Summary of Recommendations and Evidence

The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults 18 years and older (see accompanying table). A recommendation.

Rationale

Importance. Hypertension is a very prevalent condition that contributes to significant adverse health outcomes, including premature death, heart attack, renal insufficiency, and stroke.

Detection. The USPSTF found good evidence that blood pressure measurement can identify adults at increased risk of cardiovascular disease from high blood pressure.

Benefits of detection and early treatment. The USPSTF found good evidence that treatment of high blood pressure in adults substantially decreases the incidence of cardiovascular events.

Harms of detection and early treatment. The USPSTF found good evidence that screening and treatment for high blood pressure causes few major harms.

USPSTF assessment. The USPSTF concludes that there is high certainty that the net benefit of screening for high blood pressure in adults is substantial.

Clinical Considerations

• Patient population. This recommendation applies to adults without known hypertension.

• Screening tests. Office measurement of blood pressure is most commonly performed with a sphygmomanometer. High blood pressure (hypertension) is usually defined in adults as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher. Because of the variability in individual blood pressure measurements, it is recommended that hypertension be diagnosed only after two or more elevated readings are obtained on at least two visits over a period of one to several weeks.¹

• Assessment of risk. The relationship between systolic and diastolic blood pressure and cardiovascular risk is continuous and graded. The actual level of blood pressure elevation should not be the only factor in determining treatment. When making treatment decisions, physicians should consider the patient's overall cardiovascular risk profile, including smoking, diabetes, abnormal blood lipid values, age, sex, sedentary lifestyle, and obesity.

• Screening interval. Evidence is lacking to recommend an optimal interval for screening adults for hypertension. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends screening every two years in persons with blood pressure less than 120/80 mm Hg, and every year in persons with systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 90 mm Hg.²

• Pharmacologic treatment. Various pharmacologic agents are available to treat high blood pressure. The JNC 7 guidelines for treatment of high blood pressure can be accessed at http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm.

• Nonpharmacologic treatment. Non-pharmacologic therapies, such as reduction of dietary sodium intake, potassium supplementation, increased physical activity, weight loss, stress management, and reduction of alcohol intake, are associated with a reduction in blood pressure. Studies have shown that reduced drinking decreases blood pressure in persons who consume large amounts of alcohol (i.e., more than 20 drinks per week).

Discussion

In 2003, the USPSTF reviewed the evidence for screening for hypertension in adults and found that the benefits outweigh the harms.¹ The benefits of screening are well established, which prompted the USPSTF to perform a targeted literature search for evidence of the direct benefits of screening, the harms of screening, and the harms of treatment of screen-detected or mild to moderate hypertension.³ The USPSTF found no new substantial evidence about the benefits and harms of screening for high blood pressure that would lead to a change in the previous recommendation. Therefore, the USPSTF reaffirms its recommendation that physicians screen for high blood pressure in adults 18 years and older. The 2003 recommendation statement and evidence report, and the current summary of the updated literature search can be found at http://www.uspreventiveservicestaskforce.org/recommendations.htm.

Recommendations from Other Groups

The JNC 7 calls for routine blood pressure measurement at least once every two years for adults with a systolic blood pressure below 120 mm Hg and a diastolic blood pressure below 80 mm Hg, and every year for systolic blood pressure of 120 to 139 mm Hg and diastolic blood pressure of 80 to 89 mm Hg.² Similar recommendations have been issued by the American Heart Association for adults beginning at 20 years of age.⁴ The American Academy of Family Physicians strongly recommends that family physicians screen adults 18 years and older.⁵ The American College of Obstetricians and Gynecologists recommends measuring blood pressure as part of the periodic assessment in women 13 years and older.⁶