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Hypertension in adults: Blood pressure measurement and diagnosis

Hypertension in adults: Blood pressure measurement and diagnosis
Authors:
George Thomas, MD, MPH, FACP, FASN
Marc A Pohl, MD
Section Editor:
Raymond R Townsend, MD
Deputy Editors:
Karen Law, MD, FACP
John P Forman, MD, MSc
Literature review current through: Apr 2025. | This topic last updated: Mar 19, 2025.

INTRODUCTION — 

Correct measurement and interpretation of blood pressure (BP) are essential in the diagnosis and management of hypertension. Accurate measurement in any setting requires periodic BP measurement device calibration, selection of appropriate cuff size, correct patient positioning, and proper training in BP measurement.

BP measurement in the diagnosis of hypertension, including the technique required for office-based and self-measured BP will be reviewed here. An overview of hypertension in adults and discussions pertaining to patient selection for antihypertensive therapy, choice of antihypertensive therapy, secondary hypertension, management of older adults with isolated systolic hypertension, and goal BP can be found in other topics:

●(See "Overview of hypertension in adults".)

●(See "Hypertension in adults: Initial drug therapy".)

●(See "Evaluation of secondary hypertension".)

●(See "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)

●(See "Goal blood pressure in adults with hypertension".)

●(See "Treatment of hypertension in pregnant and postpartum patients", section on 'Classification of hypertensive disorders in pregnancy'.)

BLOOD PRESSURE MEASUREMENT METHODS — 

Established BP measurement methods are reviewed below and in the table (table 1).

Procedure for accurate blood pressure measurement — Accurate BP measurement by any method requires attention to the following steps summarized below and described in more detail in the table (table 2) [1]:

●Staff and device preparation

•Validated BP devices should be used and calibrated at least once a year or in accordance with manufacturer recommendations.

•If the auscultatory method is used, the staff should be trained in the appropriate technique.

●Patient preparation and BP measurement

•The patient should have an empty bladder and should avoid strenuous exercise, smoking, and caffeine in the 30 minutes preceding BP measurement.

•The patient should be in a seated position, with the back supported, feet on the floor, legs uncrossed, and arm supported at the level of the heart.

•The patient should be resting in position for at least three to five minutes prior to BP measurement. Some automated office BP (AOBP) measurement devices may have a shorter wait period [2].

•A properly sized cuff should be used (table 3). The cuff should be placed over a bare arm, with the bladder midline over the brachial artery pulsation.

•Neither the patient nor office staff (if present) should talk during the measurement.

Office-based BP measurements that deviate from these recommendations are classified as "nonstandardized," "casual," or "low-quality" measurements. While nonstandardized BP measurements may be used for screening, the potential for error limits their use in hypertension diagnosis and management [3]. (See 'Methods for measuring blood pressure' below and 'Approach to establishing the diagnosis' below.)

Methods for measuring blood pressure — The available methods for BP measurement are reviewed below and in the table (table 1). Each method has its advantages and limitations. Nonstandardized (ie, casual) BP measurement should not be used for diagnosis and management of hypertension, despite being quicker and easier than the preferred methods.

The use of each method in diagnosing hypertension is discussed below (see 'Screening for hypertension' below):

●Office-based measurement methods

•Nonstandardized ("casual" or low-quality) office BP measurement – The vast majority of clinicians' offices measure BP manually or with an oscillometric device without proper preparation and technique (table 1). (See 'Procedure for accurate blood pressure measurement' above.)

As an example, patients often have their BP measured immediately after walking into the examination room from the waiting area (ie, no rest period); have the cuff placed over clothing; and sit with no support for the arm, back, or feet. This nonstandardized (casual) method of measurement is inferior to other methods because it produces BP readings that differ considerably from readings obtained by preferred methods (typically higher than preferred methods) and because of substantial variability among clinics and providers [3-5]. The role of nonstandardized office BP measurement in hypertension screening is discussed below. (See 'Screening for hypertension' below.)

•Standardized (high-quality) office BP measurement – There are two methods for obtaining high-quality office BP measurements. The first, which does not require specialized equipment, is manual standardized office BP measurement. The second is AOBP measurement, either attended or unattended.

-Manual standardized office BP measurement – With manual standardized office BP measurement, office staff measure BP with an oscillometric device or using the auscultatory method, adhering to appropriate patient preparation and BP measurement technique (table 2 and table 1). (See 'Procedure for accurate blood pressure measurement' above.)

The use of manual standardized office BP measurement in the diagnosis of hypertension is discussed below. (See 'Approach to establishing the diagnosis' below.)

