2
For patients with diabetes mellitus, use ACE inhibitors or ARBs as first-line therapy 6

Monitor serum creatinine and potassium within 7-14 days after initiating or titrating ACE inhibitors, ARBs, or diuretics, then at least annually 2
Follow-up every 3-6 months for patients at BP goal, and monthly for patients not at BP goal 7, 2
Use home blood pressure monitoring to detect white coat effect and masked uncontrolled hypertension 3, 4