Editing Hypertension (section)

==Diagnosis==
Hypertension is diagnosed based on persistently high resting blood pressure. Elevated blood pressure measurements on at least two separate occasions is required for a diagnosis of hypertension.<ref name="AHA2017"/><ref name="ESH2023"/><ref name="WHO2023"/>

=== Measurement technique ===
For an accurate diagnosis of hypertension to be made, proper [[blood pressure measurement]] technique must be used.<ref name="Viera2017">{{cite journal | vauthors = Viera AJ | title = Screening for Hypertension and Lowering Blood Pressure for Prevention of Cardiovascular Disease Events | journal = The Medical Clinics of North America | volume = 101 | issue = 4 | pages = 701–712 | date = July 2017 | pmid = 28577621 | doi = 10.1016/j.mcna.2017.03.003 | type = Review }}</ref> Improper measurement of blood pressure is common and can change the blood pressure reading by up to 10 mmHg, which can lead to misdiagnosis and misclassification of hypertension.<ref name="Viera2017"/> Correct blood pressure measurement technique involves several steps. Proper blood pressure measurement requires the person whose blood pressure is being measured to sit quietly for at least five minutes which is then followed by the application of a properly fitted blood pressure cuff to a bare upper arm.<ref name="Viera2017"/> The person should be seated with their back supported, feet flat on the floor, and with their legs uncrossed.<ref name="Viera2017"/> The person whose blood pressure is being measured should avoid talking or moving during this process.<ref name="Viera2017"/> The arm being measured should be supported on a flat surface at the level of the heart.<ref name="Viera2017"/> Blood pressure measurement should be done in a quiet room so the medical professional checking the blood pressure can hear the [[Korotkoff sound]]s while listening to the [[brachial artery]] with a [[stethoscope]] for accurate blood pressure measurements.<ref name="Viera2017"/><ref name="Vischer2017">{{cite book| vauthors = Vischer AS, Burkard T |title=Hypertension: From basic research to clinical practice |chapter=Principles of Blood Pressure Measurement – Current Techniques, Office vs Ambulatory Blood Pressure Measurement |series=Advances in Experimental Medicine and Biology|date=2017|volume=956|pages=85–96|doi=10.1007/5584_2016_49|pmid=27417699|type=Review|isbn=978-3-319-44250-1}}</ref> The blood pressure cuff should be deflated slowly (2–3 mmHg per second) while listening for the Korotkoff sounds.<ref name="Vischer2017"/> The [[urinary bladder|bladder]] should be emptied before a person's blood pressure is measured since this can increase blood pressure by up to 15/10 mmHg.<ref name="Viera2017"/> Multiple blood pressure readings (at least two) spaced 1–2 minutes apart should be obtained to ensure accuracy.<ref name="Vischer2017"/> Ambulatory blood pressure monitoring over 12 to 24 hours is the most accurate method to confirm the diagnosis.<ref name="ReferenceA">{{cite journal | vauthors = Siu AL | title = Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement | journal = Annals of Internal Medicine | volume = 163 | issue = 10 | pages = 778–786 | date = November 2015 | pmid = 26458123 | doi = 10.7326/m15-2223 | doi-access = free }}</ref> An exception to this is those with very high blood pressure readings, especially when there is poor [[organ (anatomy)|organ]] function.<ref name="NICE127 full"/>

With the availability of 24-hour [[ambulatory blood pressure]] monitors and [[bloodpressure#Home monitoring|home blood pressure]] machines, the importance of not wrongly diagnosing those who have [[white coat hypertension]] has led to a change in protocols. In the United Kingdom, the current best practice is to follow up a single raised clinic reading with ambulatory measurement, or less ideally with home blood pressure monitoring over 7 days.<ref name="NICE127 full">{{cite book |author=National Clinical Guidance Centre |title=Hypertension (NICE CG 127) |publisher=[[National Institute for Health and Clinical Excellence]] |chapter=7 Diagnosis of Hypertension, 7.5 Link from evidence to recommendations |pages=102 |date=August 2011 |chapter-url=http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf |access-date=22 December 2011 |url-status=dead |archive-url=https://web.archive.org/web/20130723014309/http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf |archive-date=23 July 2013 }}</ref> The [[United States Preventive Services Task Force]] also recommends getting measurements outside of the healthcare environment.<ref name="ReferenceA"/> [[Pseudohypertension in the elderly]] or noncompressibility artery syndrome may also require consideration. This condition is believed to be due to [[calcification]] of the arteries resulting in abnormally high blood pressure readings with a blood pressure cuff while intra arterial measurements of blood pressure are normal.<ref>{{cite journal | vauthors = Franklin SS, Wilkinson IB, McEniery CM | title = Unusual hypertensive phenotypes: what is their significance? | journal = Hypertension | volume = 59 | issue = 2 | pages = 173–178 | date = February 2012 | pmid = 22184330 | doi = 10.1161/HYPERTENSIONAHA.111.182956 | doi-access = free }}</ref> [[Orthostatic hypertension]] is when blood pressure increases upon standing.<ref>{{cite journal | vauthors = Kario K | title = Orthostatic hypertension: a measure of blood pressure variation for predicting cardiovascular risk | journal = Circulation Journal | volume = 73 | issue = 6 | pages = 1002–1007 | date = June 2009 | pmid = 19430163 | doi = 10.1253/circj.cj-09-0286 | doi-access = free }}</ref>

