Given a 24‑hour ambulatory blood pressure average of 129/80 mmHg, does this meet Canadian hypertension criteria and require pharmacologic treatment?

24-Hour MAPA of 129/80 mmHg: Canadian Hypertension Diagnosis and Treatment

Your 24-hour ambulatory blood pressure of 129/80 mmHg meets the diagnostic threshold for hypertension by Canadian guidelines, but whether you require pharmacologic treatment depends on your overall cardiovascular risk, presence of target organ damage, and comorbid conditions.

Diagnostic Criteria for Hypertension

By the most recent (2024) European Society of Cardiology guidelines, a 24-hour ambulatory BP ≥130/80 mmHg defines hypertension 1. Your reading of 129/80 mmHg falls just below the systolic threshold but meets the diastolic threshold.

However, older Canadian and European guidelines used slightly different cutoffs:

• The 2007 European Society of Hypertension/Cardiology guidelines defined hypertension as 24-hour ambulatory BP of 125–130/80 mmHg 1
• Canadian Hypertension Society guidelines from 1999 recommended considering normal values for 24-hour ambulatory BP when making treatment decisions 2

Your BP of 129/80 mmHg would be classified as hypertension by the 2024 ESC threshold of ≥130/80 mmHg 1, and borderline by the 2007 threshold of 125–130/80 mmHg 1.

Treatment Decision Algorithm

Step 1: Assess Your Cardiovascular Risk Profile

Treatment is mandatory if you have:

• Diabetes mellitus (target <130/80 mmHg) 3
• Chronic kidney disease (target <130/80 mmHg) 3
• Established cardiovascular disease (prior MI, stroke, angina) 3
• Target organ damage (left ventricular hypertrophy, retinopathy, proteinuria) 3

Step 2: Calculate Your Global Cardiovascular Risk

If you do NOT have the above conditions, treatment thresholds depend on your 10-year cardiovascular risk:

• High risk (≥20% 10-year CV risk): Treat at 24-hour ambulatory BP ≥130/80 mmHg 1
• Moderate risk (10–20% 10-year CV risk): Consider treatment at ≥130/80 mmHg, especially if approaching 135/85 mmHg daytime average 1
• Low risk (<10% 10-year CV risk): Lifestyle modification first; pharmacotherapy if BP remains ≥135/85 mmHg daytime or ≥130/80 mmHg 24-hour average after 3–6 months 1

Step 3: Confirm with Daytime and Nighttime Values

Review your daytime and nighttime averages from the MAPA report:

• Daytime hypertension: ≥135/85 mmHg 1
• Nighttime hypertension: ≥120/70 mmHg 1

If your daytime BP is ≥135/85 mmHg or nighttime BP is ≥120/70 mmHg, this strengthens the diagnosis of hypertension even though your 24-hour average is borderline 1.

Treatment Recommendations

If Treatment Is Indicated:

First-line pharmacologic options for most patients without compelling indications:

• Thiazide diuretics (preferred for general population) 3
• ACE inhibitors (except in Black patients without compelling indications) 3
• Long-acting calcium channel blockers 3
• Angiotensin receptor blockers (ARBs) 3

Target blood pressure: <130/80 mmHg by 24-hour ambulatory monitoring 1, which corresponds to office BP <140/90 mmHg 1.

If Treatment Is NOT Yet Indicated:

Implement intensive lifestyle modifications for 3–6 months:

• Sodium restriction to <100 mmol/day (2.3 g sodium or 6 g salt) 3
• 30–60 minutes of aerobic exercise 4–7 days per week 3
• Maintain healthy body weight (BMI 18.5–24.9 kg/m²) and waist circumference (<102 cm men, <88 cm women) 3
• Limit alcohol to ≤14 units/week (men) or ≤9 units/week (women) 3
• DASH dietary pattern (high in fruits, vegetables, low-fat dairy, whole grains) 3

Repeat ambulatory BP monitoring in 3–6 months to reassess 1.

Critical Pitfalls to Avoid

• Do not assume your BP is normal simply because it falls below 130 mmHg systolic; the diastolic component of 80 mmHg meets the hypertension threshold 1
• Do not rely solely on office BP measurements for diagnosis or treatment decisions, as they may overestimate true BP by 5–10 mmHg 1
• Do not delay treatment if you have diabetes, chronic kidney disease, or established cardiovascular disease—these conditions mandate pharmacotherapy at your current BP level 3
• Verify that your MAPA device was validated using international standardized protocols and that ≥70% of readings were usable 1

Next Steps

1. Discuss your complete cardiovascular risk profile with your physician (age, sex, smoking status, cholesterol, family history, presence of diabetes or kidney disease) 3
2. Review daytime and nighttime BP averages from your MAPA report to confirm the diagnosis 1
3. If treatment is deferred, commit to intensive lifestyle modification and repeat ambulatory monitoring in 3–6 months 3
4. If treatment is initiated, aim to achieve target BP <130/80 mmHg (24-hour ambulatory) within 3 months 1, 4