-Automated office BP (AOBP) measurement – AOBP measurement uses a specialized oscillometric BP device that can be programmed to measure the BP a specified number of times, at specified time intervals, following a specified rest period. Typically, the device is programmed to wait five minutes and then take three BP measurements at one-minute intervals.

With unattended AOBP, office staff orient the patient to the procedure, position the patient and BP cuff using the appropriate technique, and leave the patient alone in the room after the machine is activated, thereby diminishing the white coat effect. With attended AOBP, office staff remain present in the room while the oscillometric device is in use (table 1). (See 'Procedure for accurate blood pressure measurement' above.)

The use of AOBP in the diagnosis of hypertension is discussed below. (See 'Approach to establishing the diagnosis' below.)

●Ambulatory BP monitoring (ABPM) – ABPM is performed using a wearable device prescribed by the clinician. The ABPM device measures BP multiple times over a 24- to 48-hour period, usually every 15 to 30 minutes during the daytime and every 30 to 60 minutes during sleep [6].

The use of ABPM in the diagnosis of hypertension is discussed below. (See 'ABPM' below.)

Other aspects of ambulatory measurement, including the technical aspects of performing ABPM, are presented separately. (See "Ambulatory blood pressure monitoring: Indications and procedure".)

●Self-measured BP (SMBP) – With SMBP, BP measurements are taken at home or in another nonclinical setting using a personal BP measurement device. While most devices are automated, older devices may require manual cuff inflation. As with other BP measurement strategies, appropriate preparation and technique should still be used. (See 'Procedure for accurate blood pressure measurement' above.)

The use of SMBP in the diagnosis of hypertension is discussed below. (See 'SMBP' below.)

Other methods

Alternative sites of measurement — Though brachial BP measurement is preferred, BP can also be measured in the leg or wrist if necessary. Devices that measure pressure in the finger are not recommended [6].

●Leg BP – In certain scenarios, BP must be measured in the legs, including in patients who cannot have BP measured in the arms (due to surgery, indwelling catheters, vascular fistulae, etc) and in patients with suspected coarctation of the aorta, in whom there may be an arm-to-leg gradient. (See "Clinical manifestations and diagnosis of coarctation of the aorta", section on 'Blood pressure and pulses'.)

When measuring BP in the thigh, the cuff should be placed around the bottom third of the thigh, with the cuff center line aligned with the popliteal artery. The principles of BP measurement in the leg are similar to those described above in the arm, with the use of an appropriately sized cuff and proper preparation and technique. (See 'Procedure for accurate blood pressure measurement' above.)

In healthy individuals, the systolic pressure in the lower extremity is usually higher than that in the brachial artery [7]. In a systematic review of 44 studies comparing arm and leg BP readings performed in the supine position, mean systolic BP was higher in both the calf (by 10 mmHg, 95% CI 4-16 mmHg) and in the ankle (17 mmHg, 95% CI 15-21 mmHg) compared with the arm [8]. However, the high variability in arm-leg BP difference in these studies can make it difficult to reliably translate leg pressures into arm pressures. In addition, no oscillometric BP monitors have been validated for lower-extremity BP measurements.

●Wrist BP – Measurement of BP at the radial artery (wrist) may sometimes be necessary in people for whom a sufficiently large cuff cannot be obtained and in patients with breast cancer who have had axillary lymph node resection [9]. However, given questions about accuracy, BP measurement at the wrist should not be used if brachial BP measurement is feasible.

Technical considerations may make accurate measurement of BP at the wrist more challenging than measurements taken at the brachial artery [2]. At the wrist, the hydrostatic pressure related to the lower position of the wrist relative to the heart can result in a false elevation of BP. This can be minimized by taking the BP with the wrist kept at the level of the heart. In addition, an automatic device's sensor must remain directly over the radial artery for an accurate reading, and wrist flexion may interfere with appropriate sensor positioning.

Cuffless blood pressure monitors — Cuffless BP monitors estimate BP indirectly through measurements of photoplethysmography, pulse wave analysis, pulse transit time, and other parameters. While this wearable technology offers the opportunity for comfortable, continuous BP monitoring, further studies are needed to confirm their accuracy and validate performance against established, standardized methods before they are used to make treatment decisions. In one observational study of 51 patients comparing 24-hour ABPM with seven-day average BP measured with a cuffless device that used a combination of photoplethysmography and pulse wave analysis, daytime BP measurements were similar with both methods, whereas nighttime systolic and diastolic measurements were consistently higher with the cuffless monitor (mean difference 12.5 [95% CI 9.3-15.8] and 4.1 [95% CI 2.2-6.0], respectively) [10].

