---
title: Hypertension Diagnosis and Treatment
description: A comprehensive clinical reference on the diagnosis and management of hypertension.
keywords: [hypertension, blood pressure, antihypertensive, ASCVD, target organ damage]
category: clinical
---

## Diagnostic Criteria

Hypertension is defined as a sustained elevation in systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg, according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Diagnosis is confirmed by obtaining at least two elevated blood pressure readings on separate occasions.

Blood pressure should be measured using an automated, validated device with the patient seated quietly for 5 minutes prior. Proper cuff size is essential, and measurements should be taken in both arms, with the higher value used for diagnosis. White coat hypertension, defined as elevated office readings with normal out-of-office measurements, should be ruled out using 24-hour ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).

## Cardiovascular Risk Assessment

All patients with hypertension require a comprehensive cardiovascular risk assessment. This should include a thorough medical history, physical exam, basic lab testing (complete metabolic panel, lipid panel, urinalysis), and assessment for target organ damage. Recommended tests include:

- Electrocardiogram (ECG) to evaluate for left ventricular hypertrophy (LVH)
- Urine albumin-to-creatinine ratio (UACR) to screen for kidney damage
- Estimated glomerular filtration rate (eGFR) to assess kidney function
- Carotid intima-media thickness (CIMT) or ankle-brachial index (ABI) to evaluate for atherosclerosis

The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score should be calculated to guide intensity of blood pressure lowering and need for additional risk-reducing therapies.

## Hypertension Staging and Treatment

The 2017 ACC/AHA guidelines categorize hypertension into the following stages:

- Elevated: SBP 120-129 and DBP <80 mmHg
- Stage 1: SBP 130-139 or DBP 80-89 mmHg
- Stage 2: SBP ≥140 or DBP ≥90 mmHg

For patients with Stage 1 hypertension and low ASCVD risk (<10% 10-year risk), initial management should focus on lifestyle modifications such as weight loss, exercise, sodium restriction, and moderation of alcohol intake. Pharmacologic treatment is recommended for those with Stage 1 hypertension and high ASCVD risk (≥10% 10-year risk) or for any patient with Stage 2 hypertension.

First-line antihypertensive medications include:
- Thiazide-type diuretics (hydrochlorothiazide 12.5-25 mg daily)
- Angiotensin-converting enzyme (ACE) inhibitors (lisinopril 10-40 mg daily)
- Angiotensin II receptor blockers (ARBs, e.g. losartan 50-100 mg daily) 
- Calcium channel blockers (amlodipine 5-10 mg daily)

For patients requiring multiple medications, a combination of a renin-angiotensin system (RAS) blocker plus a calcium channel blocker or diuretic is preferred. The target blood pressure goal is <130/80 mmHg for most adults, with more stringent goals for certain high-risk populations.

## Resistant Hypertension

Resistant hypertension is defined as blood pressure above goal despite adherence to a maximum-tolerated 3-drug regimen including a diuretic. Secondary causes should be ruled out, including:

- Medication non-adherence or interactions
- Obstructive sleep apnea
- Chronic kidney disease
- Primary aldosteronism
- Pheochromocytoma
- Coarctation of the aorta

For confirmed resistant hypertension, additional medications such as spironolactone, clonidine, hydralazine, or minoxidil may be added. Renal denervation and baroreceptor activation therapy are emerging interventional options. Close monitoring for adverse effects is crucial.

## Hypertensive Emergencies and Urgencies

Hypertensive emergencies involve severe elevations in blood pressure (SBP ≥180 or DBP ≥120 mmHg) accompanied by acute target organ damage. Immediate blood pressure lowering is required to prevent life-threatening complications such as aortic dissection, hypertensive encephalopathy, or eclampsia.

Recommended management includes intravenous antihypertensive medications such as:
- Nicardipine (5-15 mg/hr titrated to goal)
- Labetalol (20 mg IV bolus, then 2-8 mg/min infusion)
- Sodium nitroprusside (0.3-10 μg/kg/min infusion)

The target is to lower BP by no more than 25% within the first hour, then to a SBP <160 and DBP <110 mmHg over the next 2-6 hours.

Hypertensive urgencies involve severe elevations without acute organ damage. Oral medications like lisinopril, amlodipine, or clonidine can be used to lower BP gradually over 24-48 hours, with a target reduction of 25-30%.

## Special Populations

Certain patient populations require unique hypertension management approaches:

- Diabetes: Target BP <130/80 mmHg. First-line agents include ACE inhibitors and ARBs.
- Chronic Kidney Disease: Target BP <130/80 mmHg. RAS blockers are preferred.
- Elderly: More stringent SBP goal of <130 mmHg. Start low and go slow with medications.
- Pregnancy: Methyldopa, labetalol, and nifedipine are safe antihypertensive options.

Careful monitoring and titration of therapy is essential in these high-risk groups to balance blood pressure control with safety.

## Conclusion

Hypertension is a highly prevalent condition that requires a comprehensive, evidence-based approach to diagnosis and management. Accurate blood pressure measurement, cardiovascular risk assessment, appropriate treatment escalation, and vigilant monitoring for target organ damage and medication adverse effects are all crucial elements of hypertension care. Adherence to clinical practice guidelines can help clinicians provide optimal, guideline-directed management for their patients.