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...................................................................... 4.7.1. Definition and classification of hypertension BP is classified according to seated office BP (Table 12), with approximately corresponding values according to ABPM or home BP average values in Table 13.

4.7.2. Blood pressure measurement 4.7.2.1 Office blood pressure measurement Office BP should be measured in standardized conditions using validated auscultatory or (semi)automatic devices, as described in Table 14.

4.7.2.2 Unattended automated office blood pressure measurement Repeated automated office BP readings may improve the reproducibility of BP measurement. If the patient is seated alone and unobserved, unattended automated office BP measurement may reduce or eliminate the ‘white-coat’ effect, and unattended automated office BP measurements are usually lower than conventional office BP measurements, and more similar to ambulatory daytime BP or home BP values. There is limited information on the prognostic value of unattended automated office BP measurements.4

4.7.2.3 Ambulatory blood pressure monitoring ABPM is the average of repeated automated measurements of BP during the daytime, night-time, and over 24 h. ABPM is a better pre- dictor of hypertension-mediated organ damage (HMOD) and clinical outcomes than office BP, and identifies ‘white-coat’ hypertension and masked hypertension (see below). Diagnostic thresholds for hypertension are lower with ABPM than office BP (Table 12).4

4.7.2.4 Home blood pressure monitoring Home BP is the average of all BP readings performed with a validated semiautomatic monitor, for at least 3 consecutive days (ideally 6 - 7 days), with readings in the morning and evening, taken seated in a quiet room after 5 min of rest. Home BP monitoring (HBPM) thresholds for the diagnosis of hypertension are lower than those for office BP (Table 12). Patient self-monitoring may have a beneficial effect on medication adherence and BP control.4 Clinical indications for ambulatory or home monitoring are shown in Table 15.

4.7.3 Screening and diagnosis of hypertension Ideally, all adults should be screened for the presence of hypertension,578,579 but most countries lack the required resources and infrastructure. Formally, these guidelines recommend opportunistic screening at least in susceptible individuals, such as those who are overweight or have a family history of hypertension (see section 3.1).

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Table 12 Categories for conventionally measured seated office blood pressurea

Category SBP (mmHg) DBP (mmHg) Optimal <120 and <80 Normal 120129 and/or 8084 High-normal 130139 and/or 8589 Grade 1 hypertension 140159 and/or 9099 Grade 2 hypertension 160179 and/or 100109 Grade 3 hypertension >_180 and/or >_110 Isolated systolic hypertensionb >_140 and <90 BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure. aBP category is defined according to seated clinic BP and by the highest level of BP, whether systolic or diastolic. bIsolated systolic hypertension is graded 1, 2, or 3 according to SBP values in the ranges indicated.

Table 13 Definitions of hypertension according to office, ambulatory, and home blood pressure

Category SBP (mmHg) DBP (mmHg) Office BPa >_140 and/or >_90 Ambulatory BP

Daytime (or awake) mean >_135 and/or >_85 Night-time (or asleep) mean >_120 and/or >_70 24-h mean >_130 and/or >_80 Home BP mean >_135 and/or >_85 BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure. aRefers to conventional office BP rather than unattended office BP. Table 14 Considerations in blood pressure measurement

Patients should be seated comfortably in a quiet environment for 5 min before BP measurements. Three BP measurements should be recorded, 12 min apart, and additional measurements if the first two readings differ by >10 mmHg. BP is recorded as the average of the last two BP readings. Additional measurements may have to be performed in patients with unstable BP values due to arrhythmias, such as in patents with AF, in whom manual auscultatory methods should be used as most automated devices have not been validated for BP measurement in AF. Use a standard bladder cuff (1213 cm wide and 35 cm long) for most patients, but use larger and smaller cuffs for larger (arm circumference >32 cm) and smaller (arm circumference <26 cm) arms, respectively. The cuff should be positioned at the level of the heart with the back and arm supported, to avoid muscle contraction and isometric-exercisedependant increases in BP. When using auscultatory methods, use phase I and V (sudden reduction/ disappearance) Korotkoff sounds to identify SBP and DBP, respectively. Measure BP in both arms at the first visit to detect possible between-arm differences. Use the arm with the higher value as the reference. Measure BP 1 min and 3 min after standing from the seated position in all patients at the first measurement to exclude orthostatic hypotension. Lying and standing BP measurements should also be considered in subsequent visits in older people, in people with DM, and in other conditions in which orthostatic hypotension may frequently occur. Initial orthostatic hypotension may occur <1 min after standing and may be difficult to detect with conventional measurement techniques. Record heart rate and use pulse palpation to exclude arrhythmia.

AF = atrial fibrillation; BP = blood pressure; DBP = diastolic blood pressure; DM = diabetes mellitus; SBP = systolic blood pressure. .......................................................................................................

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