Stage 2 Hypertension: Classification and Treatment
Stage 2 hypertension is defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, based on an average of at least 2 readings obtained on at least 2 separate occasions. 1
Blood Pressure Classification
Stage 2 hypertension represents the highest category in the 2017 ACC/AHA classification system and requires immediate intervention:
- Normal BP: <120/<80 mm Hg 1
- Elevated BP: 120-129/<80 mm Hg 1
- Stage 1 Hypertension: 130-139/80-89 mm Hg 1
- Stage 2 Hypertension: ≥140/≥90 mm Hg 1
When systolic and diastolic values fall into different categories, the higher category should be used for classification and risk stratification. 2
Measurement Requirements
Blood pressure diagnosis must be based on proper measurement technique to avoid misclassification. 1, 3
Key measurement standards include:
- Patient seated quietly for at least 5 minutes with back supported, feet flat on floor, and arm at heart level 3
- Average of at least 2 readings, 1 minute apart, on at least 2 separate occasions 1, 3
- Use validated, calibrated devices with appropriate cuff size 3
- Confirm diagnosis with out-of-office monitoring (home or ambulatory BP monitoring) to exclude white coat hypertension 1, 3
Treatment Approach for Stage 2 Hypertension
All patients with Stage 2 hypertension require immediate initiation of both nonpharmacological therapy and antihypertensive medications, typically starting with 2 agents of different classes. 1
Immediate Management Algorithm:
Evaluate within 1 month of initial diagnosis 1
Initiate combination therapy immediately with 2 antihypertensive agents of different classes 1
Patients with BP ≥160/100 mm Hg require prompt treatment, careful monitoring, and upward dose adjustment as necessary 1
For very high BP (SBP ≥180 mm Hg or DBP ≥110 mm Hg), prompt evaluation and immediate antihypertensive drug treatment is mandatory 1
First-Line Pharmacological Therapy:
The preferred initial regimen combines agents from these classes: 4, 5
- Thiazide or thiazide-like diuretics (hydrochlorothiazide or chlorthalidone) 4
- ACE inhibitors or angiotensin receptor blockers (enalapril, lisinopril, candesartan) 6, 4
- Calcium channel blockers (amlodipine) 4
These medications have proven efficacy in reducing cardiovascular morbidity and mortality, with a 10 mm Hg SBP reduction decreasing CVD events by approximately 20-30%. 4
Nonpharmacological Interventions (Mandatory for All):
Lifestyle modifications must be initiated simultaneously with medications: 4, 5
- Weight loss if overweight/obese 4
- Dietary sodium restriction and potassium supplementation 4
- Healthy dietary pattern (DASH diet) 4
- Regular physical activity 4
- Alcohol moderation or elimination 4
The BP-lowering effects of lifestyle modifications are partially additive and enhance medication efficacy. 4
Treatment Targets
The blood pressure goal for most adults <65 years is <130/80 mm Hg; for adults ≥65 years, the target is SBP <130 mm Hg. 4
Treatment should be titrated according to both office and home BP measurements to achieve these targets. 4
Follow-Up and Monitoring
Reassess BP in 1 month after initiating treatment to evaluate response and adjust therapy as needed. 1
For patients on renin-angiotensin system inhibitors or diuretics, assess electrolytes and renal function 2-4 weeks after initiating therapy. 1
Home BP monitoring should be performed daily, ideally for at least 1 week, beginning 2 weeks after treatment changes. 3
Critical Pitfalls to Avoid
Do not use immediate-release nifedipine, hydralazine, or nitroglycerin for acute BP management in hypertensive urgencies or emergencies, as these agents cause unpredictable BP reductions. 7
Do not delay treatment initiation in Stage 2 hypertension—the 2-fold increase in CVD risk compared to normal BP mandates immediate intervention. 1
Do not rely solely on office BP measurements—confirm diagnosis and guide treatment with out-of-office monitoring to detect white coat effect or masked uncontrolled hypertension. 1, 3
Special Considerations
Patients with Stage 2 hypertension and BP ≥160/100 mm Hg require particularly aggressive management with prompt treatment and careful upward dose titration. 1
The absolute CVD risk reduction from BP lowering is greater in patients at higher baseline risk (those with diabetes, chronic kidney disease, or established CVD), making aggressive treatment even more critical in these populations. 1