Hypertension Criteria

Aka: Hypertension Criteria, Hypertension Reduction Goal, High-Normal Blood Pressure, Stage 1 Hypertension, Stage 2 Hypertension, Stage 3 Hypertension, Stage 4 Hypertension, Hypertension Risk Stratification, Hypertension Risk Group A, Hypertension Risk Group B, Hypertension Risk Group C, Blood Pressure Goals in Hypertension, Indications for Antihypertensive Management

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II. Precautions

  1. Per AAFP, Blood Pressure target remains <140/90 mmHg for most adults with Hypertension (unless otherwise indicated)
    1. Lower Blood Pressure goals (e.g. <130/80) do not reduce mortality and increase adverse effects
    2. Lower Blood Pressure goals may reduce Myocardial Infarctions and Congestive Heart Failure (hence ACC/AHA targets)
    3. Arguedas (2020) Cochrane Database Syst Rev 12(12):CD004349 +PMID: 33332584 [PubMed]
  2. Patients with the greatest Cardiovascular Risk have the greatest benefit from Hypertension control
    1. Sundstrom (2014) Lancet 384(9943): 591-8 [PubMed]

III. Criteria: Hypertension in Adults

  1. Background
    1. The Running tally of goal BP changes to guidelines every few years is listed below
    2. Are these goal changes sound?
      1. http://ja.ma/2DeCBTs
  2. AAFP Guidelines 2022
    1. Note that AAFP Guidelines diverge from the ACC/AHA 2017 targets of <130/80 for everyone
    2. BP <140/90 mmHg recommended for most patients
      1. Targets <140/90 do not reduce overall mortality, require more medications, and risk adverse events (e.g. Syncope)
    3. BP <135/85 mmHg reduces risk of Myocardial Infarction
      1. Targets <130/80 reduce Myocardial Infarction risk in 3.7 years (NNT 137)
      2. SPRINT goals SBP <120 mmHg lowered short-term MI risk, but significantly increased complications
        1. Wright (2015) N Engl J Med 373(22): 2103-16 [PubMed]
    4. References
      1. Coles (2022) Am Fam Physician 106(6): 722A-K [PubMed]
      2. Arguedas (2020) Cochrane Database Syst Rev (12): CD004349 [PubMed]
      3. Salz (2022) Cochrane Database Syst Rev (11): CD010315 [PubMed]
  3. ACC/AHA Guidelines 2017 with update in 2021 (ADA recommends JNC-8 guidelines)
    1. BP <120/80 mmHg (normal)
      1. Goal ideal Blood Pressure
    2. BP >=120/80 mmHg (elevated)
      1. Lifestyle changes and evaluate for Medication Causes of Hypertension
    3. BP >=130/80 mmHg (Stage 1 Hypertension)
      1. Start Antihypertensives in cardiovascular disease, Diabetes Mellitus, Chronic Kidney Disease, >10% CV risk
        1. https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
      2. Start with nonpharmacologic management (lifestyle changes) in lower risk patients
        1. After 3-6 months, if persistent BP >=130/80 mmHg, consider Antihypertensive medications
        2. Added in ACC/AHA guideline update 2021
    4. BP >140/90 mmHg (Stage 2 Hypertension)
      1. Start Antihypertensives if not already started
      2. Also encourage Nonpharmacologic Management of Hypertension (e.g. DASH Diet)
    5. References
      1. http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065
      2. https://www.acc.org/latest-in-cardiology/articles/2021/06/21/13/05/new-guidance-on-bp-management-in-low-risk-adults-with-stage-1-htn
  4. JNC-8 Guidelines (modified as of 2013)
    1. Criteria
      1. BP <120/80 mmHg (Normal Blood Pressure)
      2. BP >120/80 mmHg (Elevated Blood Pressure)
      3. BP >140/90 mmHg (Stage 1 Hypertension)
        1. Home Blood Pressures >135/85 (Internation Society Hypertension 2020)
        2. 24 Hour Ambulatory >130/80 (Internation Society Hypertension 2020)
      4. BP >160/100 mmHg (Stage 2 Hypertension)
    2. Goals
      1. Renal Insufficiency: <140/90 mmHg
      2. Diabetes Mellitus: <140/90 mmHg
        1. ADA recommends <140/80 mmHg
        2. Age >80 years: <150/90 mmHg
      3. No Diabetes Mellitus or renal disease
        1. Age <60 years: <140/90 mmHg
        2. Age >60 years: <150/90 mmHg
    3. References
      1. James (2014) JAMA 311(5):507-20 [PubMed]
  5. Goal Blood Pressures for Hypertensive Patients (JNC-7 Guidelines)
    1. Hypertension without Co-morbidity: <140/90
    2. Diabetes Mellitus: <130/80
    3. Congestive Heart Failure: <130/80
    4. Renal Insufficiency: <130/80
    5. Renal Failure and >1g Proteinuria/24 hours: <125/75
  6. JNC-7 Blood Pressure definitions
    1. Optimal Blood Pressure: <115/80
    2. Normal Blood Pressure: <120/80
    3. Pre-Hypertension: 120-139/80-89
    4. Stage 1 Hypertension: 140-159/90-99
    5. Stage 2 Hypertension: >160/100
  7. Stages eliminated in JNC-7
    1. Stage 3 Hypertension: 180-209/110-119
    2. Stage 4 Hypertension: >210/120
  8. Isolated Systolic Hypertension
    1. Systolic Blood Pressure: >140 mmHg
    2. Diastolic Blood Pressure: <90 mmHg

