medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: High blood pressure in adults (The Basics)" and "Patient education: Controlling your blood pressure through lifestyle (The Basics)" and "Patient education: Coping with high drug prices (The Basics)" and "Patient education: Medicines for high blood pressure (The Basics)" and "Patient education: High blood pressure emergencies (The Basics)") Beyond the Basics topics (see "Patient education: High blood pressure in adults (Beyond the Basics)" and "Patient education: High blood pressure treatment in adults (Beyond the Basics)" and "Patient education: High blood pressure, diet, and weight (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)") https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 25/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate SUMMARY AND RECOMMENDATIONS Definition of hypertension The following definitions and staging system, which are based upon appropriately measured blood pressure ( table 1), were suggested in 2017 by the American College of Cardiology/American Heart Association (ACC/AHA) (see 'Definitions' above): Normal blood pressure Systolic <120 mmHg and diastolic <80 mmHg Elevated blood pressure Systolic 120 to 129 mmHg and diastolic <80 mmHg Hypertension: - Stage 1 Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg Stage 2 Systolic at least 140 mmHg or diastolic at least 90 mmHg If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage. The diagnosis of hypertension requires integration of home or ambulatory blood pressure monitoring (ABPM) in addition to measurements made in the clinical setting ( table 3). Meeting one or more of these criteria using ABPM qualifies as hypertension (see 'Definitions based upon ambulatory and home readings' above): A 24-hour mean of 125 mmHg systolic or 75 mmHg diastolic Daytime (awake) mean of 130 mmHg systolic or 80 mmHg diastolic Nighttime (asleep) mean of 110 mmHg systolic or 65 mmHg diastolic We find the daytime (awake) average of 130 mmHg systolic or 80 mmHg diastolic to be the most useful of these definitions. Measurement of blood pressure Proper technique and interpretation of the blood pressure is essential in the diagnosis and management of hypertension (see 'Blood pressure measurement' above): A number of steps should ideally be followed to achieve maximum accuracy of office measurement ( table 1). Rather than an auscultatory device (one that requires a stethoscope), we recommend using an oscillometric blood pressure device designed https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 26/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate specifically for the office setting. Automated office blood pressure (AOBP) devices can take multiple consecutive readings in the office with the patient sitting and resting alone (ie, unattended measurement) or with an attendant present. Either unattended or attended AOBP better predicts the results of awake (daytime) ABPM than traditional office blood pressure measurement and may reduce the white coat effect. (See 'Office- based blood pressure measurement' above.) ABPM is the preferred method for confirming the diagnosis of hypertension. High- quality data suggest that ABPM predicts target organ damage and cardiovascular events better than office blood pressure readings. (See 'Ambulatory blood pressure monitoring' above.) To measure blood pressure at home, patients should be instructed to use a validated, automated oscillometric device that measures blood pressure in the brachial artery (upper arm) and to perform measurements in a quiet room after five minutes of rest in the seated position with the back and arm supported and legs uncrossed. At least 12 to 14 measurements should be obtained, with both morning and evening measurements taken, over a period of one week each month. (See 'Home blood pressure monitoring' above.) Diagnosis of hypertension In an individual patient, we feel that making the diagnosis of hypertension requires the integration of multiple blood pressure readings, the use of appropriate technique, and also the use of measurements made outside of the usual office setting ( algorithm 1). (See 'Making the diagnosis of hypertension' above.) A diagnosis can be made, without further confirmatory readings, in the following uncommon scenarios: A patient who presents with hypertensive urgency or emergency (ie, patients with blood pressure 180 mmHg systolic or 120 mmHg diastolic). A patient who presents with an initial blood pressure 160 mmHg systolic or 100 mmHg diastolic and who also has known target end-organ damage (eg, left ventricular hypertension [LVH], hypertensive retinopathy, ischemic cardiovascular disease). In all other patients who have an elevated office blood pressure, the diagnosis of hypertension should be confirmed using out-of-office blood pressure measurement whenever possible. ABPM is considered the gold standard in determining out-of-office blood pressure. However, many payers require evidence of normal out-of-office readings https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 