What are the updated definitions of blood pressure (BP) categories and stages in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines updated their definitions of BP categories and stages. [97]

In children up to age 13 years, BP categories and stages are defined as follows:

  • Normal BP: Below 90th percentile
  • Elevated BP: From the 90th percentile or higher to less than the 95th percentile or 120/80 mm Hg to below the 95th percentile (whichever is lower) 
  • Stage 1 hypertension: From the 95th percentile or higher to less than the 95th percentile plus 12 mm Hg, or 130/80 to 139/89 mm Hg (whichever is lower) 
  • Stage 2 hypertension: The 95th percentile or higher plus 12 mm Hg, or 140/90 mm Hg or higher (whichever is lower)

In children aged 13 years or older, BP categories and stages are defined as follows:

  • Normal BP: SBP Less than 120 mm Hg and DBP less than 80 mm Hg (ie, < 120/< 80 mm Hg)
  • Elevated BP: 120/below 80 mm Hg to 129/below 89 mm Hg (ie, 120/< 80 to 129/< 80 mm Hg)
  • Stage 1 hypertension: 130/80 to 139/89 mm Hg
  • Stage 2 hypertension: At 140/90 mm Hg or higher (≥140/90 mm Hg)

The 2017 American Academy of Pediatrics (AAP) recommendations include the following [97] :

  • Measure BP yearly in all children and adolescents aged 3 years and older.
  • Evaluate BP in all children and adolescents aged 3 years and older at every healthcare visit if they are obese, are taking medications known to increase BP, have renal disease, or a history of aortic arch obstruction or coarctation, or diabetes.
  • Trained clinicians in the office setting should make a hypertension diagnosis children or adolescents in the presence of auscultatory-confirmed BP readings at or over the 95th percentile for age and height at three separate visits.
  • Perform ambulatory BP monitoring (ABPM) to confirm hypertension in children and adolescents with elevated BP measurements for 1 year or longer or with stage 1 hypertension over three clinic visits.
  • Perform ABPM in children and adolescents with suspected white coat syndrome; the diagnosis is based on a mean systolic BP (SBP) and diastolic BP below the 95th percentile and an SBP and DBP load less than 25%.
  • Children and adolescents aged 6 years and older do not need to undergo extensive evaluation for secondary causes of hypertension if there is a family history of hypertension, they are overweight/obese, and/or do not have a history or physical examination findings suggestive of a secondary cause of hypertension.
  • In children and adolescents undergoing evaluation for high BP, obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history, as well as perform a physical examination to identify findings suggestive of secondary causes of HTN.
  • At the time when pharmacologic therapy for hypertension is being considered, perform echocardiography to evaluate for cardiac target organ damage (LV mass, geometry, and function).
  • Hypertensive children and adolescents being evaluated for left ventricular hypertrophy (LVH) should not undergo electrocardiography.
  • LVH should be defined as an LV mass greater than 51 g/m 2 (males and females) for children and adolescents older than age 8 years and defined by an LV mass greater than 115 g/body surface area (BSA) (boys) or more than 95 g/BSA (girls).
  • Screening Doppler renal ultrasonography may be used to assess for potential renal artery stenosis (RAS) in normal weight children and adolescents age 8 years and older with suspected renovascular hypertension
  • Routine testing for microalbuminuria is not recommended for children and adolescents primary hypertension.
  • Nonpharmacologic and pharmacologic treatment goals in children and adolescents diagnosed with hypertension should be a reduction in SBP and DBP to below the 90th percentile and less than 130/80 mm Hg in adolescents aged 13 years and older.
  • Failure of lifestyle modifications in hypertensive children and adolescents (especially those with LVH on echocardiography, symptomatic hypertension, or stage 2 hypertension without a clearly modifiable factor) should prompt initiation of pharmacotherapy with an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), long-acting calcium channel blocker (CCB), or thiazide diuretic.
  • Evaluate children and adolescents with chronic kidney disease (CKD) for hypertension at each medical encounter. In the presence of both CKD and hypertension, treat to lower the 24-hour mean arterial pressure (MAP) below the 50th percentile by ABPM. Regardless of apparent BP control with office measures, assess BP by ABPM at least yearly to screen for masked hypertension in children and adolescents with both CKD and hypertension.
  • Evaluate for proteinuria in children and adolescents with both CKD and hypertension. If all three conditions are present, treat with an ACEI or ARB.
  • Evaluate children and adolescents with type 1 or 2 diabetes for hypertension at each medical encounter. Treat if the BP is at or over the 95th percentile or more than 130/80 mm Hg in adolescents aged 13 years and older.

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