What are the diagnostic criteria and treatment options for hypertension?

Diagnosis and Management of Hypertension

Hypertension should be diagnosed after two or more elevated readings obtained on at least two visits over 1-several weeks, with blood pressure classified as normal (<120/80 mmHg), elevated (120-129/<80 mmHg), stage 1 hypertension (130-139/80-89 mmHg), or stage 2 hypertension (≥140/≥90 mmHg). 1

Diagnostic Criteria

Blood Pressure Classification

• Normal: <120/80 mmHg
• Elevated: 120-129 mmHg systolic and <80 mmHg diastolic
• Stage 1 Hypertension: 130-139 mmHg systolic or 80-89 mmHg diastolic
• Stage 2 Hypertension: ≥140 mmHg systolic or ≥90 mmHg diastolic 1

Proper Measurement Technique

• Use a properly calibrated and validated device
• Ensure proper patient preparation (seated, back supported, arm at heart level)
• Take at least 2-3 readings with 1-2 minutes between them
• Confirm diagnosis with out-of-office measurements (home or ambulatory monitoring) to avoid white coat hypertension 1

Diagnostic Confirmation

• Diagnosis requires elevated readings on at least two separate visits
• Single-visit measurements can overestimate prevalence by approximately 12.6% 2
• Home BP threshold corresponding to clinic BP of 130/80 mmHg is approximately 130/80 mmHg across different ethnic groups 3

Treatment Options

Lifestyle Modifications (First-Line for All Patients)

• Diet: Mediterranean or DASH diet recommended to reduce BP and cardiovascular disease (CVD) risk 4
• Physical Activity: Regular aerobic exercise (150-300 minutes/week) complemented with resistance training 2-3 times/week 4
• Weight Management: Aim for BMI 20-25 kg/m² and waist circumference <94 cm (men) and <80 cm (women) 4
• Sodium Reduction: Limit sodium intake and increase potassium intake 5
• Alcohol Limitation: Consume less than 100g/week of pure alcohol, preferably avoid completely 4
• Smoking Cessation: Stop tobacco use and refer to cessation programs 4
• Sugar Restriction: Limit free sugar to maximum 10% of energy intake, avoid sugar-sweetened beverages 4

Pharmacological Treatment

When to Initiate Medication

• Elevated BP with low/medium CVD risk: Start with lifestyle modifications 4
• Elevated BP with high CVD risk: After 3 months of lifestyle intervention, start medication if confirmed BP ≥130/80 mmHg 4
• Confirmed BP ≥140/90 mmHg: Promptly initiate both lifestyle measures and pharmacological treatment regardless of CVD risk 4

First-Line Medications

• Recommended initial therapy: Combination treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) 4, 5
• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or diuretic 4
  • Fixed-dose single-pill combinations recommended for better adherence 4

Treatment Escalation

• If BP not controlled with two-drug combination, increase to three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 4
• Avoid combining two RAS blockers (ACE inhibitor and ARB) 4
• Beta-blockers recommended when specific indications exist (angina, post-MI, heart failure) 4

Blood Pressure Targets

• Target systolic BP of 120-129 mmHg for most adults if well tolerated 4
• If target cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 4

Treatment Monitoring and Follow-up

• Measure BP at every routine clinical visit or at least every 6 months 1
• Monitor until target BP is achieved (within 3 months) 1
• Maintain BP-lowering treatment lifelong if well tolerated 4
• Take medications at the most convenient time of day to improve adherence 4

Common Pitfalls and Caveats

• Diagnostic errors: Relying on single-visit measurements can lead to overdiagnosis 2
• White coat hypertension: Confirm office readings with home or ambulatory monitoring 1
• Medication adherence: Fixed-dose combinations improve adherence compared to multiple pills 4
• Elderly patients: Consider frailty and orthostatic hypotension when initiating therapy 4
• Therapeutic inertia: Failure to intensify treatment when BP goals are not met 1

Hypertension is the leading risk factor for cardiovascular disease globally, affecting approximately one-third of adults 1. Proper diagnosis and management significantly reduce the risk of coronary heart disease, heart failure, stroke, and all-cause mortality 1, 5.