What are the stages of hypertension and their management?

Hypertension Stages and Management

Blood Pressure Classification

The current standard defines hypertension stages as: Normal (<120/<80 mm Hg), Elevated (120-129/<80 mm Hg), Stage 1 Hypertension (130-139/80-89 mm Hg), and Stage 2 Hypertension (≥140/≥90 mm Hg), based on the 2017 ACC/AHA guidelines. 1, 2

Specific BP Categories:

• Normal BP: Systolic <120 mm Hg AND diastolic <80 mm Hg 1
• Elevated BP: Systolic 120-129 mm Hg AND diastolic <80 mm Hg 1
• Stage 1 Hypertension: Systolic 130-139 mm Hg OR diastolic 80-89 mm Hg 1
• Stage 2 Hypertension: Systolic ≥140 mm Hg OR diastolic ≥90 mm Hg 1, 2

Important: When systolic and diastolic readings fall into different categories, classify the patient by the higher category. 1 Diagnosis requires an average of ≥2 properly measured readings on ≥2 separate occasions. 1, 2

Measurement Requirements

Before diagnosing any stage of hypertension, ensure proper BP measurement technique: 2

• Patient seated quietly for ≥5 minutes with back supported
• Feet flat on floor, arm at heart level
• Average of ≥2 readings, 1 minute apart
• Confirm diagnosis with out-of-office monitoring (home or ambulatory BP monitoring) to exclude white coat hypertension 2

Management by Stage

Normal BP (<120/<80 mm Hg)

• Encourage healthy lifestyle habits 1
• Reassess annually 1

Elevated BP (120-129/<80 mm Hg)

• Implement nonpharmacologic therapy (lifestyle modifications) only 1
• No immediate drug therapy indicated 1
• Reassess in 3-6 months 1

Key lifestyle modifications include: 1, 3

• Weight reduction to ideal body weight
• DASH dietary pattern with sodium <1500 mg/day and increased potassium intake
• Regular aerobic exercise (90-150 minutes/week)
• Alcohol limitation (≤2 drinks/day for men, ≤1 drink/day for women)

Stage 1 Hypertension (130-139/80-89 mm Hg)

Treatment depends on cardiovascular disease (CVD) risk stratification: 1

High-Risk Patients (initiate drug therapy immediately):

• Known CVD (prior MI, stroke, heart failure) 1
• 10-year ASCVD risk ≥10% 1
• Age ≥65 years 1
• Diabetes mellitus 1
• Chronic kidney disease 1

For high-risk patients: Start lifestyle modifications PLUS single antihypertensive agent 1

Exception: For secondary stroke prevention in drug-naïve patients, initiate therapy only when BP ≥140/90 mm Hg 1

Non-High-Risk Patients:

• Lifestyle modifications alone initially 1
• Initiate drug therapy only if BP remains ≥140/90 mm Hg after 3-6 months of lifestyle intervention 1

Stage 2 Hypertension (≥140/≥90 mm Hg)

Immediately initiate both nonpharmacologic therapy AND antihypertensive medications for ALL patients. 2

Start with 2 antihypertensive agents from different classes when BP is >20/10 mm Hg above goal. 1, 2 This applies to most Stage 2 patients since the target is <130/80 mm Hg. 1

For patients with BP ≥160/100 mm Hg: Treat promptly with aggressive upward dose titration and careful monitoring. 2

First-Line Pharmacologic Therapy

Preferred initial drug classes (choose from): 3

• Thiazide or thiazide-like diuretics (chlorthalidone, hydrochlorothiazide)
• ACE inhibitors (lisinopril, enalapril)
• Angiotensin receptor blockers (ARBs) (candesartan, losartan)
• Calcium channel blockers (amlodipine)

For combination therapy: Use drugs with complementary mechanisms of action from the above classes. 1, 3

Treatment Targets

Target BP for most patients: <130/80 mm Hg 1

For patients ≥65 years: Target systolic BP <130 mm Hg (no specific diastolic target recommended) 1

Minimum acceptable control (audit standard): <150/90 mm Hg, though this is suboptimal 1

Follow-Up Schedule

• Stage 2 Hypertension: Reassess in 1 month after initiating treatment 2
• Stage 1 Hypertension (on medication): Reassess in 1-2 months 1
• Elevated BP or Stage 1 (lifestyle only): Reassess in 3-6 months 1

Laboratory monitoring: Check electrolytes and renal function 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics. 1, 2

Home BP monitoring: Perform daily for ≥1 week, beginning 2 weeks after treatment changes. 2

Critical Pitfalls to Avoid

• Improper BP measurement biases readings upward, leading to overdiagnosis and overtreatment 1
• Failing to confirm diagnosis with out-of-office monitoring risks treating white coat hypertension 2
• Undertreating Stage 2 hypertension with monotherapy when combination therapy is indicated 1, 2
• Ignoring cardiovascular risk stratification in Stage 1 hypertension leads to either undertreatment of high-risk patients or overtreatment of low-risk patients 1
• Using immediate-release nifedipine or hydralazine for hypertensive urgencies—these should be avoided 4