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Description: Update of the 2007 U.S. Preventive Services Task Recommendation: The USPSTF recommends screening for
Force (USPSTF) reafrmation recommendation statement on high blood pressure in adults aged 18 years or older. (A
screening for high blood pressure in adults. recommendation)
The USPSTF recommends obtaining measurements outside of
the clinical setting for diagnostic conrmation before starting
Methods: The USPSTF reviewed the evidence on the diagnostic
treatment.
accuracy of different methods for conrming a diagnosis of hy-
pertension after initial screening and the optimal rescreening in- Ann Intern Med. 2015;163:778-786. doi:10.7326/M15-2223 www.annals.org
terval for diagnosing hypertension. For author afliation, see end of text.
* For a list of USPSTF members, see the Appendix (available at www.annals
.org).
Population: This recommendation applies to adults aged 18 This article was published online rst at www.annals.org on 13 October
years or older without known hypertension. 2015.
778 Annals of Internal Medicine Vol. 163 No. 10 17 November 2015 www.annals.org
Recommendation Screen for high blood pressure; obtain measurements outside of the clinical setting for diagnostic confirmation.
Grade: A
Persons at increased risk for high blood pressure are those who have high-normal blood pressure (130139/8589 mm Hg), those
Risk Assessment
who are overweight or obese, and African Americans.
Office measurement of blood pressure is done with a manual or automated sphygmomanometer. Proper protocol is to use the mean
of 2 measurements taken while the patient is seated, allow for 5 min between entry into the office and blood pressure
Screening Tests measurement, use an appropriately sized arm cuff, and place the patients arm at the level of the right atrium. Multiple
measurements over time have better positive predictive value than a single measurement.
Ambulatory and home blood pressure monitoring can be used to confirm a diagnosis of hypertension after initial screening.
Adults aged 40 y and persons at increased risk for high blood pressure should be screened annually. Adults aged 18 to 39 y with
Screening Interval
normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 y.
For nonblack patients, initial treatment consists of a thiazide diuretic, calcium-channel blocker, angiotensin-converting enzyme
Treatment and inhibitor, or angiotensin-receptor blocker. For black patients, initial treatment is thiazide or a calcium-channel blocker. Initial or add-
Interventions on treatment for patients with chronic kidney disease consists of either an angiotensin-converting enzyme inhibitor or an
angiotensin-receptor blocker (not both).
Balance of Benefits
The net benefit of screening for high blood pressure in adults is substantial.
and Harms
For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please
go to www.uspreventiveservicestaskforce.org.
The USPSTF also assessed the accuracy of these blood Screening Tests
pressure measurements and methods in conrming the Ofce Blood Pressure Measurement
diagnosis of hypertension. In addition, it reviewed data Ofce measurement of blood pressure is most
on optimal screening intervals for diagnosing hyperten- commonly done with a manual or automated sphygmo-
sion in adults. manometer. Little research has been done on the best
Benets of Early Detection and Treatment approach to measuring blood pressure in the ofce set-
ting. Most clinical trials of hypertension treatment, at a
The USPSTF found good evidence that screening
minimum, used the mean of 2 measurements taken
for and treatment of high blood pressure in adults sub-
while the patient was seated (some used the mean of
stantially reduces the incidence of cardiovascular
the second and third measurements), allowed for at
events.
least 5 minutes between entry into the ofce and blood
Harms of Early Detection and Treatment pressure measurement, used an appropriately sized
The USPSTF found good evidence that screening arm cuff, and placed the patient's arm at the level of the
for and treatment of high blood pressure has few major right atrium during measurement. Multiple measure-
harms. ments over time have better positive predictive value
USPSTF Assessment for hypertension than a single measurement. Auto-
The USPSTF concludes with high certainty that the mated ofce blood pressure, which is an average of
net benet of screening for high blood pressure in multiple automated measurements taken while the pa-
adults is substantial. tient is alone in a room, may yield results similar to
those of daytime ABPM (4, 5). Blood pressure is af-
fected by various short-term factors, such as emotions,
CLINICAL CONSIDERATIONS stress, pain, physical activity, and drugs (including
Patient Population Under Consideration caffeine and nicotine). In addition to within-patient tem-
This recommendation applies to adults aged 18 poral variability, isolated clinic hypertension in the
years or older without known hypertension. medical setting and in the presence of medical person-
www.annals.org Annals of Internal Medicine Vol. 163 No. 10 17 November 2015 779
Figure 2. Proportion of elevated ofce blood pressure readings that are conrmed as hypertension by ABPM or HBPM.