SCREENING FOR HYPERTENSION — 

Hypertension screening is recommended for all adults [11,12]. Most patients have their BP measured at every clinic visit with nonstandardized (casual) office BP measurement. (See 'Methods for measuring blood pressure' above.)

While we discourage the use of nonstandardized BP measurement for the diagnosis and management of hypertension, this method is useful as an initial screen to identify patients who may have hypertension:

●Patients with elevated nonstandardized BP – When elevated BP (systolic >120 mmHg or diastolic >80 mmHg) is noted by nonstandardized office BP measurement, the measurement should be repeated using appropriate preparation and technique with a standardized office BP measurement method. (See 'Procedure for accurate blood pressure measurement' above and 'Methods for measuring blood pressure' above.)

When elevated BP persists with standardized measurement, additional sequential BP measurements are needed before hypertension is diagnosed. (See 'Approach to establishing the diagnosis' below.)

●Patients with normal nonstandardized BP – When normal BP (systolic <120 mmHg and diastolic <80 mmHg) is present by nonstandardized office BP measurement, then repeating the measurement with a standardized method is typically unnecessary. The errors inherent in nonstandardized BP measurement tend to produce a reading that is higher than the BP that would be found with a superior measurement method [13,14]. Thus, unless masked hypertension is suspected because hypertension target-organ damage is present, a normal nonstandardized BP measurement excludes a diagnosis of hypertension. (See 'Masked hypertension' below.)

APPROACH TO ESTABLISHING THE DIAGNOSIS

Confirm the elevated screening BP using a standardized method — When elevated BP (systolic >120 mmHg or diastolic >80 mmHg) is noted on a nonstandardized (casual) office BP measurement (see 'Screening for hypertension' above), it should be confirmed with either automated office BP (AOBP) or manual standardized office BP, with attention to appropriate preparation and technique (table 2). AOBP is preferred because it reduces the possibility of white coat hypertension.

If the patient's BP is elevated by repeat measurement using AOBP or manual standardized office BP, additional confirmatory BP measurements are needed to establish a diagnosis of hypertension. (See 'Options for establishing the diagnosis' below.)

However, if the repeat BP by AOBP or manual standardized measurement is >160 mmHg systolic and/or >100 mmHg diastolic, this single reading may be sufficient to establish the diagnosis of hypertension. (See 'Diagnostic criteria' below.)

Options for establishing the diagnosis — Among patients whose repeat BP is >130 mmHg systolic and/or >80 mmHg diastolic, establishing a diagnosis of hypertension requires a series of repeated BP measurements. Unless out-of-office measurements are used to confirm the diagnosis, multiple sequential office visits will be needed to confirm elevated BP using standardized office-based measurements (table 1).

Out-of-office BP (preferred method) — When ambulatory BP monitoring (ABPM) or self-measured BP (SMBP) are available, these methods are preferred [11,15]. Compared with ABPM (the gold standard), the sensitivity and specificity of office-based BP measurements are poor [15,16]. Office-based BP measurements also introduce the possibility of white coat and masked hypertension.

ABPM — We prioritize ABPM for the diagnosis of hypertension, when available. Because ABPM is a better predictor of future cardiovascular events when compared with office-based BP measurements, it is considered the gold standard for diagnosing hypertension [1,17-20]. ABPM also excludes the possibility of white coat and masked hypertension, captures the effects of normal daily activities on BP, yields a greater number of readings than can be obtained during a typical office encounter, and provides information on the behavior of BP during sleep, which has independent prognostic value [21]. (See 'White coat hypertension' below and 'Masked hypertension' below.)

However, despite data supporting the accuracy of ABPM, accessibility remains limited due to practice start-up expenses and lack of insurance coverage in many settings. As eligibility criteria and cost continue to evolve and increasing numbers of primary care practices prioritize investment in ABPM, access to ABPM for hypertension diagnosis and management may become more widespread [22]. (See "Ambulatory blood pressure monitoring: Indications and procedure".)

ABPM is considered the reference standard for diagnosing hypertension because it has the strongest association with cardiovascular outcomes. As an example, in a cohort study of nearly 60,000 patients followed for a mean of 9.7 years, ABPM was strongly associated with all-cause mortality after adjustment for office BP (hazard ratio [HR] 1.43 per one standard deviation increment, 95% CI 1.37-1.49), whereas the association between office BP and mortality was lost after adjustment for ABPM (HR 1.04, 95% CI 1.00-1.09) [19]. Findings were consistent across age groups and genders and among those treated and untreated for hypertension. A number of other studies reached similar conclusions [15,21,23,24].