IV. Criteria: Hypertension in Children and Adolescents (based on age, height, gender over at least 3 values)

  1. Normal Blood Pressure
    1. Blood Pressure <90% for age, height, gender or
    2. Blood Pressure <120/80 for age 13 years or older
  2. Elevated Blood Pressure or Prehypertension
    1. Blood Pressure 90% to 95% for age, height, gender or
    2. Blood Pressure >120/80 mmHg for age 13 years or older
  3. Stage I Hypertension
    1. Blood Pressure 95 to 99% plus 12 mm Hg for age, height, gender or
    2. Blood Pressure >130/80 mmHg for age 13 years or older
  4. Stage II Hypertension
    1. Blood Pressure >99% plus 12 mm Hg for age, height, gender or
    2. Blood Pressure >140/90 mmHg for age 13 years or older
  5. Hypertensive Urgency
    1. Systolic Blood Pressure more than 30 mmHg above 95th percentile or
    2. Systolic Blood Pressure >180/120 mmHg for age 13 years or older
  6. References
    1. Flynn (2017) Pediatrics 140(3): e20171904 [PubMed]

V. Criteria: Hypertension in Adolescents

  1. Age 16-18 years
    1. Significant Hypertension: BP> 142/92
    2. Severe Hypertension: BP> 150/98
  2. Age: 13-15 years
    1. Significant Hypertension: BP> 136/86
    2. Severe Hypertension: BP> 144/92

VI. Criteria: Hypertension in Children

  1. Age 10-12 years
    1. Significant Hypertension: BP> 126/82
    2. Severe Hypertension: BP> 134/90
  2. Age 6-9 years
    1. Significant Hypertension: BP> 122/78
    2. Severe Hypertension: BP> 130/86
  3. Age 3-5 years
    1. Significant Hypertension: BP> 116/76
    2. Severe Hypertension: BP> 124/84
  4. Age 1 month to 2 years
    1. Significant Hypertension: BP> 112/74
    2. Severe Hypertension: BP> 118/82
  5. Age 8-30 days
    1. Significant Hypertension: SBP> 104
    2. Severe Hypertension: SBP> 110
  6. Age <7 day old
    1. Significant Hypertension: SBP> 96
    2. Severe Hypertension: SBP> 106

VII. Types: Risk Group A - Adults at Low Cardiovascular Risk

  1. Criteria
    1. No Cardiovascular Risks (See Risk Group B)
    2. No Target organ damage or Cardiovascular Disease
  2. Prehypertension (120-129 / 80)
    1. Lifestyle Modification in Hypertension
  3. Stage 1 Hypertension (130-139/ 80)
    1. Lifestyle Modification in Hypertension
    2. Consider Antihypertensive after 3-6 months
      1. Hydrochlorothiazide is a good first choice in most patients
  4. Stage 2 Hypertension or greater (>140/90)
    1. Lifestyle Modification in Hypertension
    2. Hypertension Combination Therapy

VIII. Types: Risk Group B - Adults at Moderate Cardiovascular Risk (or >10% CV risk in 10 years)

  1. Criteria
    1. Tobacco Abuse
    2. Dyslipidemia
    3. Renal Insufficiency
    4. Patient age over 60 years
    5. Male gender of postmenopausal women
    6. Cardiovascular Family History
    7. No Diabetes Mellitus
    8. No Target organ damage or Cardiovascular Disease
  2. Prehypertension (120-129 / 80)
    1. Lifestyle Modification in Hypertension
  3. Stage 1 Hypertension (130-139/ 80)
    1. Lifestyle Modification in Hypertension
    2. Antihypertensive (e.g. Hydrochlorothiazide)
  4. Stage 2 Hypertension or greater (>140/90)
    1. Lifestyle Modification in Hypertension
    2. Hypertension Combination Therapy

IX. Types: Risk Group C - Adults at High Cardiovascular Risk (or >20% CV risk in 10 years)

  1. Criteria
    1. Target organ damage or Cardiovascular Disease
      1. Left Ventricular Hypertrophy
      2. Angina or prior Myocardial Infarction
      3. Prior coronary revascularization
      4. Cerebrovascular Accident (Stroke or CVA)
      5. Transient Ischemic Attack (TIA)
      6. Nephropathy or Chronic Kidney Disease
      7. Peripheral Vascular Disease
      8. Retinopathy
    2. Cardiovascular Risks (See Risk Group B)
  2. Prehypertension (120-129 / 80) or greater
    1. Lifestyle Modification in Hypertension
    2. Consider Antihypertensive therapy
      1. However Blood Pressure lowering <130/80 is associated with adverse outcomes
    3. Consider Hypertension Combination Therapy if >20/10 over goal

X. Resources

  1. http: //www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf

XI. Reference

  1. (1987) Pediatrics 79(1):1-25 [PubMed]
  2. (1997) Arch Intern Med 157:2413-46 [PubMed]
  3. (2000) NKF Consensus Report
  4. Chobanian (2003) JAMA 289:2560-72 [PubMed]
  5. Clarke (2023) Am Fam Physician 108(3): 352-9 [PubMed]

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