27/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate (suspected white coat hypertension) for reimbursement of ABPM. As such, we suggest home blood pressure measurement as the initial strategy to confirm the diagnosis of hypertension in most patients: Hypertension is diagnosed if the mean home blood pressure, when measured with appropriate technique and with a device that has been validated in the office, is 130 mmHg systolic or 80 mmHg diastolic. ABPM is an alternative to home blood pressure monitoring in settings where ABPM is readily available, particularly if adequate home blood pressures cannot be obtained, if there is doubt about the validity of home readings, or if there is a large discrepancy between office and home readings. When using ABPM, hypertension is diagnosed if the mean daytime blood pressure is 130 mmHg systolic or 80 mmHg diastolic. Occasionally, out-of-office confirmation of hypertension is not possible because of issues with availability of equipment, insurance, and cost. In these situations, a diagnosis of hypertension can be confirmed by serial (at least three) office-based blood pressure measurements spaced over a period of weeks to months with a mean of 130 mmHg systolic 80 mmHg diastolic. While use of appropriate technique is important in all patients, it is particularly essential in those in whom the diagnosis of hypertension is based solely upon office readings ( table 1). In settings where out-of-office blood pressure measurement is not readily available, we suggest using AOBPM. Evaluation of hypertension When hypertension is suspected based upon office readings or confirmed based upon out- of-office blood pressure readings, an evaluation should be performed to determine the following (see 'Evaluation' above): The extent of target-organ damage, if any The presence of established cardiovascular or kidney disease The presence or absence of other cardiovascular risk factors Lifestyle factors that could potentially contribute to hypertension Potential interfering substances (eg, chronic use of nonsteroidal antiinflammatory drugs [NSAIDs], oral contraceptives) Treatment of hypertension Lifestyle modification should be prescribed to all patients with elevated blood pressure or hypertension ( table 9); however, not all patients diagnosed with hypertension require pharmacologic therapy. (See 'Nonpharmacologic therapy' above.) https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 28/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate The decision to initiate drug therapy should be individualized and involve shared decision- making between patient and provider. In general, we suggest that antihypertensive drug therapy be initiated in the following hypertensive patients (see 'Who should be treated with pharmacologic therapy?' above): Patients with out-of-office daytime blood pressure 135 mmHg systolic or 85 mmHg diastolic (or an average office blood pressure 140 mmHg systolic or 90 mmHg diastolic if out-of-office readings not available) Patients with an out-of-office blood pressure (mean home or daytime ambulatory) 130 mmHg systolic or 80 mmHg diastolic (or, if out-of-office readings are unavailable, the average of appropriately measured office readings 130 mmHg systolic or 80 mmHg diastolic) who have one or more of the following features: Established clinical cardiovascular disease (eg, chronic coronary syndrome [stable ischemic heart disease], heart failure, carotid disease, previous stroke, or peripheral arterial disease) - - - Type 2 diabetes mellitus Chronic kidney disease Age 65 years or older An estimated 10-year risk of atherosclerotic cardiovascular disease of at least 10 percent (calculator 1) However, in patients who have stage 1 hypertension (130 to 139 mmHg systolic or 80 to 89 mmHg diastolic), we would consider withholding antihypertensive therapy among those 75 years or older or those who do not have established cardiovascular disease, diabetes, or chronic kidney disease if, in addition, they have recurrent falls, dementia, multiple comorbidities, orthostatic hypotension, residence in a nursing home, or limited life expectancy. (See 'Who should be treated with pharmacologic therapy?' above.) Some patients have a compelling indication for a specific drug or drugs that are unrelated to primary hypertension ( table 10). If there are no specific indications for a particular medication based upon comorbidities, we recommend that initial therapy be chosen from among the following four classes of medications (see 'Choice of initial antihypertensive agents' above): Thiazide-like or thiazide-type diuretics Long-acting calcium channel blockers (most often a dihydropyridine such as amlodipine) Angiotensin-converting enzyme (ACE) inhibitors https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 29/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Angiotensin II receptor blockers (ARBs) Our suggestions for goal blood pressure are as follows and depend upon the patient s baseline risk of having a cardiovascular event (see 'Blood