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 based on multiple readings obtained on separate occasions. 1

Diagnostic Criteria

Blood Pressure Categories

The ACC/AHA guidelines establish four distinct categories 1:

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

Confirmation Requirements

Blood pressure should be measured at every routine clinical visit, and elevated readings must be confirmed on a separate day before diagnosing hypertension. 1 The exception is patients with cardiovascular disease and BP ≥180/110 mm Hg, who can be diagnosed at a single visit. 1

Proper Measurement Technique

Accurate measurement is critical, as most errors bias readings upward, leading to over-diagnosis and over-treatment 1:

• Patient seated with feet flat on floor, arm supported at heart level 1
• After 5 minutes of rest 1
• Appropriate cuff size for upper arm circumference 1
• Orthostatic measurements should be checked initially and as indicated to assess for autonomic neuropathy 1

Confirmation Methods Beyond Office Readings

Home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) should be used to confirm office readings and exclude white coat hypertension. 2, 3 These methods better correlate with cardiovascular risk than office measurements alone and may improve medication adherence. 1

Initial Diagnostic Workup

Once hypertension is confirmed, the following tests should be obtained 2, 3:

• 12-lead ECG 2
• Basic metabolic panel 2
• Fasting lipid panel 2
• Fasting glucose or HbA1c 2
• Urinalysis with albumin-to-creatinine ratio 2
• Thyroid-stimulating hormone (TSH) 2

Treatment Thresholds and Targets

When to Initiate Drug Therapy

The decision to start medication depends on both BP level and cardiovascular risk stratification. 1

High-Risk Patients (≥65 years, diabetes, CKD, known CVD, or 10-year ASCVD risk ≥10%)

• Initiate drug therapy at BP ≥130/80 mm Hg 1
• Exception: For secondary stroke prevention in drug-naïve patients, start at ≥140/90 mm Hg 1

Non-High-Risk Patients

• Initiate drug therapy at BP ≥140/90 mm Hg 1
• For Stage 1 hypertension (130-139/80-89 mm Hg), attempt lifestyle modifications alone for maximum 3 months before adding medications 1

Blood Pressure Targets

Target BP is <130/80 mm Hg for most adults under 65 years. 1, 2, 3, 4 For adults ≥65 years, target systolic BP is <130 mm Hg (no specific diastolic target recommended). 1

Pharmacological Treatment

First-Line Agents

First-line therapy consists of thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide), ACE inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers. 2, 3, 4

• ACE inhibitors are reasonable first-line agents for most patients with diabetes 1
• For patients with microalbuminuria or clinical nephropathy: ACE inhibitors (type 1 and type 2 diabetes) or ARBs (type 2 diabetes) are first-line 1
• β-blockers and diuretics have repeatedly shown benefit in reducing cardiovascular events 1

Combination Therapy

When BP is >20/10 mm Hg above goal, initiate treatment with two drugs having complementary mechanisms of action. 1 Many patients require three or more drugs to achieve target BP. 1

Special Populations

Pregnancy

• Transition to methyldopa, nifedipine, and/or labetalol during pregnancy 1
• Never use ACE inhibitors, ARBs, or direct renin inhibitors in pregnancy 1

Older Adults (≥65 years)

• Treatment with SBP goal <130 mm Hg is recommended for noninstitutionalized, ambulatory, community-dwelling adults 1
• For those with high comorbidity burden and limited life expectancy, use clinical judgment and shared decision-making 1

Diabetes

• BP targets should be <130/80 mm Hg 1
• Blood pressure should be measured at every routine diabetes visit 1

Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mm Hg despite adherence to 3+ antihypertensive agents at optimal doses (including a diuretic), or requiring 4+ medications. 1

Before diagnosing resistant hypertension, exclude pseudoresistance by:

• Ensuring accurate office BP measurement 1
• Assessing medication adherence 1
• Obtaining home or ambulatory BP readings to exclude white coat effect 1
• Screening for secondary causes (primary aldosteronism, CKD, renal artery stenosis, pheochromocytoma, obstructive sleep apnea) 1

Critical Pitfalls to Avoid

• Improper measurement technique (not resting 5 minutes, wrong cuff size, arm not supported) leads to falsely elevated readings and over-diagnosis 1
• Diagnosing hypertension on a single visit (except in emergencies ≥180/110 mm Hg with CVD) 1
• Failing to confirm with home or ambulatory monitoring, missing white coat hypertension 1, 2
• Starting all Stage 1 hypertensive patients on medications immediately without risk stratification 1
• Using ACE inhibitors or ARBs in women of childbearing age without contraception counseling 1