SMBP — When ABPM is not feasible due to expense or lack of access, self-measured BP (SMBP) is a reasonable alternative measurement strategy. SMBP correlates more closely with the results of 24-hour or daytime ambulatory monitoring than office-based measurements [6,25-27]. SMBP can also exclude the possibility of white coat hypertension and can detect masked hypertension. (See 'White coat hypertension' below and 'Masked hypertension' below.)

When used in the diagnosis of hypertension, at least 12 SMBP readings should be obtained over a period of at least one week. Typically, we ask patients to take two BP measurements twice daily (two readings, separated by one minute, between 7 and 10 AM and another two readings between 1 and 10 PM) for seven days (table 4) [1,28]. The average of the 28 BP readings is then used for clinical decision-making. (See 'Diagnostic criteria' below.)

There are many BP measurement devices that can be purchased by the patient (online or in stores). The US Food and Drug Administration does not require formal validation studies for a manufacturer to sell a BP device; it is enough for the manufacturer to claim "substantial equivalence" with other devices already on the market [29]. Similarly, most other countries do not require formal validation in order for devices to be marketed. Less than 15 percent of commercially available BP devices worldwide have published information on device accuracy [30], and only approximately 20 percent of the most commonly purchased devices have been validated [31]. Concerns about this have led to the development of websites to help patients and clinicians know which BP devices have undergone actual validation studies. Sites hosted by the International Society of Hypertension, the American Medical Association, and Hypertension Canada provide listings of validated monitors.

Various trials have shown that patients who self-measure their BP longitudinally have improved BP control and better medication adherence [32-43]. However, when compared with office BP measurement, SMBP is limited by accessibility and cost as the patient or caregiver must have access to a calibrated BP monitor and an appropriately sized cuff and the patient must be able to operate the device using proper technique (table 2) [9].

The association between SMBP and cardiovascular events has been demonstrated in several studies [44-46]. In a prospective study of 2100 Finnish adults followed for a mean of 6.8 years, systolic SMBP was predictive of cardiovascular events (HR 1.22, 95% CI 1.09-1.37), whereas systolic office BP was not (HR 1.01, 95% CI 0.92-1.12) [45]. Diastolic SMBP measurements were similarly more predictive of cardiovascular events compared with diastolic office BP. In another prospective study, SMBP demonstrated stronger predictive power than casual office BP for stroke and transient ischemic attack [44].

Standardized office-based BP (alternative method) — Most patients are diagnosed with hypertension using standardized office-based BP measurement, with unattended AOBP, attended AOBP, or manual standardized office-based BP methods. (See 'Methods for measuring blood pressure' above.)

Using office-based measurements to establish the diagnosis of hypertension has several advantages, including the convenience of employing routine clinical visits, the availability of calibrated instruments, and access to multiple cuff sizes. It is also the primary measurement method used by most hypertension trials.

Unattended AOBP is preferred over attended AOBP and manual standardized office BP measurement as it reduces numerous factors that impact accuracy, including the white coat response, talking during measurement, and performance error [47-52]. Some data suggest that the effect of staff presence (eg, attended AOBP) is overestimated; however, studies showing no difference in attended versus unattended AOBP followed a strict protocol including no talking or staff interaction during BP measurement, which is not usual practice in a real-life setting [2,53]. If AOBP is not available, manual standardized office BP is an acceptable alternative as adherence to procedures for accurate BP measurement improves reproducibility and minimizes variability among providers [13,14,52].

When used in the diagnosis of hypertension, standardized office BP should be measured at least twice in a visit, on at least two separate visits, spaced over at least one week. (See 'Diagnostic criteria' below.)

Nonstandardized (casual) office BP measurements (table 1) have no role in the diagnosis and management of hypertension.

DIAGNOSIS OF HYPERTENSION

Definitions — We use the American College of Cardiology/American Heart Association definitions and staging system to classify BP [54]:

●Normal BP – Systolic <120 mmHg and diastolic <80 mmHg

●Elevated BP – Systolic 120 to 129 mmHg and diastolic <80 mmHg

●Hypertension

•Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

•Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg

If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage.

The European Society of Cardiology/European Society of Hypertension guidelines define hypertension slightly differently [55]. These variances are reviewed in the table (table 5).

Diagnostic criteria — The choice of BP measurement method determines the average BP and number of readings required for the diagnosis of hypertension:

●Office-based BP measurement – When standardized office-based BP measurement is used, hypertension is diagnosed when office-based BP measurements are above 130 mmHg systolic or 80 mmHg diastolic on at least two measurements in a visit, on at least two separate visits, spaced over at least one week [56].