=== Other investigations ===
{{anchor|Laboratory tests}}
Once the diagnosis of hypertension has been made, further testing may be performed to find [[secondary hypertension]], identify comorbidities such as [[diabetes]], identify hypertension-caused organ damage such as [[chronic kidney disease]] or [[left ventricular hypertrophy|thickening of the heart muscle]], and for [[cardiovascular disease]] risk stratification.<ref name="WHOreport2023"/>

Secondary hypertension is more common in preadolescent children, with most cases caused by [[kidney disease]]. Primary or [[essential hypertension]] is more common in adolescents and adults and has multiple risk factors, including obesity and a family history of hypertension.<ref name="pmid16719248">{{cite journal | vauthors = Luma GB, Spiotta RT | title = Hypertension in children and adolescents | journal = American Family Physician | volume = 73 | issue = 9 | pages = 1558–1568 | date = May 2006 | pmid = 16719248 }}</ref>

Initial assessment upon diagnosis of hypertension should include a complete [[Medical history|history]] and [[physical examination]]. The [[World Health Organization]] suggests the following initial tests: [[serum electrolytes]], [[serum creatinine]], [[lipid panel]], [[HbA1c]] or [[fasting glucose]], [[urine dipstick]] and [[electrocardiogram]] (ECG/EKG).<ref name="WHOreport2023"/> Serum creatinine is measured to assess for the presence of kidney disease, which can be either the cause or the result of hypertension.<ref name="JNC7">{{cite journal | vauthors = Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ | title = Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure | journal = Hypertension | volume = 42 | issue = 6 | pages = 1206–1252 | date = December 2003 | pmid = 14656957 | doi = 10.1161/01.HYP.0000107251.49515.c2 | collaboration = Joint National Committee on Prevention, National High Blood Pressure Education Program Coordinating Committee | doi-access = free }}</ref> eGFR can also provide a baseline measurement of kidney function that can be used to monitor for side effects of certain [[Antihypertensive drug|anti-hypertensive drugs]] on kidney function. Testing of [[proteinuria|urine samples for protein]] is used as a secondary indicator of kidney disease. Lipid panel and glucose tests are done to identify comorbidities such as diabetes and [[hyperlipidemia]] and for cardiovascular risk stratification. Electrocardiogram (EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure, such as [[left ventricular hypertrophy|thickening of the heart muscle]] or whether the heart has experienced a prior minor disturbance such as a silent heart attack.

