What Are the Stages of Hypertension and How Are They Treated?

The stage of hypertension at diagnosis will guide your initial treatment

Woman checking blood pressure
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Many individuals are surprised to find a high blood pressure reading as an incidental finding at a routine doctor’s appointment because hypertension does not cause symptoms. In fact, the only way to diagnose hypertension is to measure blood pressure.

The American Heart Association recommends screening by measurement of blood pressure at least every two years if your blood pressure is in the normal range.

The United States Preventive Services Task Force guidelines recommend screening for all adults over the age of 18.

At the minimum, adults over the age of 40 should have their blood pressure checked at least one a year. Adults between the ages of 18 and 39 with a previous blood pressure reading between 130-139 mm Hg systolic and /or 85-89 mm Hg diastolic or with risk factors for high blood pressure, including obesity or tobacco use, should also be screened annually.

Confirming Your Diagnosis

If you have a high reading, your doctor will usually recheck your blood pressure several times before making the diagnosis. The diagnosis of hypertension and the stages of hypertension are based upon an average of two or more blood pressure readings on at least two separate occasions, although ambulatory blood pressure monitoring is recommended to confirm high blood pressure readings noted on routine screening examinations.

Home blood pressure monitoring is an alternative method of confirmation when ambulatory blood pressure monitoring is unavailable. Confirmation of high blood pressure readings in the doctor’s office are recommended because some patients may experience “white coat hypertension.”

The Stages of Hypertension Defined

Different stages of hypertension were defined by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) in 2003.

In addition to defining two stages of hypertension, JNC7 also defined prehypertension. Prehypertension is associated with cardiovascular risk, including an increased risk of coronary heart disease.

The stages of hypertension apply to adults who are not being treated with a blood pressure medication and who are not currently ill. They are defined by JNC7 as follows:

  • Normal blood pressure: systolic blood pressure less than 120 mm Hg and diastolic blood pressure < 80 mm Hg.
  • Prehypertension: systolic blood pressure from 120 to 139 mm Hg or diastolic blood pressure from 80 to 89 mm Hg.
  • Stage I hypertension: systolic blood pressure 140 to 159 mm Hg OR diastolic blood pressure from 90 to 99 mm Hg.
  • Stage 2 hypertension: systolic blood pressure greater than or equal to 160 mm Hg OR diastolic blood pressure of 100 mm Hg or more.

When using ambulatory blood pressure monitoring or home blood pressure readings, hypertension is generally defined as a 24-hour average of 130/80 mm Hg or higher; daytime average of 135/85 or higher; or nighttime average of 120/70 or higher.

Prehypertension

Almost 30 percent of adults in the United States have prehypertension. People with prehypertension have an increased risk of heart disease, although it is not as high as it is in people with hypertension. If untreated, prehypertension will usually progress to hypertension, which refers to a blood pressure of 140/90 and greater.

Prehypertension is generally treated with lifestyle modifications. In addition to diet and exercise, quitting smoking, watching alcohol intake, and maintaining a healthy weight are all important steps to take to control your blood pressure.

Stage 1 Hypertension

Sometimes, stage I hypertension is referred to as “mild” hypertension, which unfortunately fails to convey the risks associated with this condition. In addition to lifestyle changes recommended for all patients with prehypertension and hypertension, Stage 1 hypertension includes the use of one of a wide variety of antihypertensive medications that reduce blood pressure and risk of stroke and heart disease.

The choices recommended by JNC 8 include thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, or calcium channel blockers. The best choice for African American patients is a thiazide diuretics or calcium channel blocker.

National guidelines established by JNC8 recommend that African American patients with a systolic pressure 145 mm Hg or higher begin treatment right away with two medications. If your blood pressure goal has not been achieved within a month of initiating treatment with medication for hypertension, the dose of medication should be increased or another medication added.

Stage 2 Hypertension

Patients with stage 2 hypertension should be treated with lifestyle modification and initiation of two different drugs of different classes, chosen from the five different classes of blood pressure medications included in the JNC recommendations. If your blood pressure numbers fall into different stages, the higher number will be used to determine your stage.

Resistant Hypertension

Many people will require more than one or two medications to control blood pressure. Resistant hypertension is the term used to describe high blood pressure in people who still have high blood pressure despite taking at least three different types of medication. If you have resistant hypertension, your doctor will search for an underlying condition or reason. Your medication may need adjustment to achieve control.

Medications

In addition to the medication classes included in the JNC recommendations, there are several other types of medication to treat high blood pressure. These include beta blockers and diuretics; vasodilators, which prevent the muscles around the blood vessels from contracting; alpha blockers, which block nerve impulses to the blood vessels; and central-acting agents the prevent transmission of nervous system signals from the brain that cause narrowing of the blood vessels. Many people will require more than one medication to control blood pressure.

Blood Pressure Goals

The recommended treatment for hypertension includes both medications and important lifestyle changes, like diet and exercise. Your blood pressure goal will depend upon your age and whether or not you have other medical conditions. Healthy adults who are 60 years of age or older should try to achieve a blood pressure less than 150/90 mm Hg. Healthy younger adults and individuals with diabetes, coronary artery disease, or chronic kidney disease should aim for a blood pressure less than 140/90 mm Hg.

It’s important to continue to monitor your numbers and to follow through with all recommendations, since treatment of hypertension can dramatically reduce your risk of complications.

Sources:

Brown, M. M. (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report.Evidence-Based Eye Care4(3), 179-181. doi:10.1097/00132578-200307000

Egan, B. M., Bandyopadhyay, D., Shaftman, S. R., Wagner, C. S., Zhao, Y., & Yu-Isenberg, K. S. (2012). Initial Monotherapy and Combination Therapy and Hypertension Control the First Year. Hypertension59(6), 1124-1131. doi:10.1161/hypertensionaha.112.194167

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … Ortiz, E. (2014). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA311(5), 507. doi:10.1001/jama.2013.284427

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement. (2015). Annals of Internal Medicine163(10), I-32. doi:10.7326/p15-9036

Wald, D. S., Law, M., Morris, J. K., Bestwick, J. P., & Wald, N. J. (2009). Combination Therapy Versus Monotherapy in Reducing Blood Pressure: Meta-analysis on 11,000 Participants from 42 Trials. The American Journal of Medicine122(3), 290-300. doi:10.1016/j.amjmed.2008.09.038

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