When possible, confirmatory measurements with ambulatory BP monitoring (ABPM) or self-measured BP (SMBP) are recommended due to the possibility of white coat hypertension. (See 'Options for establishing the diagnosis' above and 'White coat hypertension' below.)

Though rare, hypertension is also diagnosed by one of the following single standardized office measurements:

•A single measurement of >180 mmHg systolic and/or >120 mmHg diastolic

•A single measurement of >160 mmHg systolic and/or >100 mmHg diastolic if there is also evidence of target-organ injury (coronary artery disease, heart failure, left ventricular hypertrophy, stroke, hypertensive retinopathy, chronic kidney disease)

These patients may warrant referral for emergency care. (See 'Additional evaluation and follow-up' below.)

●ABPM – When ABPM is used, hypertension is defined as a 24-hour average BP ≥125/75 mmHg or an average daytime BP ≥130/80 mmHg [1]. (See 'ABPM' above.)

●SMBP – When SMBP is used, hypertension is diagnosed if the average BP is greater than 130 mmHg systolic and/or 80 mmHg diastolic. (See 'SMBP' above.)

Masked hypertension

●Definition – Masked hypertension is present when the average out-of-office BP meets the criteria for hypertension but the average BP by office-based measurement is within the normal range. Masked hypertension is present in approximately 10 to 30 percent of adults with normal office-based BP [57,58]. Masked hypertension may be more common among men; African Americans; and patients with diabetes, chronic kidney disease, and obstructive sleep apnea [59-64]. (See "White coat and masked hypertension".)

●Diagnosis – The diagnosis of masked hypertension is difficult as it typically escapes clinical detection unless the patient routinely performs and records SMBP. Masked hypertension should be suspected in patients with evidence of hypertension target-organ damage (eg, left ventricular hypertrophy, chronic kidney disease) who have normal office-based BP. Such patients should undergo out-of-office BP measurement to detect masked hypertension. (See 'Out-of-office BP (preferred method)' above.)

Similarly, patients who are treated for hypertension may have controlled office-based BP but elevated out-of-office BP. This is called masked uncontrolled hypertension. We advise patients on antihypertensive therapy at high cardiovascular risk to obtain SMBP monthly to ensure masked uncontrolled hypertension is not overlooked [65]. If office BP readings are at or below 130/80 mmHg or the patient's goal and mean SMBP readings are consistently above this target, further evaluation with 24-hour ABPM is indicated. If ABPM is not feasible, we recommend a second week of SMBP readings approximately one month later. If neither ABPM nor SMBP can be obtained, then masked hypertension cannot be appropriately evaluated. In such cases, efforts should be made to identify and remove barriers to out-of-office BP measurement (eg, insurance appeal for ABPM or rental/loan arrangement for a personal BP measurement device) [13].

The treatment and prognosis of masked hypertension are discussed separately. (See "White coat and masked hypertension".)

DIFFERENTIAL DIAGNOSIS

White coat hypertension

Definition — White coat hypertension occurs when the average BP by office-based readings meets the criteria for hypertension, while the average BP by out-of-office measurement is within the normal range. This is termed "white coat hypertension." Patients with a diagnosis of hypertension who have uncontrolled BP in the office but controlled BP out of the office are categorized as having a "white coat effect." This is discussed in detail separately. (See "White coat and masked hypertension".)

When present, white coat hypertension and white coat effect can lead to overtreatment.

Diagnosis — A white coat response should be suspected when office BP measurements are not supported by home and self-measured BP (SMBP) readings. To diagnose white coat hypertension, office-based BP measurements should be compared with 24-hour ambulatory BP monitoring (ABPM) or SMBP readings, using appropriate technique and validated BP monitors (algorithm 1).

The diagnosis of white coat hypertension is made when office-based readings are ≥130/80 mmHg and the seven-day average SMBP is <130/80 mmHg, with one of the following confirmations [1]:

●Mean 24-hour ABPM <125/75 mmHg, or

●A second seven-day average SMBP is <130/80 mmHg

If SMBP cannot be obtained (eg, a measurement device is not covered by the patient's insurance, the patient cannot afford a device, and the patient has no other access to a BP measurement device), then we obtain an ABPM, if feasible, to establish a diagnosis of hypertension or confirm the presence of white coat hypertension. If neither SMBP nor ABPM can be obtained, then white coat hypertension should be evaluated by performing automated office BP [13]. (See 'Methods for measuring blood pressure' above.)

The white coat effect as a diagnostic consideration in patients with suspected resistant hypertension is discussed separately. (See "Definition, risk factors, and evaluation of resistant hypertension", section on 'White coat effect'.)

