Criteria for Diagnosis of Hypertension and Recommendations for Follow-Up

1. At initial presentation, patients demonstrating features of a hypertensive urgency or emergency (Supplemental Table S3) should be diagnosed as hypertensive and require immediate management (Grade D). In all other patients, at least 2 more readings should be taken during the same visit. If using AOBP, the BP calculated and displayed by the device should be used. If using non-AOBP measurement, the first reading should be discarded and the latter readings averaged.
2. If the visit 1 office BP measurement is high-normal (thresholds outlined in Section I-3) annual follow-up is recommended (Grade C).
3. If the visit 1 mean AOBP or non-AOBP measurement is high (thresholds outlined in Section I-3), a history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage (Supplemental Table S4) and associated cardiovascular risk factors (Supplemental Table S5) should be arranged within 2 visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible (Supplemental Table S6). Visit 2 should be scheduled within 1 month (Grade D).
4. If the visit 1 mean AOBP or non-AOBP SBP is ≥180 mmHg and/or DBP is ≥110 mmHg then hypertension is diagnosed (Grade D).
5. If the visit 1 mean AOBP SBP is 135-179 mmHg and/or DBP is 85-109 mmHg OR the mean non-AOBP SBP is 140-179 mmHg and/or DBP is 90-109 mmHg, out-of-office BP measurements should be performed before visit 2 (Grade C).
   1. Ambulatory BP monitoring is the recommended out-of-office measurement method (Grade D). Patients can be diagnosed with hypertension according to the thresholds outlined in Section I-3.
   2. Home BP monitoring is recommended if ambulatory BP monitoring is not tolerated, not readily available or due to patient preference (Grade D). Patients can be diagnosed with hypertension according to the thresholds outlined in Section I-3.
   3. If the out-of-office BP average is not elevated, white coat hypertension should be diagnosed and pharmacologic treatment should not be instituted (Grade C).
6. If the out-of-office measurement, although preferred, is NOT performed after visit 1, then patients can be diagnosed as hypertensive using serial office BP measurement visits if any of the following conditions are met:
   1. At visit 2, mean non-AOBP measurement (averaged across all visits) is ≥140 mmHg systolic and/or ≥90 mmHg diastolic in patients with macrovascular target organ damage, diabetes mellitus, or chronic kidney disease (glomerular filtration rate <60 mL/min/1.73m2) (Grade D);
   2. At visit 3, mean non-AOBP measurement (averaged across all visits) is ≥160 mmHg systolic or ≥100 mmHg diastolic;
   3. At visit 4 or 5, mean non-AOBP measurement (averaged across all visits) is ≥140 mmHg systolic or ≥90 mmHg diastolic.
7. Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined in Sections V, VII and VIII) (Grade D).
8. If at the last diagnostic visit the patient is not diagnosed as hypertensive and has no evidence of macrovascular target organ damage, the patient’s BP should be assessed at yearly intervals (Grade D).
9. Hypertensive patients actively modifying their health behaviors should be followed up at 3- to 6-month intervals. Shorter intervals (every 1 or 2 months) are needed for patients with higher BPs (Grade D).
10. Patients on antihypertensive drug treatment should be seen monthly or every 2 months, depending on the level of BP, until readings on 2 consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs, or target organ damage (Grade D). When the target BP has been reached, patients should be seen at 3- to 6-month intervals (Grade D).
11. Standardized office BP measurement should be used for follow-up. Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation (Grade C; new guideline).
12. Ambulatory BP monitoring or home BP is recommended for follow-up of patients with demonstrated white coat effect (Grade D; new guideline).