II. Criteria for Diagnosis & Recommendations for Follow-Up
1) At visit 1, patients demonstrating features of a hypertensive urgency or emergency Table 2 should be diagnosed as hypertensive and require immediate management (Grade D).
2) If systolic BP (SBP) is 140 mm Hg or greater and/or diastolic BP is 90 mm Hg or greater a specific visit should be scheduled for the assessment of hypertension (Grade D). If BP is high-normal (SBP 130 – 139 mm Hg and/or DBP 85 – 89 mm Hg) in the absence of diabetes or cardiovascular disease, annual follow up is recommended (Grade C).
3) At the initial visit for the assessment of hypertension, if systolic BP (SBP) is 140 mm Hg or greater and/or diastolic (DBP) blood pressure is 90 mm Hg or greater, at least two more readings should be taken during the same visit according to the recommended procedure for accurate BP determination Table 1. The first reading should be discarded and the latter two averaged. A history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage Table 3 and associated CV risk factors Table 4 should be arranged within two visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible Table 5. Schedule visit two within one month (Grade D).
4) At visit 2 for the assessment of hypertension, patients with macrovascular target organ damage, diabetes mellitus, or chronic kidney disease (GFR < 60 ml/min) can be diagnosed as hypertensive if SBP is 140 mm Hg or greater and/or DBP is 90 mm Hg or greater (Grade D).
5) At visit 2 for the assessment of hypertension, patients without macrovascular target organ damage, diabetes mellitus, and/or chronic kidney disease can be diagnosed as hypertensive if SBP is 180 mm Hg or greater and/or DBP is 110 mm Hg or greater (Grade D). Patients without macrovascular target organ damage, diabetes mellitus, or chronic kidney disease but with lower blood pressure levels should undergo further evaluation using any of the three approaches outlined below:
- Office BPs:
Using office BP measurements, patients can be diagnosed as hypertensive if the SBP is 160 mm Hg or greater or the DBP is 100 mm Hg or greater averaged across the first 3 visits, OR if the SBP averages 140 mm Hg or greater or the DBP averages 90 mm Hg or greater after 5 visits (Grade D). - Ambulatory BP monitoring (ABPM):
Using ABPM (see Section VIII), patients can be diagnosed as hypertensive if the mean awake SBP is 135 mm Hg or greater or the DBP is 85 mm Hg or greater, OR if the mean 24 hour SBP is 130 mm Hg or greater or the DBP is 80 mm Hg or greater (Grade C). - Home BP Measurement:
Using home BP measurements (see Section VII), patients can be diagnosed as hypertensive if the average SBP is 135 mm Hg or greater or the DBP is 85 mm Hg or greater (Grade C). If home BP measurement is less than 135/85 mm Hg, it is advisable to perform 24 h ABPM to confirm the mean 24 h ABPM is less than 130/80 mm Hg or the mean awake ABPM is less than 135/85 mm Hg before diagnosing white coat hypertension (Grade D).
6) Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined below) (Grade D).
7) If at the last diagnostic visit, the patient is not diagnosed as hypertensive, and has no evidence of macrovascular target organ damage, the patient’s BP should be assessed at yearly intervals (Grade D).
8) Patients receiving lifestyle modification advice (non-pharmacological treatment) should be followed up at three-to-six month intervals. Shorter intervals (one or two monthly) are needed for patients with higher BPs (Grade D).
9) Patients on antihypertensive drug treatment should be seen monthly or every two months, depending on the level of BP, until readings on two consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs or those with target organ damage (Grade D). Once the target BP has been reached, patients should be seen at three-to-six month intervals (Grade D).