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Typical tests performed
System Tests
Renal Microscopic urinalysis, proteinuria, BUN and/or creatinine
Endocrine Serum sodium, potassium, calcium, TSH
Metabolic Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides
Other Hematocrit, electrocardiogram, and chest radiograph
Sources: Harrison's principles of internal medicine[1] others[2][3][4][5][6]

Hypertension is diagnosed on the basis of a persistently high blood pressure. Traditionally,[7] this requires three separate sphygmomanometer measurements at one monthly intervals.[8] Initial assessment of the hypertensive people should include a complete history and physical examination. With the availability of 24-hour ambulatory blood pressure monitors and 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, current best practice is to follow up a single raised clinic reading with ambulatory measurement, or less ideally with home blood pressure monitoring over the course of 7 days.[7] 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 an abnormally high blood pressure readings with a blood pressure cuff while intra arterial measurements of blood pressure are normal.[9]

Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on risk factors and other symptoms, if present. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.[10] Laboratory tests can also be performed to identify possible causes of secondary hypertension, and to determine whether hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for diabetes and high cholesterol levels are usually performed because these conditions are additional risk factors for the development of heart disease and may require treatment.[11]

Serum creatinine is measured to assess for the presence of kidney disease, which can be either the cause or the result of hypertension. Serum creatinine alone may overestimate glomerular filtration rate and recent guidelines advocate the use of predictive equations such as the Modification of Diet in Renal Disease (MDRD) formula to estimate glomerular filtration rate (eGFR).[12] eGFR can also provides a baseline measurement of kidney function that can be used to monitor for side effects of certain antihypertensive drugs on kidney function. Additionally, testing of urine samples for protein is used as a secondary indicator of kidney disease. Electrocardiogram (EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure. It may also show whether there is thickening of the heart muscle (left ventricular hypertrophy) or whether the heart has experienced a prior minor disturbance such as a silent heart attack. A chest X-ray or an echocardiogram may also be performed to look for signs of heart enlargement or damage to the heart.[13]

Adults

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Classification (JNC7)[12] Systolic pressure Diastolic pressure
mmHg kPa mmHg kPa
Normal 90–119 12–15.9 60–79 8.0–10.5
Prehypertension 120–139 16.0–18.5 80–89 10.7–11.9
Stage 1 hypertension 140–159 18.7–21.2 90–99 12.0–13.2
Stage 2 hypertension ≥160 ≥21.3 ≥100 ≥13.3
Isolated systolic
hypertension
≥140 ≥18.7 <90 <12.0

In people aged 18 years or older hypertension is defined as a systolic and/or a diastolic blood pressure measurement consistently higher than an accepted normal value (currently 139 mmHg systolic, 89 mmHg diastolic: see table —Classification (JNC7)). Lower thresholds are used (135 mmHg systolic or 85 mmHg diastolic) if measurements are derived from 24-hour ambulatory or home monitoring.[7] Recent international hypertension guidelines have also created categories below the hypertensive range to indicate a continuum of risk with higher blood pressures in the normal range. JNC7 (2003)[12] uses the term prehypertension for blood pressure in the range 120-139 mmHg systolic and/or 80-89 mmHg diastolic, while ESH-ESC Guidelines (2007)[14] and BHS IV (2004)[15] use optimal, normal and high normal categories to subdivide pressures below 140 mmHg systolic and 90 mmHg diastolic. Hypertension is also sub-classified: JNC7 distinguishes hypertension stage I, hypertension stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly.[12] The ESH-ESC Guidelines (2007)[14] and BHS IV (2004),[15] additionally define a third stage (stage III hypertension) for people with systolic blood pressure exceeding 179 mmHg or a diastolic pressure over 109 mmHg. Hypertension is classified as "resistant" if medications do not reduce blood pressure to normal levels.[12]

Children

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Hypertension in neonates is rare, occurring in around 0.2 to 3% of neonates, and blood pressure is not measured routinely in the healthy newborn.[16] Hypertension is more common in high risk newborns. A variety of factors, such as gestational age, postconceptional age and birth weightneeds to be taken into account when deciding if a blood pressure is normal in a neonate.[16]

Hypertension occurs quite commonly in children and adolescents (2-9% depending on age, sex and ethnicity)[17] and is associated with long term risks of ill-health.[18] It is now recommended that children over the age of 3 have their blood pressure checked whenever they attend for routine medical care or checks, but high blood pressure must be confirmed on repeated visits before characterizing a child as having hypertension.[18] 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. Prehypertension in children is defined as average systolic or diastolic blood pressure that is greater than or equal to the 90th percentile, but less than the 95th percentile.[18] In adolescents, it has been proposed that hypertension and pre-hypertension are diagnosed and classified using the same criteria as in adults.[18]

Africa

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Egypt

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Asia

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China

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India

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Japan

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South Korea

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Taiwan

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Turkey

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Europe

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England

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France

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Germany

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Italy

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Scotland

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Practices are required to complete a cardiovascular disease (CVD) risk assessment in people who have been diagnosed with hypertension without confirmed CVD, after April 1, 2009. Some NHS Boards have local initiatives that allow for pharmacies to provide blood pressure monitoring services. The action to extend contracts for blood pressure monitoring services in pharmacies is being called into action. [19]

Techniques

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  • Ambulatory blood pressure monitoring (ABPM)
  • Home blood pressure monitoring (HBPM)

Thresholds

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People with a persistent blood pressure ≥140/90 mm Hg or those with a family history of high blood pressure should be given lifestyle advice that is continued even if drug therapy is started. Individuals with a systolic blood pressures >140 and/or a diastolic blood pressure >90 mm Hg, with cardiovascular disease, should be considered for a drug therapy that will reduce the blood pressure.[20]