ABPM
Kario, 2014 (6) 24-h 0.89 (0.850.93) 239
Inden et al, 1998 (7) 24-h 0.88 (0.830.92) 232
Pierdomenico et al, 1995 (8) 24-h 0.79 (0.740.84) 255
Khoury et al, 1992 (9) 24-h 0.52 (0.430.60) 131
Hozawa et al, 2002 (10) 24-h 0.35 (0.270.42) 150
Myers, 2010 (11) Daytime 0.93 (0.870.99) 69
Hond et al, 2003b (12) Daytime 0.92 (0.890.96) 247
Gustavsen et al, 2003 (13) Daytime 0.90 (0.880.93) 420
Zawadzka et al, 1998 (14) Daytime 0.86 (0.830.90) 410
Verdecchia et al, 1995 (15) Daytime 0.81 (0.790.83) 1333
Graves and Grossardt, 2010 (16) Daytime 0.79 (0.740.83) 313
Celis et al, 2002 (17) Daytime 0.78 (0.740.82) 419
Manning et al, 1999 (18) Daytime 0.77 (0.710.83) 186
Nasothimiou et al, 2012 (19) Daytime 0.77 (0.730.81) 361
Fogari et al, 1996 (20) Daytime 0.74 (0.680.80) 221
Ungar et al, 2004 (21) Daytime 0.74 (0.700.78) 388
Gerc et al, 2000 (22) Daytime 0.65 (0.620.67) 1466
Pessanha et al, 2013 (23) Daytime 0.61 (0.560.67) 336
Martnez et al, 1999 (24) Daytime 0.61 (0.550.66) 345
Talleruphuus et al, 2006 (25) Daytime 0.54 (0.440.63) 108
Zabludowski and Rosenfeld, 1992 (26) Daytime 0.47 (0.400.55) 171
Cuspidi et al, 2011 (27) Nighttime 0.95 (0.930.97) 658
HBPM
Hond et al, 2003b (12) HBPM 0.84 (0.800.89) 247
Kario, 2014 (6) HBPM 0.84 (0.790.88) 239
Toyama et al, 2008 (28) HBPM 0.83 (0.760.90) 100
Nasothimiou et al, 2012 (19) HBPM 0.76 (0.720.81) 361
Tanabe et al, 2008 (29) HBPM 0.51 (0.430.58) 156
Hozawa et al, 2002 (10) HBPM 0.45 (0.370.53) 150
0 0.5 1
ABPM = ambulatory blood pressure monitoring; HBPM = home blood pressure monitoring; PPV = positive predictive value.
nel (known as white coat hypertension) is well- across studies, there was signicant discordance be-
documented. Epidemiologic data suggest that 15% to tween the ofce diagnosis of hypertension and 12- and
30% of the population believed to have hypertension 24-hour average blood pressures using ABPM, with sig-
may have lower blood pressure outside of the ofce nicantly fewer patients requiring treatment based on
setting (1). The disadvantages of diagnosing hyperten- ABPM (Figure 2) (30). Elevated ambulatory systolic
sion solely in the ofce setting include measurement blood pressure was consistently and signicantly asso-
errors, the limited number of measurements that can ciated with increased risk for fatal and nonfatal stroke
be made conveniently, and the confounding risk for and cardiovascular events, independent of ofce blood
isolated clinic hypertension. pressure (Figure 3) (30). For these reasons, the USPSTF
recommends ABPM as the reference standard for con-
Ambulatory and Home Blood Pressure Monitoring rming the diagnosis of hypertension.