pressure goals (targets)' above): We suggest a goal blood pressure of <130 mmHg systolic and <80 mmHg diastolic using out-of-office measurements (or, if out-of-office blood pressure is not available, then an average of appropriately measured office readings) in most patients who qualify for antihypertensive pharmacologic therapy. However, there is some disagreement among UpToDate authors and editors. Some believe that, among selected hypertensive patients who qualify for antihypertensive therapy but who are at low absolute cardiovascular risk, a less aggressive goal blood pressure of <135 mmHg systolic and <85 mmHg diastolic (using out-of-office measurement) or <140 mmHg systolic and <90 mmHg diastolic (using an average of appropriately measured office readings) is appropriate. We suggest a less aggressive goal blood pressure of <135 mmHg systolic and <85 mmHg diastolic (using out-of-office measurement) or <140 mmHg systolic and <90 mmHg diastolic (using an average of appropriately measured office readings) in the following groups of hypertensive patients: - - Patients with highly variable (labile) blood pressure or postural hypotension Patients with side effects to multiple antihypertensive medications Patients 75 years or older with a high burden of comorbidity or a diastolic blood pressure <55 mmHg In older adults with severe frailty, dementia, and/or a limited life expectancy, or in patients who are nonambulatory or institutionalized (eg, reside in a skilled nursing facility), we individualize goals and share decision-making with the patient, relatives, and caretakers, rather than targeting one of the blood pressure goals mentioned above. ACKNOWLEDGMENT The authors and UpToDate thank Dr. Frank Domino and Dr. Norman Kaplan for authoring and contributing to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 30/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate REFERENCES 1. Muntner P, Carey RM, Gidding S, et al. Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. Circulation 2018; 137:109. 2. Yoon SS, Gu Q, Nwankwo T, et al. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012. Hypertension 2015; 65:54. 3. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2014_namcs_web_tables.pdf. 4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13. 5. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021. 6. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension global hypertension practice guidelines. J Hypertens 2020; 38:982. 7. Hypertension in adults: Diagnosis and management. National Institute for Health and Care Excellence (NICE). http://www.nice.org.uk/guidance/ng136 (Accessed on October 23, 2020). 8. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903. 9. Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension 2019; 73:e35. 10. Stergiou GS, Palatini P, Parati G, et al. 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement. J Hypertens 2021; 39:1293. 11. Beevers G, Lip GY, O'Brien E. ABC of hypertension: Blood pressure measurement. Part II- conventional sphygmomanometry: technique of auscultatory blood pressure measurement. BMJ 2001; 322:1043. 12. Roerecke M, Kaczorowski J, Myers MG. Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis. JAMA Intern Med 2019; 179:351. 13. Myers MG. A proposed algorithm for diagnosing hypertension using automated office blood pressure measurement. J Hypertens 2010; 28:703. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 31/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate 14. Shimbo D, Artinian NT, Basile JN, et al. Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association. Circulation 2020; 142:e42. 15. Viera AJ, Yano Y, Lin FC, et al. Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review. JAMA 2021; 326:339. 16. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA 2009; 302:401. 17. Sonne-Holm S, S rensen TI, Jensen G, Schnohr P. Independent effects of weight change and attained body weight on prevalence of arterial hypertension in obese and non-obese men. BMJ 1989; 299:767. 18. Staessen JA, Wang J, Bianchi G, Birkenh ger WH. Essential hypertension. Lancet 2003; 361:1629. 19. Wang NY, Young JH, Meoni LA, et al. Blood pressure change and risk of hypertension associated with parental hypertension: the Johns Hopkins Precursors Study. Arch Intern Med 2008; 168:643. 20. Carnethon MR, Evans NS, Church TS, et al. Joint associations of physical activity and aerobic fitness on the development of incident hypertension: coronary artery risk development in young adults. Hypertension 2010; 56:49. 21. Li C, Shang S, Liang W. Sleep and risk of hypertension in general American adults: the National Health and Nutrition Examination Surveys (2015-2018). J Hypertens 2023; 41:63. 22. Johnson KA, Gordon CJ, Chapman JL, et al. The association of insomnia disorder characterised by objective short sleep duration with hypertension, diabetes and body mass index: A systematic review and meta-analysis. Sleep Med Rev 2021; 59:101456. 23. Li H, Ren Y, Wu Y, Zhao X. Correlation between sleep duration and hypertension: a dose- response meta-analysis. J Hum Hypertens 2019; 33:218. 