Prognosis — In cross-sectional studies, the prevalence of white coat hypertension ranges from 10 to 20 percent [59,66-72]. White coat hypertension seems to be associated with a higher risk of adverse cardiovascular outcomes compared with normotension [68,69,73-75], although this risk is lower in magnitude than the risk of masked or sustained hypertension [76].

In a meta-analysis of 26 observational studies, patients with either untreated white coat hypertension or treated white coat effect (patients treated for hypertension with a white coat effect by office BP) were followed for 3 to 19 years [69]. Compared with normotensive individuals, untreated white coat hypertension was associated with a nonsignificantly higher risk of cardiovascular events (hazard ratio [HR] 1.26, 95% CI 1.00-1.54) and an increased risk of all-cause mortality (HR 1.20, 95% CI 1.02-1.41).

In addition to a higher cardiovascular risk, patients who are diagnosed with white coat hypertension have a three- to fourfold increased risk of developing sustained hypertension at 7 to 10 years compared with normotensive patients [68,77].

Patients with white coat hypertension do not require antihypertensive drug therapy; however, intensive lifestyle modifications and cardiovascular risk reduction should be continued, including monitoring and managing concomitant dyslipidemia and diabetes, if present. (See "Overview of primary prevention of cardiovascular disease in adults".)

Patients diagnosed with white coat hypertension should also have regular out-of-office BP monitoring, either through periodic SMBP or annual ABPM, due to the risk of developing sustained hypertension over time. (See 'ABPM' above and 'SMBP' above.)

Pseudohypertension — Compression of the brachial artery may require a cuff pressure greater than systolic in patients with stiff vessels due to marked arterial calcification. This phenomenon, called pseudohypertension, is characterized by systolic and diastolic pressures estimated from the sphygmomanometer that are 10 mmHg or more above the directly measured intra-arterial or oscillometric pressure [78].

Cuff inflation hypertension with SMBP — Occasionally, anticipatory anxiety related to cuff inflation may result in BP elevation of 4 to 7 mmHg [79]. Additionally, some personal BP monitors require the patient to manually inflate the cuff, which may prompt BP elevation by as much as 12/9 mmHg due to both physical exertion and anticipatory anxiety [80]. This effect dissipates within 5 to 20 seconds.

To mitigate cuff inflation hypertension, we instruct patients to inflate the cuff to at least 30 mmHg above systolic. The sphygmomanometer is subsequently allowed to fall no more than 2 to 3 mmHg per second to permit an exertional effect to disappear [80]. Taking multiple sequential measurements and discarding the first reading may also remove the effect of anticipatory anxiety.

ADDITIONAL EVALUATION AND FOLLOW-UP

●History and physical examination – Patients with newly diagnosed or suspected hypertension should have a detailed history (table 6) and physical examination (table 7) to estimate the time course, presence and extent of target-organ damage, and presence of other risk factors for cardiovascular disease.

●Additional evaluation – Additional evaluation should include the following (table 8):

•Electrolytes (including calcium)

•Serum creatinine, estimated glomerular filtration rate

•Fasting glucose

•Urinalysis

•Complete blood count

•Thyroid-stimulating hormone

•Lipid profile

•Urinary albumin to creatinine ratio for patients with diabetes or chronic kidney disease

•Electrocardiogram

•Calculation of 10-year cardiovascular disease risk (see "Cardiovascular disease risk assessment for primary prevention: Risk calculators")

These tests evaluate target-organ damage, cardiovascular risk, and potential causes of secondary hypertension and help guide the choice of an antihypertensive regimen.

●Referral for emergency care – Severely elevated hypertension with evidence of target-organ injury may also warrant referral for emergency care and/or prompt initiation of antihypertensive therapy. The evaluation and management of such patients are discussed separately. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)

●Follow-up – For patients with systolic >180 mmHg or diastolic >100 mmHg who are managed in the outpatient setting, follow-up should occur within several days. Follow-up for patients referred for emergency care is discussed separately. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults", section on 'Monitoring and follow-up'.)

For patients with uncomplicated, stage 1 or 2 hypertension in the absence of clinical cardiovascular disease or hypertension-related organ damage, we suggest a return visit every four weeks after medication initiation and with each medication change until BP is at goal. When possible, patients should also self-measure and record their BP for review.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: High blood pressure in adults (The Basics)" and "Patient education: Checking your blood pressure at home (The Basics)")

●Beyond the Basics topics (see "Patient education: High blood pressure in adults (Beyond the Basics)" and "Patient education: High blood pressure treatment in adults (Beyond the Basics)" and "Patient education: High blood pressure, diet, and weight (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●BP measurement methods – Blood pressure (BP) may be measured using several methods (table 1). Accurate BP measurement by any method requires attention to proper procedure and technique, including correct cuff size (table 2 and table 3). (See 'Procedure for accurate blood pressure measurement' above.)