Spain

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The Americas

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Brazil

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Canada

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Mexico

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United States

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Oceania and the Pacific

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Australia

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New Zealand

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South Pacific Islands

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References

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  1. ^ Loscalzo, Joseph; Fauci, Anthony S.; Braunwald, Eugene; Dennis L. Kasper; Hauser, Stephen L; Longo, Dan L. (2008). Harrison's principles of internal medicine. McGraw-Hill Medical. ISBN 978-0-07-147691-1.{{cite book}}: CS1 maint: multiple names: authors list (link)
  2. ^ Padwal RS; Hemmelgarn BR; Khan NA; et al. (May 2009). "The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 – blood pressure measurement, diagnosis and assessment of risk". Canadian Journal of Cardiology. 25 (5): 279–86. doi:10.1016/S0828-282X(09)70491-X. PMC 2707176. PMID 19417858. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  3. ^ Padwal RJ; Hemmelgarn BR; Khan NA; et al. (June 2008). "The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 – blood pressure measurement, diagnosis and assessment of risk". Canadian Journal of Cardiology. 24 (6): 455–63. doi:10.1016/S0828-282X(08)70619-6. PMC 2643189. PMID 18548142. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  4. ^ Padwal RS; Hemmelgarn BR; McAlister FA; et al. (May 2007). "The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 – blood pressure measurement, diagnosis and assessment of risk". Canadian Journal of Cardiology. 23 (7): 529–38. doi:10.1016/S0828-282X(07)70797-3. PMC 2650756. PMID 17534459. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  5. ^ Hemmelgarn BR; McAlister FA; Grover S; et al. (May 2006). "The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part I – Blood pressure measurement, diagnosis and assessment of risk". Canadian Journal of Cardiology. 22 (7): 573–81. doi:10.1016/S0828-282X(06)70279-3. PMC 2560864. PMID 16755312. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  6. ^ Hemmelgarn BR; McAllister FA; Myers MG; et al. (June 2005). "The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk". Canadian Journal of Cardiology. 21 (8): 645–56. PMID 16003448. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  7. ^ a b c National Clinical Guideline Centre (August 2011). "7 Diagnosis of Hypertension, 7.5 Link from evidence to recommendations". Hypertension (NICE CG 127) (PDF). National Institute for Health and Clinical Excellence. p. 102. Retrieved 2011-12-22. Cite error: The named reference "NICE127 full" was defined multiple times with different content (see the help page).
  8. ^ North of England Hypertension Guideline Development Group (1 August 2004). "Frequency of measurements". Essential hypertension (NICE CG18). National Institute for Health and Clinical Excellence. p. 53. Retrieved 2011-12-22.
  9. ^ Franklin, S. S.; Wilkinson, I. B.; McEniery, C. M. (2012 Feb). "Unusual hypertensive phenotypes: what is their significance?". Hypertension. 59 (2): 173–8. doi:10.1161/HYPERTENSIONAHA.111.182956. PMID 22184330. {{cite journal}}: Check date values in: |date= (help)
  10. ^ Luma GB, Spiotta RT (may 2006). "Hypertension in children and adolescents". Am Fam Physician. 73 (9): 1558–68. PMID 16719248. {{cite journal}}: Check date values in: |date= (help)CS1 maint: date and year (link)
  11. ^ Cite error: The named reference pmid10645931 was invoked but never defined (see the help page).
  12. ^ a b c d e Chobanian AV; Bakris GL; Black HR; et al. (December 2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  13. ^ Cite error: The named reference ABC was invoked but never defined (see the help page).
  14. ^ a b Mancia G; De Backer G; Dominiczak A; et al. (September 2007). "2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension". J. Hypertens. 25 (9): 1751–62. doi:10.1097/HJH.0b013e3282f0580f. PMID 17762635. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  15. ^ a b Williams, B.; Poulter, N. R.; Brown, M. J.; Davis, M.; McInnes, G. T.; Potter, J. F.; Sever, P. S.; Mcg Thom, S.; British Hypertension Society (2004 Mar). "Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV". Journal of Human Hypertension. 18 (3): 139–85. doi:10.1038/sj.jhh.1001683. PMID 14973512. {{cite journal}}: Check date values in: |date= (help)
  16. ^ a b Dionne JM, Abitbol CL, Flynn JT (January 2012). "Hypertension in infancy: diagnosis, management and outcome". Pediatr. Nephrol. 27 (1): 17–32. doi:10.1007/s00467-010-1755-z. PMID 21258818.{{cite journal}}: CS1 maint: date and year (link) CS1 maint: multiple names: authors list (link)
  17. ^ Din-Dzietham R, Liu Y, Bielo MV, Shamsa F (September 2007). "High blood pressure trends in children and adolescents in national surveys, 1963 to 2002". Circulation. 116 (13): 1488–96. doi:10.1161/CIRCULATIONAHA.106.683243. PMID 17846287.{{cite journal}}: CS1 maint: date and year (link) CS1 maint: multiple names: authors list (link)
  18. ^ a b c d National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents (August 2004). "The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents". Pediatrics. 114 (2 Suppl 4th Report): 555–76. doi:10.1542/peds.114.2.S2.555. PMID 15286277.{{cite journal}}: CS1 maint: date and year (link)
  19. ^ NHS Scotland. Better Heart Disease and Stroke Care Action Plan, (2009). http://www.scotland.gov.uk/Resource/Doc/277650/0083350.pdf
  20. ^ Scottish Intercollegiate Guidelines Netowrk. Risk estimation and the prevention of cardiovascular disease: A National Clinical Guideline, (2007). http://www.sign.ac.uk/pdf/sign97.pdf