24. Hartescu I, Stensel DJ, Thackray AE, et al. Sleep extension and metabolic health in male overweight/obese short sleepers: A randomised controlled trial. J Sleep Res 2022; 31:e13469. 25. Stock AA, Lee S, Nahmod NG, Chang AM. Effects of sleep extension on sleep duration, sleepiness, and blood pressure in college students. Sleep Health 2020; 6:32. 26. Carey RM, Moran AE, Whelton PK. Treatment of Hypertension: A Review. JAMA 2022; 328:1849. 27. Nakagomi A, Yasufuku Y, Ueno T, Kondo K. Social determinants of hypertension in high- income countries: A narrative literature review and future directions. Hypertens Res 2022; https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 32/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate 45:1575. 28. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997; 157:2413. 29. Lorell BH, Carabello BA. Left ventricular hypertrophy: pathogenesis, detection, and prognosis. Circulation 2000; 102:470. 30. Vakili BA, Okin PM, Devereux RB. Prognostic implications of left ventricular hypertrophy. Am Heart J 2001; 141:334. 31. Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557. 32. Flint AC, Conell C, Ren X, et al. Effect of Systolic and Diastolic Blood Pressure on Cardiovascular Outcomes. N Engl J Med 2019; 381:243. 33. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350:757. 34. Thrift AG, McNeil JJ, Forbes A, Donnan GA. Risk factors for cerebral hemorrhage in the era of well-controlled hypertension. Melbourne Risk Factor Study (MERFS) Group. Stroke 1996; 27:2020. 35. Wilson PW. Established risk factors and coronary artery disease: the Framingham Study. Am J Hypertens 1994; 7:7S. 36. Coresh J, Wei GL, McQuillan G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States: findings from the third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001; 161:1207. 37. Hsu CY, McCulloch CE, Darbinian J, et al. Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Arch Intern Med 2005; 165:923. 38. Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103:1245. 39. Taylor BC, Wilt TJ, Welch HG. Impact of diastolic and systolic blood pressure on mortality: implications for the definition of "normal". J Gen Intern Med 2011; 26:685. 40. McGrath BP, Kundu P, Daya N, et al. Isolated Diastolic Hypertension in the UK Biobank: Comparison of ACC/AHA and ESC/NICE Guideline Definitions. Hypertension 2020; 76:699. 41. Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365:434. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 33/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate 42. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA 2021; 325:1650. 43. Siu AL, U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:778. 44. Nerenberg KA, Zarnke KB, Leung AA, et al. Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2018; 34:506. 45. Bloch MJ, Basile JN. Ambulatory blood pressure monitoring to diagnose hypertension an idea whose time has come. J Am Soc Hypertens 2016; 10:89. 46. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560. 47. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007; 25:1105. 48. Forman JP, Brenner BM. 'Hypertension' and 'microalbuminuria': the bell tolls for thee. Kidney Int 2006; 69:22. 49. Cuspidi C, Lonati L, Macca G, et al. Cardiovascular risk stratification in hypertensive patients: impact of echocardiography and carotid ultrasonography. J Hypertens 2001; 19:375. 50. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2960. 51. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013; 346:f1325. 52. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 2006; 47:296. 53. Tuck ML, Sowers J, Dornfeld L, et al. The effect of weight reduction on blood pressure, plasma renin activity, and plasma aldosterone levels in obese patients. N Engl J Med 1981; 304:930. 54. Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 34/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998; 279:839. 55. Stevens VJ, Corrigan SA, Obarzanek E, et al. Weight loss intervention in phase 1 of the Trials of Hypertension Prevention. The TOHP Collaborative Research Group. Arch Intern Med 1993; 153:849. 56. Ascherio A, Rimm EB, Giovannucci EL, et al. A prospective study of nutritional factors and hypertension among US men. Circulation 1992; 86:1475. 57. Elmer PJ, Obarzanek E, Vollmer WM, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med 2006; 144:485. 58. Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121. 59. Hebert PR, Moser M, Mayer J, et al. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153:578. 60. Blood Pressure Lowering Treatment Trialists' Collaboration. Age-stratified and blood- pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis. Lancet 2021; 398:1053. 61. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281. 62. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007; 115:2761. 63. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665. 64. Reboussin DM, Allen NB, Griswold ME, et al. Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e116. