This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for high blood pressure, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition1.
Summary of Recommendation
|
Clinical Considerations Scientific Evidence Recommendations of Others References Members of the Task Force Contact the Task Force Available Products| Task Force Ratings Strength of Recommendations and Quality of Evidence |
Hypertension is usually defined in adults as a SBP of 140 mm Hg or higher, or a DBP of 90 mm Hg or higher.3 Data from the Third National Health and Nutrition Survey (NHANES III) suggest that an estimated 43 million American adults older than 25 have hypertension and that it is more common in African Americans and the elderly than in other groups. In the United States, hypertension is responsible for 35 percent of all myocardial infarctions and strokes, 49 percent of all episodes of heart failure, and 24 percent of all premature deaths.4 Additional complications of hypertension include end-stage renal disease, retinopathy, and aortic aneurysm.4-6
In 1998, an estimated $109 billion was spent on the health care of patients with hypertension and its complications; $22 billion of this total was spent on the treatment of hypertension alone.7
Hypertension in children has been defined as blood pressure levels that are above the 95th percentile based on age, sex, and height-specific values derived from large cohort studies of children.8 No studies have examined the association between elevated blood pressure in children and adolescents and the future risk for cardiovascular events. Prospective cohort studies have shown that, compared with children who have normal blood pressure, children who have hypertension are more likely to have high blood pressure as young adults.9,10
Among children with hypertension, the prevalence of secondary hypertension is estimated to be 28 percent compared with a prevalence of 1 percent to 5 percent in adults.11 However, there are limited good data on the prevalence or incidence of treatable secondary causes of hypertension among children and adults in the primary care setting, and there are no population-level data available to estimate the true incidence or prevalence of secondary hypertension in adults or children.
Office blood pressure measurement (using an appropriate upper arm cuff with either mercury, calibrated aneroid, or validated electronic sphygmomanometer) is the standard screening test for hypertension. When performed correctly, sphygmomanometry provides a measure of blood pressure that is highly correlated with intra-arterial measurement and highly predictive of cardiovascular risk.12 However, office blood pressure measurements exhibit great variability and may not represent the patient's usual blood pressure outside the clinical setting.
Ambulatory blood pressure monitoring provides a measure of average blood pressure over 24 hours as opposed to the isolated values obtained in office checks. Two recent reviews of good-quality cohort studies found that ambulatory blood pressure measurements correlate better with left ventricular mass and cardiovascular disease than do office blood pressure measurements.13,14 Ambulatory blood pressure measurement was found to be a better predictor of clinical cardiovascular outcome than clinic-based approaches.15-17 Another review found blood pressure measurements obtained through ambulatory devices more closely predictive of risk for target end organ damage than self- or office blood pressure measurements.18
Due to the limitations in the reliability of blood pressure measurements, experts commonly recommend that clinicians diagnose hypertension only after obtaining 2 or more elevated readings at 2 or more office visits at intervals of 1 to several weeks.3,13
Although no studies have examined the direct effect of screening for elevated blood pressure on clinical outcomes, many trials have demonstrated a beneficial effect of treating patients who were enrolled on the basis of elevated blood pressures detected during screening examinations. The risks associated with elevated blood pressure and the potential benefits of screening and subsequent treatment depend both on the degree of blood pressure elevation and on the presence of other cardiovascular risk factors, such as age, sex, lipid disorders, smoking, and diabetes. Although the benefits of treatment generally correlate with achieving a decrease in blood pressure, recent trials suggest the degree of blood pressure reduction is not always a valid intermediate endpoint for predicting the benefits of treatment. One study showed that the 50 percent reduction in heart failure among patients receiving chlorthalidone compared with doxazosin could not be explained by the 2 mm Hg to 3 mm Hg difference in SBP between the 2 agents.19
Evidence is emerging that antihypertensive agents differ in efficacy in reducing future cardiovascular events. For example, one trial has shown that, for high-risk hypertensive patients, chlorthalidone (a diuretic) may be superior to amlodipine (a calcium-channel blocker) or lisinopril (an angiotensin-converting enzyme inhibitor).20
Several trials that examined the effectiveness of antihypertensive medications in adults with severe (Stage 3) hypertension suggest that treatment reduces the odds of congestive heart failure by 86 percent.21 Among patients with mild to moderate elevations in blood pressure (Stages 1 and 2), treatment resulted in reduced rates of stroke among adults younger than 60. Patients older than 60 achieved further reductions in total mortality, including reductions in CVD death, stroke, coronary artery disease events, and congestive heart failure. A systematic review of 8 trials that examined the effects of treating isolated systolic hypertension in the elderly found that active treatment reduced both stroke and coronary heart disease events by 30 percent, CVD by 18 percent, and total mortality by 13 percent.22 The number needed to treat over 5 years to prevent 1 cardiovascular event was 18 for men and 38 for women.
