Last reviewed: June 2018
Last updated: January  2018

US guidelines recommend lowering diagnostic threshold for hypertension to 130/80

Almost half the US adult population (46%) will qualify for a diagnosis of hypertension under updated guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC). The guidelines recommend:

  • A new threshold for diagnosing hypertension of 130 mmHg systolic or 80 mmHg diastolic blood pressure (adults with systolic of 130-139 mmHg or diastolic of 80-89 mmHg would previously have been classified as having prehypertension). The new blood pressure categories are: elevated (120-129/<80 mmHg); stage 1 hypertension (130-139/80-89 mmHg); and stage 2 hypertension (≥140/90 mmHg).

  • Overall cardiovascular risk should be used to guide decisions on whether to treat in patients with stage 1 hypertension. Antihypertensives are now recommended for primary prevention of cardiovascular disease in any patient with stage 1 hypertension whose 10-year atherosclerotic cardiovascular disease risk score is 10% or higher.

  • The blood pressure goal for most patients is now 130/80 mmHg (previously 140/90 mmHg).

Publication of the guidelines has prompted widespread debate, with some expert commentators highlighting the disparities between these new AHA/ACC recommendations and the less aggressive approach to diagnosis and treatment of hypertension set out in the 2014 JNC8 guidelines. Listen to our podcast for more on the controversy. BMJ Best Practice Podcast: hypertension

Original source of update



History and exam

Key diagnostic factors

  • BP ≥140/90 mmHg
  • retinopathy

Other diagnostic factors

  • headache
  • visual changes
  • dyspnea
  • chest pain
  • sensory or motor deficit

Risk factors

  • obesity
  • sodium intake >1.5 g/day
  • aerobic exercise <3 times/week
  • low fruit and vegetable intake
  • moderate/high alcohol intake
  • metabolic syndrome
  • diabetes mellitus
  • black ancestry
  • age >60 years
  • family history of hypertension or coronary artery disease
  • dyslipidemia
  • sleep apnea

Diagnostic investigations

1st investigations to order

  • ECG
  • fasting metabolic panel with estimated GFR
  • fasting lipid panel
  • urinalysis
  • Hb
  • TSH
Full details

Investigations to consider

  • plasma renin activity (PRA)
  • plasma aldosterone
  • renal duplex ultrasound/MRA renal arteries/CT angiography
  • 24-hour urine pheochromocytoma screen
  • plasma fractionated metanephrines
  • 24-hour urine free cortisol
  • sleep study
  • echocardiography
Full details

Treatment algorithm


Authors VIEW ALL

Internal Medicine and Assistant Area Medical Director

Kaiser Permanente

Los Angeles



JB declares that he has no competing interests.

Dr Jeffrey Brettler would like to gratefully acknowledge Dr Joel Handler, Dr Jonathan N. Bella, Dr Moustapha Atoui, Dr Liran Blum, and Dr Michael A. Spinelli, previous contributors to this topic. JH, JNB, MA, LB, and MAS declare that they have no competing interests.

Peer reviewers VIEW ALL

Clinical Senior Lecturer in Clinical Pharmacology and Honorary Consultant Physician

University of Dundee




IM is an elected member of the British Hypertension Society Executive Committee.

Associate Professor

Department of Cardiology

University of Texas MD Anderson Cancer Center




SWY declares that he has no competing interests.

Director Barts Blood Pressure Centre of Excellence

NHS Reader in Cardiovascular Medicine

Department of Clinical Pharmacology

William Harvey Heart Centre




ML is a consultant for ROX Medical. ML receives honorarium from Cardiosonic, St. Jude Medical, and institutional grant/research support from Medtronic.

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