Hypertension: Diagnosis, Grading & Management

Hypertension Diagnosis, Grading and Management

Initiation of blood pressure-lowering treatment (lifestyle changes and medication) at different initial office blood pressure levels

Use home blood pressure monitoring (HBPM) and/or ambulatory blood pressure monitoring (24h ABPM) whenever possible. 

Abbreviations:
BP = blood pressure;
CAD = coronary artery disease;
CVD = cardiovascular disease;
HMOD = hypertension-mediated organ damage.

Adapted from The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH). Journal of Hypertension 2023, 41: 1874–2071.

Hypertension-mediated organ damage (HMOD)

1. Increased large artery stiffness:
   Pulse pressure (in older people) > 60mmHg and/or carotid–femoral pulse wave velocity >10 m/s (if available)
2. Presence of non-hemodynamically significant atheromatous plaque (stenosis) on imaging
3. Left ventricle hypertrophy on electrocardiogram (EKG) or on echocardiography
4. Moderate increase of albuminuria 30–300 mg/24 h or elevated ACR (preferably in morning spot urine) 30–300 mg/g
5. CKD stage 3 with eGFR 30–59 ml/min/1.73m²
6. Ankle–brachial index <0.9
7. Advanced retinopathy: haemorrhages or exudates, papilloedema

How to measure blood pressure (BP)

Patients should be seated comfortably in a quiet environment for 5 minutes before beginning BP measurements. Three BP measurements should be recorded, 1-2 min apart, and additional measurements only if the first two readings differ by >10 mmHg. BP is recorded as the average of the last two BP readings. Use a standard bladder cuff (12-13 cm wide and 35 cm long) for most patients but have larger and smaller cuffs available for larger (arm circumference > 32 cm) and thinner arms, respectively.

Hypertension in clinic should be confirmed with home BP measurement or 24hr ambulatory BP monitoring if a white coat effect is evoked.

Comparison of ambulatory blood pressure monitoring (24h ABPM) and home blood pressure monitoring (HBPM)

Where available, please refer to national hypertension guidelines for further information

Adapted from the 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement. Journal of Hypertension 2021, 39(7): 1293-1302