What are the diagnostic criteria and treatment options for Hypertension (HTN)?

Diagnostic Criteria and Treatment Options for Hypertension (HTN)

Hypertension is diagnosed when a person's systolic blood pressure (SBP) in the office or clinic is ≥140 mm Hg and/or their diastolic blood pressure (DBP) is ≥90 mm Hg following repeated examination. 1

Diagnostic Criteria

Office Blood Pressure Measurement

• Office BP should be measured according to these recommendations:
  • Quiet room with comfortable temperature
  • Before measurements: Avoid smoking, caffeine, and exercise for 30 minutes
  • Empty bladder; remain seated and relaxed for 3-5 minutes
  • Neither patient nor staff should talk before, during, or between measurements
  • Patient should be sitting with arm resting on table at heart level, back supported, legs uncrossed 1

Proper Measurement Technique

• Use validated electronic (oscillometric) upper-arm cuff device
• Ensure appropriate cuff size for arm circumference (smaller cuff overestimates BP)
• Take at least 2 readings at intervals of 1 minute and average them 1

Confirming the Diagnosis

• The diagnosis should not be made on a single office visit
• Usually 2-3 office visits at 1-4 week intervals are required to confirm hypertension
• Diagnosis might be made on a single visit only if BP is ≥180/110 mm Hg and there is evidence of cardiovascular disease 1
• When possible, confirm diagnosis with out-of-office BP measurements (home or ambulatory monitoring) 1

BP Classification

According to the 2020 International Society of Hypertension guidelines:

• Normal BP: <130/85 mm Hg
• High-normal: 130-139/85-89 mm Hg
• Grade 1 hypertension: 140-159/90-99 mm Hg
• Grade 2 hypertension: ≥160/100 mm Hg 1

Evaluation of Hypertensive Patients

Medical History

• Duration, severity, and progression of hypertension
• Treatment adherence and response to prior medications
• Current medication use, including herbal and over-the-counter medications
• Symptoms of possible secondary causes of hypertension 1

Physical Examination

• Pulse rate/rhythm/character
• Heart sounds, basal crackles
• Peripheral edema, bruits
• Body mass index (BMI)/waist circumference 1

Laboratory Investigations

• Basic tests:
  • Sodium, potassium, serum creatinine and eGFR
  • Lipid profile and fasting glucose (if available)
  • Urinalysis
  • 12-lead ECG 1

Additional Diagnostic Tests (when indicated)

• Echocardiography
• Carotid ultrasound
• Kidney/renal artery imaging
• Fundoscopy
• Brain CT/MRI 1

Treatment Options

Lifestyle Modifications

All patients with hypertension should receive these recommendations:

1. Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day
2. Increased dietary potassium (3500-5000 mg/day)
3. Weight loss if overweight/obese
4. Physical activity: aerobic or dynamic resistance 90-150 min/week
5. Moderation of alcohol intake (≤2 drinks/day for men, ≤1/day for women)
6. DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1

Pharmacological Treatment

When to Initiate Drug Therapy

• Sustained SBP >160 mm Hg or sustained DBP >100 mm Hg
• For sustained SBP 140-159 mm Hg or DBP 90-99 mm Hg: consider treatment based on presence of target organ damage, cardiovascular disease, diabetes, or 10-year cardiovascular risk 1

First-Line Medications

The preferred first-line medications include:

• Thiazide or thiazide-like diuretics
• Angiotensin-converting enzyme inhibitors (ACEIs)
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (CCBs) 2

Treatment Strategy

1. Start with low-dose thiazide diuretics or β-blockers in the absence of contraindications or compelling indications for other agents 1
2. If BP remains uncontrolled, add a second agent with a complementary mechanism of action
3. When BP is >20/10 mm Hg above goal, consider initiating therapy with two drugs having complementary mechanisms 1
4. Optimal BP treatment targets are SBP <140 mm Hg and DBP <85 mm Hg; minimum acceptable control is <150/<90 mm Hg 1

Special Populations

• Black patients: Initial therapy should be with CCB or thiazide diuretic 1
• Diabetes or chronic kidney disease: Target BP <130/80 mm Hg 1
• History of myocardial infarction, heart failure, or angina: β-blockers should be prescribed 1

Monitoring and Follow-up

• Patients initiating drug therapy should be followed approximately monthly for drug titration until BP is controlled
• Those with normal BP readings should be rechecked annually
• Those with elevated BP should have repeat measurements every 3-6 months 1

Common Pitfalls to Avoid

1. Diagnosing hypertension based on a single visit (leads to 12.6% overestimation of true prevalence) 3
2. Using improper cuff size (smaller cuff overestimates BP)
3. Not allowing adequate rest before measurement
4. Talking during BP measurement
5. Not considering white coat hypertension (use home or ambulatory monitoring when suspected)
6. Not addressing lifestyle modifications alongside pharmacological treatment

By following these diagnostic criteria and treatment options, healthcare providers can effectively manage hypertension and reduce the risk of cardiovascular disease, stroke, and mortality in affected patients.