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Am Fam Physician. 2021;103(12):763-765

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Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Use an average threshold of 140/90 mm Hg for office diagnosis of hypertension, but 135/85 mm Hg for home and 130/80 mm Hg for 24-hour ambulatory monitoring.

• Initial assessment in a patient who is hypertensive should evaluate for cardiovascular risk and any hypertension-mediated organ damage.

• Consider lifestyle interventions for three to six months before medication in patients with grade 1 hypertension and no comorbidities.

• After starting medication, target blood pressure is less than 140/90 mm Hg within three months, and after three months reduce target to less than 130/80 mm Hg in patients younger than 65 years.

From the AFP Editors

Hypertension is one of the leading causes of death globally each year, accounting for up to 30% of myocardial infarctions. Although the prevalence of hypertension is increasing, many patients are underdiagnosed and undertreated. The International Society of Hypertension (ISH) has published summary guidelines based on major international guidelines published between 2017 and 2020 on the control of hypertension. These summary guidelines include essential recommendations and suggestions for optimal care.

Diagnosis

Because blood pressure (BP) readings vary by measurement technique, diagnostic criteria are specific to the technique (Table 1). In health care settings that include the physician's office, hypertension is diagnosed when BP is 140/90 mm Hg or greater, ideally using an electronic device and following standard protocols for measurement, including repeat measurements.

LocationThreshold (mm Hg)
Office140/90
Home135/85
24-hour ambulatory monitoring
 24-hour average130/80
 Daytime average135/85
 Nighttime average120/70

The ISH recommends categorizing grade 1 hypertension for BP levels less than 160/100 mm Hg and grade 2 hypertension for any higher BP levels. Hypertension should only be diagnosed from a single BP reading if the measurement is 180/110 mm Hg or higher with evidence of cardiovascular disease requiring immediate treatment. Otherwise, the patient should be reassessed every one to four weeks to confirm BP elevations.

Although outpatient office measurements continue to be the most common means of diagnosing hypertension, home and ambulatory readings are more consistent and better reflect hypertension-mediated organ damage risk. Out-of-office readings can differentiate white coat hypertension, with elevated office measurements, and masked hypertension, where measurements are lower in the office.

When BP is measured at home, hypertension is diagnosed if readings are consistently 135/85 mm Hg or greater. With 24-hour ambulatory monitoring, hypertension is diagnosed based on one of three criteria: 24-hour average BP of 130/80 mm Hg or greater, daytime average BP of 135/85 mm Hg or greater, or nighttime average BP of 120/70 mm Hg or greater.

Assessment

After diagnosing hypertension, further assessment is recommended to identify cardiovascular risk factors and signs of hypertension-mediated organ damage. The cardiovascular risk factors of diabetes mellitus, dyslipidemia, obesity, or nicotine use affect one-half of people with hypertension. In addition to history and physical examination, a cost-effective assessment includes serum chemistry levels, fasting glucose level, fasting lipid panel, urinalysis, and electrocardiography. Cardiovascular risk should be estimated using a calculator such as the Framingham Risk Score (https://www.mdcalc.com/framingham-risk-score-hard-coronary-heart-disease). Other studies, such as echocardiography, renal artery evaluation, or brain imaging, are not routinely recommended.

Treatment

Lifestyle modifications are essential for managing hypertension, and optimal treatment starts with diet and activity. Dietary changes include salt reduction, moderation of alcohol consumption, and a diet high in vegetables and fruit that is low in added sugars and saturated fats (e.g., DASH diet). Activity recommendations include aerobic and resistance exercises for at least 30 minutes or more at least five days per week. Other important modifications include smoking cessation and stress reduction (Table 2).

ModificationDescription
Alcohol moderationAbstain from binge drinking
Limit to moderate daily consumption (i.e., 1.5 standard drinks per day for women and 2 for men)
DietIncrease consumption of dairy, fruits, polyunsaturated fats, vegetables, and whole grains
Increase consumption of foods high in calcium, magnesium, and potassium (e.g., avocados, legumes, nuts, seeds, tofu)
Increase consumption of vegetables high in nitrites (e.g., leafy vegetables, beetroot)
Reduce consumption of foods high in sugar, and saturated or trans fats
Healthy drinksConsider hibiscus tea, pomegranate juice, beetroot juice, and cocoa
Moderate consumption of coffee, and green and black tea
Physical activityAdd strength or resistance training 2 to 3 days per week
Moderate intensity aerobic activity (e.g., walking, jogging, cycling, yoga, swimming) at least 5 days per week
Salt reductionAvoid adding salt when cooking or dining
Limit consumption of high salt foods, including fast foods, processed foods, and soy sauce
Many breads and cereals are high in salt
Smoking cessationSmoking cessation programs and adjuncts are recommended
Stress reductionDaily mindfulness or meditation appears to improve blood pressure measurements
Weight lossEvaluate obesity by waist-to-height ratio less than 0.5, or by ethnic-specific body mass index targets
Limit obesity, particularly truncal obesity

Because medications require long-term adherence, initiating medication can be delayed in many cases. When patients have grade 1 hypertension without cardiovascular disease, chronic kidney disease, diabetes, or signs of organ damage, lifestyle therapy for three to six months is recommended. Pharmacotherapy should be started if BP remains uncontrolled, especially in patients 50 years or older. Treatment should be initiated immediately in patients with comorbidities or grade 2 hypertension, if possible.

Within the first three months of starting pharmacotherapy, the BP target should be less than 140/90 mm Hg. Recommended long-term blood pressure targets are less than 130/80 mm Hg in patients younger than 65 years and less than 140/90 mm Hg in patients 65 years or older.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

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