===Classification in adults===
The circumstances of measurement can influence blood pressure measurements.<ref name=ESC2024/> Guidelines use different thresholds for office (also known as clinic), home (when the patient measures their blood pressure at home), and [[ambulatory blood pressure]] (using an automated device over 24 hours).<ref name=ESC2024/>
{| class="wikitable"
|+ Blood pressure classifications
|-
! Categories
! colspan="3" | [[Systolic blood pressure]], [[mmHg]]
! rowspan=2 | and/or
! colspan="3" | [[Diastolic blood pressure]], mmHg
|-
! Method
! Office
! Home
! 24h [[Ambulatory blood pressure|ambulatory]]
! Office
! Home
! 24h ambulatory
|-
! colspan="8" | [[American College of Cardiology]]/[[American Heart Association]] (2017)<ref name=Whelton2022>{{Cite journal |last1=Whelton |first1=Paul K |last2=Carey |first2=Robert M |last3=Mancia |first3=Giuseppe |last4=Kreutz |first4=Reinhold |last5=Bundy |first5=Joshua D |last6=Williams |first6=Bryan |date=2022-09-14 |title=Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines |journal=European Heart Journal |language=en |volume=43 |issue=35 |pages=3302–3311 |doi=10.1093/eurheartj/ehac432 |doi-access = free |issn=0195-668X |pmc=9470378 |pmid=36100239}}</ref>
|-
| Normal
| <120
|<120
| <115
| and
| <80
|<80
| <75
|-
| Elevated
| 120–129
|120–129
| 115–124
| and
| <80
|<80
| <75
|-
| Hypertension, stage 1
| 130–139
|130–134
| 125–129
| or
| 80–89
|80–84
| 75–79
|-
| Hypertension, stage 2
| ≥140
|≥135
| ≥130
| or
| ≥90
|≥85
| ≥80
|-
! colspan="8" | [[European Society of Cardiology]] (2024)<ref name=ESC2024>{{Cite journal |last1=McEvoy |first1=John William |last2=McCarthy |first2=Cian P |last3=Bruno |first3=Rosa Maria |last4=Brouwers |first4=Sofie |last5=Canavan |first5=Michelle D |last6=Ceconi |first6=Claudio |last7=Christodorescu |first7=Ruxandra Maria |last8=Daskalopoulou |first8=Stella S |last9=Ferro |first9=Charles J |last10=Gerdts |first10=Eva |last11=Hanssen |first11=Henner |last12=Harris |first12=Julie |last13=Lauder |first13=Lucas |last14=McManus |first14=Richard J |last15=Molloy |first15=Gerard J |display-authors=5 |date=2024-08-30 |title=2024 ESC Guidelines for the management of elevated blood pressure and hypertension: Developed by the task force on the management of elevated blood pressure and hypertension of the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO) |journal=European Heart Journal |volume=45 |issue=38 |pages=3912–4018 |language=en |doi=10.1093/eurheartj/ehae178 |doi-access=free |pmid=39210715 |issn=0195-668X}}</ref>
|-
| Non-elevated
| <120
|<120
| <115
| and
| <70
|<70
| <65
|-
| Elevated
| 120–139
|120–135
| 115–129
| and
| 70–89
|70–85
| 65–79
|-
| Hypertension
| ≥140
|≥135
| ≥130
| or
| ≥90
|≥85
| ≥80
|-
! colspan="8" | [[European Society of Hypertension]]/[[International Society of Hypertension]] (2023)<ref name=ESH2023>{{Cite journal |last1=Mancia |first1=Giuseppe |last2=Kreutz |first2=Reinhold |last3=Brunström |first3=Mattias |last4=Burnier |first4=Michel |last5=Grassi |first5=Guido |last6=Januszewicz |first6=Andrzej |last7=Muiesan |first7=Maria Lorenza |last8=Tsioufis |first8=Konstantinos |last9=Agabiti-Rosei |first9=Enrico |last10=Algharably |first10=Engi Abd Elhady |last11=Azizi |first11=Michel |last12=Benetos |first12=Athanase |last13=Borghi |first13=Claudio |last14=Hitij |first14=Jana Brguljan |last15=Cifkova |first15=Renata |display-authors = 5 |date=2023-12-01 |title=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) |journal=Journal of Hypertension |volume=41 |issue=12 |pages=1874–2071 |doi=10.1097/HJH.0000000000003480 |issn=1473-5598 |pmid=37345492|doi-access=free |hdl=11379/603005 |hdl-access=free }}</ref>
|-
| Optimal
| <120
| {{N/A}}
| {{N/A}}
| and
| <80
| {{N/A}}
| {{N/A}}
|-
| Normal
| 120–129
| {{N/A}}
| {{N/A}}
| and/or
| 80–84
| {{N/A}}
| {{N/A}}
|-
| High normal
| 130–139
| {{N/A}}
| {{N/A}}
| and/or
| 85–89
| {{N/A}}
| {{N/A}}
|-
| Hypertension, grade 1
| 140–159
|≥135
| ≥130
| and/or
| 90–99
|≥85
| ≥80
|-
| Hypertension, grade 2
| 160–179
| {{N/A}}
| {{N/A}}
| and/or
| 100–109
| {{N/A}}
| {{N/A}}
|-
| Hypertension, grade 3
| ≥180
| {{N/A}}
| {{N/A}}
| and/or
| ≥110
| {{N/A}}
| {{N/A}}
|}

===Children===
Hypertension occurs in around 0.2 to 3% of newborns; however, blood pressure is not measured routinely in healthy newborns.<ref name=Dionne>{{cite journal | vauthors = Dionne JM, Abitbol CL, Flynn JT | title = Hypertension in infancy: diagnosis, management and outcome | journal = Pediatric Nephrology | volume = 27 | issue = 1 | pages = 17–32 | date = January 2012 | pmid = 21258818 | doi = 10.1007/s00467-010-1755-z | s2cid = 10698052 }}</ref> Hypertension is more common in high risk newborns. A variety of factors, such as [[Gestational age (obstetrics)|gestational age]], postconceptional age, and [[birth weight]] need to be taken into account when deciding if blood pressure is normal in a newborn.<ref name=Dionne />

Hypertension defined as elevated blood pressure over several visits affects 1% to 5% of children and adolescents and is associated with long-term risks of ill-health.<ref name=fourth>{{cite journal | title = The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents | journal = Pediatrics | volume = 114 | issue = 2 Suppl 4th Report | pages = 555–576 | date = August 2004 | pmid = 15286277 | doi = 10.1542/peds.114.2.S2.555 | author1 = National High Blood Pressure Education Program Working Group on High Blood Pressure in Children Adolescents | doi-broken-date = 2 December 2024 | hdl = 2027/uc1.c095473177 | hdl-access = free }}</ref> Blood pressure rises with age in childhood and, in children, hypertension is defined as an average systolic or diastolic blood pressure on three or more occasions equal or higher than the 95th percentile appropriate for the sex, age, and height of the child. High blood pressure must be confirmed on repeated visits however before characterizing a child as having hypertension.<ref name=fourth /> In adolescents, it has been proposed that hypertension is diagnosed and classified using the same criteria as in adults.<ref name=fourth />