●Hypertension screening and evaluation

•Screening – Most patients have their BP measured at every clinic visit with nonstandardized office BP (table 1). While we discourage the use of nonstandardized BP measurement for the diagnosis and management of hypertension, this method is useful as an initial screen to identify patients who may have hypertension. (See 'Methods for measuring blood pressure' above.)

•Diagnosing hypertension – Making a diagnosis of hypertension requires a series of repeated BP measurements on multiple occasions, using one of three methods (table 1). Most patients are diagnosed with hypertension using an office-based BP method. (See 'Standardized office-based BP (alternative method)' above.)

When ambulatory BP monitoring (ABPM) or self-measured BP (SMBP) is available, it is preferred for diagnosing hypertension. These methods better predict cardiovascular outcomes than office-based measurements and avoid the possibility of white coat and masked hypertension. (See 'Options for establishing the diagnosis' above and 'White coat hypertension' above.)

●Definitions – We use the American College of Cardiology/American Heart Association definitions and staging system to classify BP:

•Normal BP – Systolic <120 mmHg and diastolic <80 mmHg

•Elevated BP – Systolic 120 to 129 mmHg and diastolic <80 mmHg

•Hypertension

-Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

-Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg

If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage. (See 'Definitions' above.)

●Diagnostic criteria – The choice of BP measurement strategy determines the average BP and number of readings required to diagnose hypertension (see 'Options for establishing the diagnosis' above and 'Diagnostic criteria' above):

•Office-based BP measurement – Average BP ≥130 mmHg systolic or 80 mmHg diastolic based on at least two measurements in a visit, on at least two separate visits, spaced over at least one week, using a standardized office-based BP measurement method (eg, unattended automated office BP [AOBP], attended AOBP, or routine office-based BP). (See 'Standardized office-based BP (alternative method)' above.)

Hypertension is also diagnosed by:

-A single standardized office measurement of systolic >180 mmHg and/or diastolic >120 mmHg

-A single standardized office measurement of systolic >160 mmHg and/or diastolic >100 mmHg if there is also evidence of target-organ injury (eg, coronary artery disease, heart failure, left ventricular hypertrophy, stroke, hypertensive retinopathy, chronic kidney disease)

•ABPM – A 24-hour average BP ≥125/75 mmHg or average daytime BP ≥130/80 mmHg. (See 'ABPM' above.)

•SMBP – Average BP ≥130/80 mmHg using at least 12 measurements over at least one week, including both morning and evening measurements. (See 'SMBP' above.)

●Differential diagnosis

•White coat hypertension – White coat hypertension occurs when the average BP by office-based measurement meets the criteria for hypertension, while the average BP by non-office measurement is within the normal range. Because of the potential risks of overtreatment, patients with white coat hypertension should not have therapy initiated or intensified. Instead, regular out-of-office BP monitoring should be performed as there is an increased risk of developing sustained hypertension over time. (See 'White coat hypertension' above.)

•Masked hypertension – Masked hypertension occurs when the average out-of-office BP meets the criteria for hypertension, while the average by office-based measurement is within the normal range. Patients with masked hypertension should have prompt initiation of antihypertensive treatment as masked hypertension is associated with an increased risk of adverse cardiovascular outcomes. (See 'Masked hypertension' above.)

●Additional evaluation and follow-up – Patients with newly diagnosed or suspected hypertension should have a detailed history, physical examination, and additional studies to evaluate for end-organ damage, cardiovascular risk, and potential causes of secondary hypertension (table 8). (See 'Additional evaluation and follow-up' above.)

Severely elevated hypertension with evidence of target-organ injury may also warrant referral for emergency care or prompt initiation of antihypertensive therapy. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)

For patients with systolic >180 mmHg or diastolic >100 mmHg who are managed in the outpatient setting, follow-up should occur within several days. For patients with uncomplicated, stage 1 or 2 hypertension in the absence of clinical cardiovascular disease or end-organ damage, we suggest a return visit every four weeks after medication initiation and with each medication change until BP is at goal.

ACKNOWLEDGMENTS

The UpToDate editorial staff acknowledges Norman Kaplan, MD, who contributed to earlier versions of this topic review.

We are saddened by the death of George Bakris, MD, who passed away in June 2024. UpToDate acknowledges Dr. Bakris's past work as a section editor for this topic.

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Topic 3879 Version 69.0

References

1 : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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 Task Force on Clinical Practice Guidelines.

2 : Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

3 : International Consensus on Standardized Clinic Blood Pressure Measurement - A Call to Action.

