Diagnosis

2013 CHEP Recommendations

1. At initial presentation, 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 mmHg and/or diastolic BP (DBP) is ≥90 mmHg, a specific visit should be scheduled for the assessment of hypertension (Grade D).  If BP is high-normal (SBP 130 – 139 mmHg and/or DBP 85 – 89 mmHg), annual follow-up is recommended (Grade C).
3. At the initial visit for the assessment of hypertension, if SBP is >140 mmHg and/or DBP is >90 mmHg, at least two more readings should be taken during the same visit using a validated device and 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 (CKD; GFR < 60 ml/min/1.73m² ) can be diagnosed as hypertensive if SBP is ≥140 mmHg and/or DBP is ≥90 mmHg (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 the SBP is ≥180 mmHg or greater and/or the DBP is ≥110 mmHg (Grade D). Patients without macrovascular target organ damage, diabetes mellitus, or CKD but with lower BP levels should undergo further evaluation using any of the three approaches outlined  below:
   1. Office manuel BPs:
      Using office manual BP measurements, patients can be diagnosed as hypertensive if the SBP is ≥160 mmHg or the DBP is ≥100 mmHg averaged across the first 3 visits, or if the SBP averages ≥140 mmHg or the DBP averages ≥90 mmHg averaged across 5 visits (Grade D).
      
   2. 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 if the mean 24 hour SBP is ≥130 mm Hg or greater or the DBP is ≥80 mm Hg. (Grade C).
   3. Home BP Measurement:
      Using home BP measurements (see recommendation Home Measurement of BP), patients can be diagnosed as hypertensive if the average SBP is ≥135 mmHg or the DBP is ≥ 85 mmHg (Grade C). If the average home BP is < 135/85 mmHg, it is advisable to either repeat home monitoring to confirm the home BP is < 135/85 mmHg or perform 24-hour ABPM to confirm that the mean 24-hour ABPM is <130/80 mmHg and the mean awake ABPM is <135/85 mmHg 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 to be hypertensive, and has no evidence of macrovascular target organ damage, the patient’s BP should be assessed at yearly intervals (Grade D).
8. Hypertensive patients receiving lifestyle modification advice alone (nonpharmacological treatment) should be followed up at three to six month intervals.  Shorter intervals (every one or two months) 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 target organ damage (Grade D). Once the target BP has been reached, patients should be seen at three-to six-month intervals (Grade D).