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 35/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate 65. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507. 66. Webb AJ, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta- analysis. Lancet 2010; 375:906. 67. Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med 2009; 122:290. 68. Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2018; 72:e53. 69. Severe symptomless hypertension. Lancet 1989; 2:1369. 70. O'Mailia JJ, Sander GE, Giles TD. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med 1987; 107:185. 71. Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 1996; 276:1328. 72. Schmieder RE, Rockstroh JK, Messerli FH. Antihypertensive therapy. To stop or not to stop? JAMA 1991; 265:1566. 73. Nelson MR, Reid CM, Krum H, et al. Short-term predictors of maintenance of normotension after withdrawal of antihypertensive drugs in the second Australian National Blood Pressure Study (ANBP2). Am J Hypertens 2003; 16:39. 74. Freis ED, Thomas JR, Fisher SG, et al. Effects of reduction in drugs or dosage after long-term control of systemic hypertension. Am J Cardiol 1989; 63:702. 75. Finnerty FA Jr. Stepped-down therapy versus intermittent therapy in systemic hypertension. Am J Cardiol 1990; 66:1373. Topic 3852 Version 78.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 36/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate GRAPHICS Checklist for accurate measurement of blood pressure Key steps for proper BP Specific instructions measurements Step 1: Properly prepare the 1. Have the patient relax, sitting in a chair (feet on floor, back patient supported) for >5 minutes. 2. The patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement. 3. Ensure patient has emptied their bladder. 4. Neither the patient nor the observer should talk during the rest period or during the measurement. 5. Remove all clothing covering the location of cuff placement. 6. Measurements made while the patient is sitting or lying on an examining table do not fulfill these criteria. Step 2: Use proper technique for BP measurements 1. Use a BP measurement device that has been validated, and ensure that the device is calibrated periodically.* 2. Support the patient's arm (eg, resting on a desk). 3. Position the middle of the cuff on the patient's upper arm at the level of the right atrium (the midpoint of the sternum). 4. Use the correct cuff size, such that the bladder encircles 80% of the arm, and note if a larger- or smaller-than-normal cuff size is used. 5. Either the stethoscope diaphragm or bell may be used for auscultatory readings. Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension 1. At the first visit, record BP in both arms. Use the arm that gives the higher reading for subsequent readings. 2. Separate repeated measurements by 1 to 2 minutes. 3. For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate SBP. Inflate the cuff 20 to 30 mmHg above this level for an auscultatory determination of the BP level. 4. For auscultatory readings, deflate the cuff pressure 2 mmHg per second, and listen for Korotkoff sounds. Step 4: Properly document accurate BP readings 1. Record SBP and DBP. If using the auscultatory technique, record SBP and DBP as onset of the first Korotkoff sound and disappearance of all Korotkoff sounds, respectively, using the nearest even number. 2. Note the time of most recent BP medication taken before measurements. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 37/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Step 5: Average the readings 1. Use an average of 2 readings obtained on 2 occasions to estimate the individual's level of BP. Step 6: Provide BP readings 1. Provide patients the SBP/DBP readings both verbally and in to patient writing. BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure. Reproduced from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 115862 Version 3.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 38/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Definition of hypertension according to office, ambulatory, and home BP levels per guideline statements Daytime Nighttime 24-hour SBP/DBP Clinic HBPM ABPM ABPM ABPM 130/80 130/80 130/80 110/65 125/75 ACC/AHA Guidelines [1] 2017 140/90 135/85 135/85 120/70 130/80 ESC/ESH Guidelines [2] 2018 BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; HBPM: home blood pressure monitoring; ABPM: ambulatory blood pressure monitoring; ACC/AHA: American College of Cardiology/American Heart Association; ESC/ESH: European Society of Cardiology/European Society of Hypertension. Data from: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71:e127. 2. Williams B, Giuseppe M, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021. Graphic 119219 Version 1.