4 : Blood pressure measurements are unreliable to diagnose hypertension in primary care.

5 : Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial.

6 : Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association.

7 : Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association.

8 : Defining the relationship between arm and leg blood pressure readings: a systematic review and meta-analysis.

9 : Recommendations for blood pressure measurement in large arms in research and clinical practice: position paper of the European society of hypertension working group on blood pressure monitoring and cardiovascular variability.

10 : Evaluation of Aktiia cuffless blood pressure monitor across 24-h, daytime, and night-time measurements versus ambulatory monitoring: a prospective, single-centre observational study.

11 : Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

12 : Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement.

13 : Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis.

14 : Comparison of three office blood pressure measurement techniques and their effect on hypertension prevalence in the general population.

15 : Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force.

16 : Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review.

17 : Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement.

18 : 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).

19 : Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59 124 patients.

20 : Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease.

21 : Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study.

22 : The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007-2010.

23 : Ambulatory blood pressure and mortality: a population-based study.

24 : Prognostic impact of clinic and ambulatory blood pressure components in high-risk type 2 diabetic patients: the Rio de Janeiro Type 2 Diabetes Cohort Study.

25 : Home blood pressure monitoring in CKD.

26 : Home blood pressure measurement: a systematic review.

27 : Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review.

28 : European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring.

29 : The evolution of substantial equivalence in FDA's premarket review of medical devices.

30 : Lancet Commission on Hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure.

31 : Availability, Cost, and Consumer Ratings of Popular Nonvalidated vs Validated Blood Pressure-Measuring Devices Sold Online in 10 Countries.

32 : Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association.

33 : Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension.

34 : Blood pressure management through application-based telehealth platforms: a systematic review and meta-analysis.

35 : Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis.

36 : Effectiveness of home blood pressure telemonitoring: a systematic review and meta-analysis of randomised controlled studies.

37 : Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

38 : Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis.

39 : Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis.

40 : Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial.

41 : Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

42 : Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial.

43 : PERson-centredness in Hypertension management using Information Technology: a randomized controlled trial in primary care.

44 : Prediction of stroke by self-measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study.

45 : Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study.

46 : Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan.

47 : Attended versus unattended automated office blood pressure measurement in the diagnosis and treatment of hypertension.

48 : Sympathetic Neural Mechanisms Underlying Attended and Unattended Blood Pressure Measurement.

49 : Attended vs unattended systolic blood pressure measurement: A randomized comparison in patients with cardiovascular disease.

50 : Office Blood Pressure Measurement: The Weak Cornerstone of Hypertension Diagnosis.

51 : Comparison of automated oscillometric versus auscultatory blood pressure measurement.

52 : Comparison of Automated Office Blood Pressure With Office and Out-Off-Office Measurement Techniques.

53 : Attended Versus Unattended Blood Pressure Measurement in a Real Life Setting.

54 : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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 Task Force on Clinical Practice Guidelines.

55 : 2018 ESC/ESH Guidelines for the management of arterial hypertension.

56 : Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement.

57 : Prevalence of Masked Hypertension Among US Adults With Nonelevated Clinic Blood Pressure.

58 : Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.

59 : Predictors of the Home-Clinic Blood Pressure Difference: A Systematic Review and Meta-Analysis.

60 : Masked Hypertension and Cardiovascular Disease Events in a Prospective Cohort of Blacks: The Jackson Heart Study.

61 : Masked hypertension in diabetes mellitus: treatment implications for clinical practice.

62 : Masked Hypertension and Elevated Nighttime Blood Pressure in CKD: Prevalence and Association with Target Organ Damage.

63 : Ambulatory Blood Pressure Phenotypes in Adults Taking Antihypertensive Medication with and without CKD.

64 : Masked hypertension in obstructive sleep apnea syndrome.

65 : Proportion of US Adults Recommended Out-of-Clinic Blood Pressure Monitoring According to the 2017 Hypertension Clinical Practice Guidelines.

66 : Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis.

67 : Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study.

68 : Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements.

69 : Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis.

70 : True resistant hypertension: is it possible to be recognized in the office?

71 : Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association.

72 : Independent predictors of isolated clinic ('white-coat') hypertension.

73 : White-Coat Hypertension Without Organ Damage: Impact on Long-Term Mortality, New Hypertension, and New Organ Damage.

74 : Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome.

75 : Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population.

76 : Should Out-of-Office Monitoring Be Performed for Detecting White Coat Hypertension?

77 : Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study.

78 : Pseudohypertension: a new assessment.

79 : Effect of anticipation and cuff inflation on blood pressure during self-measurement.

80 : Effects of cuff inflation on self-recorded blood pressure.