The relative benefit of treating high blood pressure appears similar across different levels of cardiovascular risk. As a result, individuals with higher absolute risk for experiencing future adverse cardiovascular events because of other coexisting risk factors experience greater absolute benefit from blood pressure reduction than those at lower risk for future adverse cardiovascular events. This benefit appears to hold true across all age groups and for reduction in both systolic and diastolic blood pressure.
The effect of more aggressive blood pressure treatment goals in patients within the general population has not been well studied. Patients with diabetes appear to derive additional benefit when blood pressure treatment goals are set below 140/90 mm Hg. In the United Kingdom Prospective Diabetes Study (UKPDS), patients with diabetes who were randomized to more aggressive blood pressure reduction (mean blood pressure of 144/82 mm Hg) were found to reduce the number of events of any diabetes-related clinical endpoint by 24 percent and to reduce diabetes-related deaths by 32 percent, compared with patients in the less aggressive reduction arm (mean blood pressure of 154/87).23 Similar effects were observed in the Hypertension Optimal Treatment (HOT) Trial, which showed that more aggressive treatment of blood pressure in diabetic patients reduced major cardiovascular events by 49 percent.24 The few trials that have examined the effect of aggressive blood pressure reduction in patients with renal insufficiency or renal failure found mixed results.
No studies have examined the effects of nonpharmacological therapies (e.g., weight reduction, increased physical activity, sodium reduction, potassium supplementation, decreased alcohol intake, and stress management) on CVD events. A number of short-term randomized controlled trials (RCTs), however, have studied the effects of nonpharmocological therapies on blood pressure. A systematic review found that interventions to promote weight loss lowered blood pressure.25 Evidence has also shown moderate physical activity to be more effective than vigorous activity in reducing SBP.26 Several studies have demonstrated that reducing dietary sodium intake lowers blood pressure among people with hypertension.27,28 In a systematic review of the effect of oral potassium supplementation on blood pressure, potassium supplementation (60 mmol or more) was estimated to lower SBP by 3.1 mm Hg and DBP by 2.0 mm Hg.29 Among patients whose alcohol consumption is high (20 to 40 standard drinks per week), reducing alcohol consumption by at least 50 percent produced a 3.3 mm Hg reduction in SBP and 2.0 mm Hg reduction in DBP.30 Evidence on the effects of stress management suggests stress reduction/relaxation and cognitive therapy-based interventions lower blood pressure. However, the actual benefit of stress management remains unclear because many of the trials included in the review were of only fair quality. Evidence is insufficient to determine the combined impact of multiple, simultaneous nonpharmacological interventions.
While no RCTs have examined the effects of pharmacological interventions on blood pressure in children, several uncontrolled short-term trials found that various agents could decrease blood pressure over several days to 4 weeks. No longer-term studies of the effects of medications in children are available. Few studies have evaluated the effects of nonpharmacological interventions in reducing elevated blood pressure in children.
Initially, some studies suggested that screening and labeling individuals with hypertension may result in adverse psychological effects and transient increases in absenteeism.31-36 However, studies that have measured psychological well-being have found inconsistent effects of screening and diagnosis. