Evaluation of hypertension

Summary

Hypertension is a common disorder that affects a large proportion of the community. It is usually asymptomatic and is detected on routine exam or after the occurrence of a complication such as heart attack or stroke.[1]

The 2025 American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults defines hypertension as any systolic blood pressure measurement of ≥130 mmHg or any diastolic blood pressure measurement of ≥80 mmHg.[2] AHA/ACC blood pressure categories are defined as follows:

Elevated blood pressure: systolic blood pressure of 120-129 mmHg and diastolic blood pressure of <80 mmHg
Stage 1 hypertension: systolic blood pressure of 130-139 mmHg or diastolic blood pressure of 80-89 mmHg
Stage 2 hypertension: systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg

The AHA/ACC guidelines were mainly based on the results of the SPRINT trial, which investigated intensive or standard hypertension treatment in people with a systolic blood pressure of ≥130 mmHg with an increased cardiovascular risk (but without diabetes).[3]

European guideline blood pressure categories are defined as follows:[4]

Elevated blood pressure: office systolic blood pressure 120-139 mmHg or office diastolic blood pressure 70-89 mmHg
Hypertension: office systolic blood pressure ≥140 mmHg or office diastolic blood pressure ≥90 mmHg.

For the diagnosis of elevated blood pressure or hypertension to be made, the European guidelines recommend confirmation with out-of-office measurements or at least one repeat office measurement at a subsequent visit.[4] Isolated systolic hypertension is defined as a systolic blood pressure ≥140 mmHg, with a diastolic blood pressure <90 mmHg.[4]

The UK National Institute for Health and Care Excellence states that a diagnosis of hypertension is confirmed in those with:[5]

a clinic blood pressure of ≥140/90 mmHg, and
daytime ambulatory blood pressure monitoring average or home blood pressure monitoring average of ≥135/85 mmHg.

Although different studies have used a variety of cut-off points for the diagnosis of hypertension in the community, any blood pressure >120 mmHg systolic is associated with an increased cardiovascular risk. The importance of hypertension is its relation to other cardiovascular risk factors and consequent overall cardiovascular risk.

The AHA/ACC defines resistant hypertension as:[2]

Blood pressure above goal (i.e., >130/80 mmHg) despite the concurrent use of at least 3 antihypertensive agents with complementary mechanisms of action (including a diuretic) at maximum or maximally tolerated doses.
Blood pressure at goal but requiring 4 or more antihypertensive agents.

The diagnosis of resistant hypertension requires the exclusion of white-coat hypertension and poor adherence with antihypertensive medication.[2]

This topic addresses the evaluation of hypertension in adults.

Epidemiology

According to a global analysis of trends in hypertension, the number of adults ages 30-79 years with hypertension increased from 650 million to 1.28 billion in the period 1990-2019.[6] Based on National Health and Nutrition Survey (NHANES) data from 2021-2023, an estimated 125.9 million US adults ages ≥20 years have hypertension (defined as self-reported use of antihypertensive medication, systolic BP ≥130 mmHg, diastolic BP ≥80 mmHg, or if patients have been told that they have high blood pressure at least twice by a healthcare professional).[7] During this period, the prevalence of hypertension was 28.9% among those ages 20-44 years, 61.3% among those ages 45-64 years, and 74.2% among those age ≥65 years.[7] The prevalence may be similar or higher in Western Europe.[8] [9]

In 2010, the estimated global age-standardized prevalence of hypertension in adults age ≥20 years was 31.1%; 28.5% in high-income countries and 31.5% in low- and middle-income countries.[10]

Prevalence by sex has been found to differ with age.[7] [10] In men and women age <75 years, hypertension prevalence was greater in men; among those age ≥75 years, the percentage of females with hypertension was higher than that for males (NHANES data from 2021-2023).[7]

Hypertension is more prevalent in black people than in white people, starting in childhood, with 76% of black men and women developing hypertension by age 55 years, compared with 55% and 40% of white men and women, respectively.[11]

The exact prevalence of hypertension is difficult to assess, as it is usually asymptomatic. Prevalence is expected to rise as the "cut-off" value for hypertension is redefined at a lower level.

Approximately 8.5% to 20% of US adults with hypertension have resistant hypertension.[2]

Complications and hypertension-mediated organ damage

Studies have shown that treatment of hypertension can reduce the incidence of future cardiovascular and cerebrovascular events.[12] [13] The aim of early diagnosis and treatment of hypertension is to lower overall cardiovascular risk and prevent cerebrovascular events.

The effects of chronic hypertension on organ systems are referred to as hypertension-mediated organ damage.

Left ventricular hypertrophy, cardiovascular disease, cerebrovascular disease, hypertensive retinopathy, and nephropathy are the most common manifestations.[14] The presence of left ventricular hypertrophy is a poor prognostic sign, and regression of left ventricular hypertrophy improves prognosis.[15] Patients with resistant hypertension are at higher risk of experiencing cardiovascular and cerebrovascular events and developing chronic kidney disease.[16]

Cardiovascular risk

Guidelines on the management of hypertension emphasize the importance of calculating and managing the overall cardiovascular risk of a patient, rather than focusing only on blood pressure readings. The ACC and AHA have published an online tool to calculate patients' 10-year and lifetime risk of atherosclerotic cardiovascular disease.ACC: ASCVD Risk Estimator Plus

For individuals ages 40-70 years, each increment of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure across the entire blood pressure range from 115/75 to 185/115 mmHg doubles the risk of cardiovascular disease.[17] The European Society for Cardiology has proposed that sex-specific thresholds may be appropriate as lower blood pressure levels are associated with an increased risk of cardiovascular disease in women.[18] Treating associated cardiovascular risk factors such as obesity, diabetes, hypercholesterolemia, and smoking are as important as managing hypertension in lowering overall cardiovascular risk.

Library

Hypertensive retinopathy

Citations

Key Articles

Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 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 Joint Committee on clinical practice guidelines. J Am Coll Cardiol. 2025 Nov 4;86(18):1567-678.[Abstract][Full Text]
McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024 Oct 7;45(38):3912-4018.[Full Text]
National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Nov 2023 [internet publication].[Full Text]
Waguespack DR, Dwyer JP. Assessment of blood pressure: techniques and implications from clinical trials. Adv Chronic Kidney Dis. 2019 Mar;26(2):87-91.[Abstract]

Other Online Resources

ACC: ASCVD Risk Estimator Plus

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Diseases