Hypertension is a common disorder that affects a large proportion of the community. It is usually asymptomatic and is detected on routine exam or after the occurrence of a complication such as a heart attack or stroke.[1]
The 2017 ACC/AHA guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults defines hypertension as any systolic blood pressure measurement of ≥130 mmHg or any diastolic blood pressure measurement of ≥80 mmHg.[2] ACC/AHA blood pressure categories are defined as follows:
- Elevated blood pressure: systolic blood pressure of 120-129 mmHg and diastolic blood pressure of <80 mmHg
- Stage 1 hypertension: systolic blood pressure of 130-139 mmHg and/or diastolic blood pressure of 80-89 mmHg
- Stage 2 hypertension: systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg.
The 2017 ACC/AHA guidelines definition represents a more aggressive approach to diagnosis and treatment of hypertension compared with Joint National Committee (JNC) 7 and JNC 8 recommendations, where blood pressure in the range of 120-139 mmHg/80-89 mmHg is considered prehypertension and blood pressure >140/90 mmHg is considered elevated.[3] [4]
Publication of the 2017 ACC/AHA guidelines has prompted widespread debate, and there are calls for the recommendations to be revisited. Implementing the guidelines would increase the prevalence of hypertension by 26.8% in the US. Critics are concerned that labelling more patients as hypertensive could increase psychological morbidity, as well as exposing lower-risk patients to the potential harm of antihypertensive medications.[5]
The 2017 ACC/AHA guidelines were mainly based on the results of the SPRINT trial, which investigated intensive or standard hypertension treatment in people with a systolic blood pressure of ≥130 mmHg with an increased cardiovascular risk (but without diabetes).[6] Listen to our podcast for more on the controversy.BMJ Best Practice Podcast: hypertension
European guideline blood pressure categories are defined as follows:[7]
- Elevated blood pressure: office systolic blood pressure 120-139 mmHg or office diastolic blood pressure 70-89 mmHg
- Hypertension: office systolic blood pressure ≥140 mmHg or office diastolic blood pressure ≥90 mmHg.
For the diagnosis of elevated blood pressure or hypertension to be made, the European guidelines recommend confirmation with out-of-office measurements or at least one repeat office measurement at a subsequent visit.[7] Isolated systolic hypertension is defined as a systolic blood pressure ≥140 mmHg, with a diastolic blood pressure <90 mmHg.[7]
The UK National Institute for Health and Care Excellence states that a diagnosis of hypertension is confirmed in those with:[8]
- a clinic blood pressure of ≥140/90 mmHg, and
- daytime ambulatory blood pressure monitoring average or home blood pressure monitoring average of ≥135/85 mmHg.
Although different studies have used a variety of cut-off points for the diagnosis of hypertension in the community, any blood pressure >120 mmHg systolic is associated with an increased cardiovascular risk. The importance of hypertension is its relation to other cardiovascular risk factors and consequent overall cardiovascular risk.
The AHA defines resistant hypertension as:[9]
- Clinic blood pressure >130/80 mmHg despite the concurrent use of at least 3 antihypertensive agents (including an ACE inhibitor or angiotensin receptor antagonist, a long-acting calcium channel blocker, and a diuretic) at maximum or maximally tolerated doses.
- Patients who require 4 or more antihypertensive agents to achieve their target blood pressure are also considered to have resistant hypertension. The diagnosis requires the exclusion of white-coat hypertension and poor adherence with antihypertensive medication.
This topic addresses the evaluation of hypertension in adults.
