What are the blood pressure values and management options for stage 2 hypertension?

Stage 2 Hypertension Blood Pressure Values

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, 2, 3

Blood Pressure Classification

The current ACC/AHA classification system divides blood pressure into four categories 1, 2, 3:

• Normal BP: <120/<80 mm Hg 3
• Elevated BP: 120-129/<80 mm Hg 3
• Stage 1 Hypertension: 130-139/80-89 mm Hg 3
• Stage 2 Hypertension: ≥140/≥90 mm Hg 1, 2, 3

When systolic and diastolic readings fall into different categories, the higher category determines the classification. 3

Proper Measurement Requirements

Accurate diagnosis requires proper technique 2, 3:

• Patient seated quietly for ≥5 minutes with back supported, feet flat on floor, arm at heart level 2, 3
• Use proper cuff size on bare arm 3
• No conversation during measurement, empty bladder 3
• Average of at least 2 readings, 1 minute apart 2
• Measurements on at least 2 separate occasions 2
• Confirm diagnosis with out-of-office monitoring (home or ambulatory BP) to exclude white coat hypertension 2

Management of 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, 2, 3

Initial Treatment Approach

• Start combination therapy immediately with 2 antihypertensive agents of different classes 2
• First-line agents include thiazide/thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers 4
• Patients with BP ≥160/100 mm Hg require particularly aggressive management with prompt treatment and careful upward dose titration 2

Follow-Up Timeline

• Reassess BP in 1 month after initiating treatment to evaluate response and adjust therapy 2
• For patients on renin-angiotensin system inhibitors or diuretics, assess electrolytes and renal function 2-4 weeks after initiating therapy 2
• Home BP monitoring should be performed daily for at least 1 week, beginning 2 weeks after treatment changes 2

Treatment Target

The target BP for most patients is <130/80 mm Hg 3, 4, with titration based on both office and home BP measurements 2.

Key Differences from Prior Guidelines

This classification represents a significant departure from JNC 7 (2003), which defined hypertension as ≥140/90 mm Hg and divided it into Stage 1 (140-159/90-99 mm Hg) and Stage 2 (≥160/≥100 mm Hg) 1, 3. The 2017 ACC/AHA guidelines lowered the threshold to ≥130/80 mm Hg for Stage 1, making the current Stage 2 definition (≥140/≥90 mm Hg) equivalent to the former Stage 1 threshold 1, 3.