Diagnostic Approach

Diagnosis requires demonstrating persistently elevated blood pressure on ≥2 occasions.

Blood pressure classification (adults ≥18 years old):

• Normal: <120/<80 mmHg
• Elevated: 120-129/<80 mmHg
• Stage 1 hypertension: 130-139/80-89 mmHg
• Stage 2 hypertension: ≥140/≥90 mmHg

Accurate measurement is essential using proper technique:

• Use validated equipment with correct cuff size
• Patient should be rested and calm
• Use proper positioning with arm supported at heart level
• Take at least 2 readings separated by 1-2 min

Out-of-office monitoring confirms diagnosis:

• Home blood pressure monitoring
• 24-hour ambulatory blood pressure monitoring

Identify comorbid conditions or secondary causes:

• Fasting glucose, hemoglobin A1c to screen for diabetes
• Fasting lipid panel for dyslipidemia
• Kidney function tests for chronic kidney disease
• Urinalysis for proteinuria/hematuria
• Screen for obstructive sleep apnea

Assess cardiovascular risk:

• Framingham risk score
• ACC/AHA Pooled Cohort Equations
• Chronic kidney disease or diabetes confer high risk

Evaluate for end-organ damage:

• Fundoscopic exam for retinopathy
• EKG for left ventricular hypertrophy
• Echocardiogram for heart failure
• Ultrasound for renal artery stenosis

Take thorough history to identify possible secondary causes:

• Drug or substance use
• History of coarctation, kidney disease, etc
• Onset at young age or with symptoms suggestive of endocrine or renal cause

Accurate classification is key for treatment decisions – repeated readings at multiple visits required for diagnosis.

Pseudohypertension is possible in older patients with stiff arteries.

White coat and masked hypertension common pitfalls requiring out-of-office monitoring.