Next Steps After Suspecting Hypertension
After initial assessment reveals suspected hypertension, you must confirm the diagnosis with out-of-office blood pressure measurements using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), with the specific approach determined by the initial screening BP level and cardiovascular risk. 1
Immediate Action Based on Screening BP Level
BP 120-139/70-89 mmHg (Elevated BP in High-Risk Patients)
- Confirm with out-of-office measurements using ABPM and/or HBPM, or if not feasible, repeat office measurements on multiple visits 1
- This applies specifically to individuals with increased cardiovascular disease (CVD) risk 1
- Schedule repeat assessment within 1 year 1
BP 140-159/90-99 mmHg (Stage 1 Hypertension Range)
- Diagnosis must be based on out-of-office BP measurement with ABPM and/or HBPM as the preferred method 1
- If out-of-office monitoring is not logistically or economically feasible, use repeated office measurements on more than one visit 1
- Out-of-office measurements correlate better with end-organ damage than office readings 1
- Beware of white coat hypertension: up to 55% of patients with office systolic BP 140-149 mmHg may have normal out-of-office readings 1
BP 160-179/100-109 mmHg (Stage 2 Hypertension)
- Confirm as soon as possible (within 1 month) preferably with ABPM or HBPM 1
- Check upper and lower extremity BP (right arm, left arm, and one leg) to assess for coarctation or peripheral vascular disease 1
- Begin cardiovascular risk assessment and consider lifestyle counseling 1
BP ≥180/110 mmHg (Severe Hypertension)
- First, exclude hypertensive emergency by assessing for acute end-organ damage (cardiac, renal, neurologic injury) 1, 2
- If no emergency exists, confirm diagnosis promptly (preferably within 1 week) before starting treatment 1
- If hypertensive emergency is present, admit to intensive care unit for immediate parenteral BP reduction 2
Out-of-Office BP Monitoring Specifications
Home Blood Pressure Monitoring (HBPM)
- Obtain at least 12-14 measurements over 1 week for optimal treatment decisions 1
- Measure both morning and evening BP before any medications 1
- Use validated automated devices with appropriate cuff size; avoid finger cuffs 1
- HBPM threshold for hypertension: ≥135/85 mmHg (5 mmHg lower than office readings) 1, 3
- Contraindication: Patients with atrial fibrillation or arrhythmias may get unreliable oscillometric readings 1
Ambulatory Blood Pressure Monitoring (ABPM)
- Provides 24-hour average and detects absence of nocturnal dipping 1
- ABPM threshold for hypertension: ≥130/80 mmHg (24-hour average) 3
- Specific indications for ABPM: suspected white coat hypertension, masked hypertension, episodic hypertension, resistant hypertension, autonomic dysfunction, or unexplained end-organ damage 1
Critical Pitfalls to Avoid
White Coat Hypertension (WCH)
- Occurs in 10-20% of primary care patients with elevated office BP 1
- Defined as office BP >140/90 mmHg but out-of-office BP <135/85 mmHg 1
- Missing this leads to unnecessary treatment 1
Masked Hypertension
- Prevalence 10-40%; normal office BP but elevated out-of-office readings 1
- Carries the same cardiovascular risk as true hypertension but is frequently missed without out-of-office monitoring 1
- Consider in patients with unexplained end-organ damage despite normal office readings 1
Measurement Technique Requirements
- Use validated automated device with appropriate cuff size 1, 3
- Take average of 2-3 readings, 1-2 minutes apart 1
- Measure BP in both arms at some point; variation <10 mmHg is acceptable 1
- Patient should be seated with arm at heart level 1