In addition to ofce blood pressure measurement, Good-quality evidence suggests that conrmation
ABPM and HBPM may be used to conrm a diagnosis of hypertension with HBPM may be acceptable. Several
of hypertension after initial screening. Ambulatory studies showed that elevated home blood pressure
blood pressure monitoring devices are small, portable was signicantly associated with increased risk for car-
machines that record blood pressure at regular inter- diovascular events, stroke, and all-cause mortality, in-
vals over 12 to 24 hours while patients go about their dependent of ofce blood pressure (Figure 4) (38 41).
normal activities and while they are sleeping. Measure- However, fewer studies have compared HBPM with of-
ments are typically taken at 20- to 30-minute intervals. ce blood pressure measurement, so the evidence is
Home blood pressure measurement devices are fully not as substantial as it is for ABPM (1). Therefore, the
automated oscillometric devices that record measure- USPSTF considers ABPM to be the reference standard
ments taken from the patient's brachial artery. Many of for conrming the diagnosis of hypertension. However,
these devices are available for retail purchase, and the USPSTF acknowledges that the use of ABPM may
some have undergone technical validation according be problematic in some situations. Home blood pres-
to recommended protocols. sure monitoring using appropriate protocols is an alter-
The USPSTF found convincing evidence that ABPM native method of conrmation if ABPM is not available.
is the best method for diagnosing hypertension. Al- Measurements from the ofce, HBPM, and ABPM must
though the criteria for establishing hypertension varied be interpreted with care and in the context of the indi-
780 Annals of Internal Medicine Vol. 163 No. 10 17 November 2015 www.annals.org
Figure 3. Risk for cardiovascular outcomes and death: 24-h ambulatory monitoring of systolic blood pressure, adjusted for
ofce blood pressure.
CV events or mortality
Dolan et al, 2005 (33) CV mortality 1.19 (1.131.27)
Gasowski et al, 2008 (37) CV mortality 1.42 (1.141.77)
Ohkubo et al, 2005 (31) CV mortality 1.27 (1.041.55)
Staessen et al, 1999 (32) CV mortality 1.11 (0.881.40)
Clement et al, 2003 (35) MI or stroke, fatal and nonfatal 1.30 (1.101.55)
Hermida et al, 2011 (36) Major CV events (CV death, MI, or stroke) 1.33 (1.171.52)
Stroke
Dolan et al, 2005 (33) Stroke, fatal 1.28 (1.151.43)
Mesquita-Bastos et al, 2010 (34) Stroke, fatal or nonfatal 1.37 (1.201.56)
Ohkubo et al, 2005 (31) Stroke, fatal or nonfatal 1.40 (1.211.62)
Staessen et al, 1999 (32) Stroke, fatal or nonfatal 1.36 (1.041.79)
All-cause mortality
Clement et al, 2003 (35) All-cause mortality 1.02 (0.861.20)
Dolan et al, 2005 (33) All-cause mortality 1.13 (1.081.19)
Staessen et al, 1999 (32) All-cause mortality 1.09 (0.921.29)
0.5 1 2
Weights are from random-effects analysis. CV = cardiovascular; HF = heart failure; HR = hazard ratio; MI = myocardial infarction.
www.annals.org Annals of Internal Medicine Vol. 163 No. 10 17 November 2015 781
Figure 4. Risk for cardiovascular outcomes and death: home monitoring of systolic blood pressure, adjusted for ofce blood
pressure.
CV events or mortality
Fagard et al, 2005 (38) CV events (stroke, MI, or CV death) 1.17 (1.021.33)
Ohkubo et al, 1998 (39) CV mortality 1.23 (1.001.51)
Stroke
Asayama et al, 2006 (40) Stroke/TIA (first) 1.39 (1.221.59)
All-cause mortality
Niiranen et al, 2010 (41) All-cause mortality (adjusted) 1.22 (1.091.37)
0.5 1 2
Weights are from random-effects analysis. CV = cardiovascular; HR = hazard ratio; MI = myocardial infarction; TIA = transient ischemic attack.
1y 2y 3y 4y 5y
Weighted mean incidence of hypertension (range), % 2.5 (2.54.4) 7.7 (1.212.3) 14.2 (6.624.9) 12.4 (2.123.7) 13.8 (2.128.4)
Studies (participants), n 2 (17 740) 6 (76 753) 6 (25 443) 5 (25 778) 16 (54 240)
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Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice