What are the diagnostic criteria and treatment options for hypertension?

Diagnosis of Hypertension

Hypertension is diagnosed when blood pressure is consistently ≥130/80 mm Hg, measured using proper technique with validated devices, and confirmed through multiple readings or out-of-office measurements. 1

Blood Pressure Measurement Standards

Office BP Measurement

• Use validated device (manual auscultatory or automated upper-arm cuff) 1
• Patient seated comfortably for 5 minutes before measurement 2
• Arm supported at heart level 1
• Appropriate cuff size (improper size can falsely elevate readings by 10-40 mmHg) 2
• Take at least 2-3 readings, 1-2 minutes apart 1
• Additional measurements if first two readings differ by >10 mmHg 1
• Use average of last two readings 1
• Avoid talking during measurement (can increase readings by 10-15 mmHg) 2
• Measure BP in both arms at first visit; use arm with higher BP for subsequent readings 1

Out-of-Office BP Measurement

• Home BP monitoring (HBPM): threshold for hypertension is >135/85 mmHg 2
• 24-hour ambulatory BP monitoring (ABPM): threshold is >130/80 mmHg (24-hour average) 2
• Out-of-office measurements are preferred for confirming diagnosis when available 1

Blood Pressure Classification

Category	Systolic BP (mmHg)	Diastolic BP (mmHg)
Normal	<120	and <80
Elevated	120-129	and <80
Stage 1 Hypertension	130-139	or 80-89
Stage 2 Hypertension	≥140	or ≥90

1, 2

Diagnostic Algorithm

1. Initial Screening:

   • If BP <130/85 mmHg: Remeasure after 3 years 1
   • If BP ≥130/85 mmHg: Confirm with home or ambulatory BP monitoring 1
   • If BP 160-179/100-109 mmHg: Confirm as soon as possible (within 1 month) 1
   • If BP ≥180/110 mmHg: Evaluate for hypertensive emergency 1

2. Confirmation of Diagnosis:

   • Multiple office readings on more than one visit (except for severe hypertension) 1
   • OR out-of-office measurements (HBPM or ABPM) 1
   • Home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg confirms hypertension 1

3. Special Considerations:

   • Standing BP should be measured in elderly or diabetic patients to exclude orthostatic hypotension 1
   • White coat hypertension: elevated BP in clinical settings but normal at home 2
   • Masked hypertension: normal BP in clinical settings but elevated outside 2

Initial Evaluation

Laboratory Tests

• Urinalysis for protein and blood 1
• Serum creatinine and electrolytes 1
• Blood glucose (ideally fasted) 1
• Lipid profile (total and HDL cholesterol) 1
• Electrocardiogram 1

Assessment for Secondary Causes

• Medication review (NSAIDs, oral contraceptives, steroids, sympathomimetics) 1
• Renal disease (proteinuria, hematuria, abnormal kidney function) 1
• Renovascular disease (abdominal or loin bruit) 1
• Endocrine disorders (pheochromocytoma, Conn's syndrome, Cushing's) 1
• Sleep apnea (neck circumference >40 cm) 1

Cardiovascular Risk Assessment

• SCORE2 recommended for ages 40-69 years 1
• SCORE2-OP recommended for ages ≥70 years 1
• Assessment of target organ damage 1

Monitoring and Follow-up

• Adults with normal BP (<120/80 mmHg): Recheck at least every 5 years 2
• Adults with elevated BP (120-129/<80 mmHg): Recheck annually 2
• Adults with "high normal" BP (130-139/85-89 mmHg): Recheck annually 2
• Patients on treatment: Monitor until target BP is achieved (within 3 months) 1

Common Pitfalls in Diagnosis

• Improper cuff size (too small inflates readings) 2
• Failure to allow adequate rest before measurement 1
• Talking during measurement 2
• Unsupported arm (can increase readings by 10 mmHg) 2
• Full bladder (can increase readings by 10-15 mmHg) 2
• Recent caffeine, smoking, or exercise (temporarily elevates readings) 2
• Relying on a single measurement 1
• Failing to consider white coat or masked hypertension 1

By following these diagnostic criteria and measurement protocols, clinicians can accurately diagnose hypertension and initiate appropriate management strategies to reduce cardiovascular risk.