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 39/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Diagnosis of hypertension in adults https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 40/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 41/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate ABPM: ambulatory blood pressure monitoring; AOBPM: automated office blood pressure monitoring. Home blood pressure must be performed adequately in order for the measurements to be used for diagnosis and management. To be adequate: The accuracy of the home device should be verified in the clinician's office; the patient should measure their blood pressure while seated (with feet flat on the floor), with arm supported (such as on a table), and after several minutes of rest; the blood pressure should be measured at different times per day and over a series of multiple days. A common strategy is to have the patient measure their blood pressure twice daily (once in the morning and once in the evening) for 7 days. Readings from the first day are discarded, and the remaining 12 measurements are averaged. Home blood pressure should not be used for diagnosis and management if it cannot be performed adequately. Adequate home blood pressure should be possible in most cases. Inexpensive devices to measure blood pressure at home are available over the counter. Alternatively, such devices can be borrowed (eg, provided by the clinic). Only rarely are such devices unavailable or unaffordable. ABPM is performed by having the patient wear, typically for 24 hours, an electronic blood pressure device that automatically measures the blood pressure, usually every half-hour during the day and hourly at night. We use the mean daytime value to determine the presence of hypertension. ABPM is possible if it is available in the clinic or via an external vendor and if it can be paid for by the patient's insurance or by the patient. Blood pressure measured in the office may vary according to the manner in which it is obtained. If blood pressure in the office is to be used for the diagnosis of hypertension (rather than using out-of- office blood pressures), we suggest performing unattended AOBPM (using a device that can average multiple readings while the patient sits alone in a room). Unattended AOBPM may provide a measurement that is 5 to 10 mmHg less than a manual measurement (ie, with a stethoscope). Office blood pressure must be performed with proper technique (eg, patient given time to rest, seated with feet flat on the floor, use of multiple measurements, appropriate-sized cuff placed on bare arm, etc). Office blood pressure measured with improper technique should not be used for diagnosis and management of hypertension. Refer to UpToDate topics on measurement of blood pressure for details of proper technique. Graphic 105050 Version 7.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 42/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Corresponding values of SBP/DBP for clinic, HBPM, daytime, nighttime, and 24-hour ABPM measurements Daytime Nighttime Clinic HBPM 24-hour ABPM ABPM ABPM 120/80 120/80 120/80 100/65 115/75 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90 SBP: systolic blood pressure; DBP: diastolic blood pressure; HBPM: home blood pressure monitoring; ABPM: ambulatory blood pressure monitoring. References: 1. Uhlig K, Balk EM, Patel K, et al. Self-Measured Blood Pressure Monitoring: Comparative E ectiveness. Agency for Healthcare Research and Quality, Rockville, MD 2012. 2. Margolis KL, Asche SE, Bergdall AR, et al. E ect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA 2013; 310:46. 3. McManus RJ, Mant J, Haque MS, et al. E ect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA 2014; 312:799. 4. Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:778. 5. Yi SS, Tabaei BP, Angell SY, et al. Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record. Circ Cardiovasc Qual Outcomes 2015; 8:138. 6. Agarwal R, Bills JE, Hecht TJW, et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2011; 57:29. 7. O'Brien E, Stergiou GS. The pursuit of accurate blood pressure measurement: a 35-year travail. J Clin Hypertens (Greenwich) 2017; 19:746. 8. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159. 9. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: a joint scienti c statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension 2008; 52:10. 10. National Clinical Guideline Centre. Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. Roayl College of Physicians, London 2011. Reproduced from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 116037 Version 1.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 43/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Reasons to evaluate a patient for masked or white coat hypertension Antihypertensive Suspected Reason treatment status classification Not on treatment Masked hypertension Office-based blood pressures 10 mmHg or less below the patient's goal (eg, systolic pressure 120 to 129 mmHg) On treatment Masked uncontrolled Office-based blood pressures below the patient's goal plus any of the following: hypertension Elevated atherosclerotic cardiovascular disease risk (eg, 10-year atherosclerotic cardiovascular disease risk >10%) Chronic kidney disease Diabetes mellitus Evidence of new or worsening end-organ