Definition of hypertension: 

According to most mainstream standards, hypertension should be diagnosed when a person’s systolic blood pressure (SBP) is less than 140 mm Hg, and their diastolic blood pressure (DBP) is less than 90 mm Hg after repeated assessment. High-normal blood pressure is used to identify people who might benefit from lifestyle changes and who could need pharmaceutical therapy if there are plausible reasons.

Isolated systolic hypertension, defined as a high SBP (140 mm Hg) and a low DBP (90 mm Hg), is frequent in young and older people. Isolated systolic hypertension is the most prevalent essential hypertension in young people, including children, adolescents, and adults. It is more frequent among the elderly, who experience hardening of the major arteries and increased pulse pressure (difference between SBP and DBP). 

Individuals with verified hypertension (grades 1 and 2) should be treated with the appropriate medications.

Section 3 delves into the specifics of measuring blood pressure at home, at the workplace, and on the go.

Section 3: Hypertension Diagnosis and Blood Pressure Measurement

• The most prevalent method for diagnosing and monitoring hypertension is to take your blood pressure in the office or clinic.
• The diagnosis should not be made in a single office visit if feasible. To confirm the diagnosis of hypertension, 2–3 office visits at 1–4-week intervals (depending on the BP level) are usually necessary. If the blood pressure is less than 180/110 mm Hg and you have signs of cardiovascular disease (CVD), you may be able to get a diagnosis in only one visit.
• If practicable and accessible, an out-of-office blood pressure measurement should be used to confirm the diagnosis of hypertension.

Hypertension Diagnosis – Office Blood Pressure Measurement

Initial evaluation: 

Initial assessment: Take your blood pressure in both arms simultaneously, if possible. If the difference between arms in repeated measures is more significant than 10 mm Hg, utilize the component with the higher BP. If the discrepancy is more significant than 20 mm Hg, you should look into it further.

Standing blood pressure: When symptoms suggest postural hypotension, measure after 1 minute and again after 3 minutes in treated hypertensives and at the initial visit in the elderly and diabetics.

Unattended office blood pressure: measures conducted while the patient is alone in the office give a more consistent examination and lower BP values than typical office measurements with an ambiguous threshold for hypertension diagnosis. Most treatment decisions require confirmation of out-of-office blood pressure.

Hypertension Diagnosis – Out-of-Office Blood Pressure Measurement

Out-of-office blood pressure measurements (taken at home or with 24-hour ambulatory blood pressure monitoring [ABPM]) are more reliable than in-office readings. They are more closely linked to hypertension-induced organ damage and the risk of cardiovascular events and can detect white coat and masked hypertension.

Out-of-office blood pressure monitoring is frequently required for proper hypertension diagnosis and treatment decisions. The BP level must be verified via home or ambulatory BP monitoring in untreated or treated participants with office BP defined as high-normal BP or graded one hypertension (systolic 130–159 mm Hg or diastolic 85–99 mm Hg).

White Coat and Masked Hypertension

White coat hypertension affects 10%–30% of people who visit clinics for high blood pressure, while disguised hypertension affects 10%–15% of people.

White coat hypertension: These people are in the middle of the cardiovascular risk spectrum, between normotensives and sustained hypertensives. Repeated BP readings in the office and out of the office are required to confirm the diagnosis. Drug therapy may not be necessary if their absolute cardiovascular risk is modest and there is no hypertension-mediated organ damage (HMOD). 

They should, however, be supplemented with lifestyle changes, as they may cause long-term hypertension that needs medication.

Masked hypertension: Patients with masked hypertension are at the same risk of cardiovascular events as those with chronic hypertension. 

Repeated in-office and out-of-office measurements are required to confirm the diagnosis. Masked hypertension may need medication to get out-of-office blood pressure back to normal.

Section 4: Diagnostic / Clinical Tests

Medical History

• Patients with hypertension are frequently asymptomatic; nevertheless, particular symptoms may indicate secondary hypertension or hypertensive consequences, which should be investigated further. It’s best to have a comprehensive medical and family history checked.
• Blood pressure: New-onset hypertension, duration, previous BP levels, current and previous antihypertensive medication, other medications/over-the-counter medicines that can affect BP, history of antihypertensive medication intolerance (side-effects), adherence to antihypertensive treatment, prior hypertension caused by oral contraceptives or pregnancy.
• Risk factors: Personal history of cardiovascular disease (CVD) is a risk factor (myocardial infarction, heart failure [HF], stroke, transient ischemic attacks [TIA], diabetes, dyslipidemia, chronic kidney disease [CKD], smoking status, diet, alcohol intake, physical activity, psychosocial aspects, history of depression). Hypertension, CVD, (familial) hypercholesterolemia and diabetes run in the family.
• Assessment of overall cardiovascular risk: Chest discomfort, shortness of breath, palpitations, claudication, peripheral edema, headaches, blurred vision, nocturia, hematuria, and dizziness are symptoms or indicators of hypertension or coexisting disorders.
• Symptoms/signs of hypertension/coexisting illnesses: Secondary hypertension symptoms include muscle weakness/tetany, cramps, arrhythmias (hypokalemia/primary aldosteronism), flash pulmonary edema (renal artery stenosis), sweating, palpitations, frequent headaches (pheochromocytoma), snoring, daytime sleepiness (obstructive sleep apnea), snoring, daytime sleepiness (obstructive sleep.

Physical Examination

• A complete physical examination can help confirm the diagnosis of hypertension and identify HMOD and secondary hypertension, and should include the following:
• Pulse rate, rhythm, and character, jugular venous pulse/pressure, apex beat, additional heart sounds, basal crackles, peripheral edema, bruits (carotid, abdominal, femoral), and radio-femoral delay
• Other organs/systems: enlarged kidneys, neck circumference >40 cm (obstructive sleep apnea), enlarged thyroid, increased BMI/waist circumference, fatty deposits, and striae (Cushing disease/syndrome).

Laboratory Investigations and ECG

Blood tests: Sodium, potassium, serum creatinine and estimated glomerular filtration rate (eGFR). If available, lipid profile and fasting glucose. 

Urine test: Dipstick urine test. 

12-lead ECG: Detection of atrial fibrillation, left ventricular hypertrophy (LVH), ischemic heart disease.

Additional Diagnostic Tests

Additional tests, if needed, can be performed to examine and confirm the presence of HMOD, coexisting illnesses, or secondary hypertension.

Techniques of Imaging

Echocardiography: LVH, systolic/diastolic dysfunction, atrial dilation, and aortic coarctation are all shown on echocardiography.

Carotid ultrasound: Ultrasound of the carotid arteries reveals plaques (atherosclerosis) and stenosis.

Kidneys/renal artery and adrenal imaging: Renal parenchymal disease, renal artery stenosis, adrenal lesions, and other abdominal pathology: Ultrasound/renal artery Duplex; CT/MR-angiography: renal parenchymal disease, renal artery stenosis, adrenal lesions, and other abdominal pathology.

Fundoscopy: Retinal abnormalities, hemorrhages, papilledema, tortuosity, and nipping are all seen during a fundoscopy.

Brain CT/MRI: Ischemic or hemorrhagic brain damage caused by hypertension on brain CT/MRI.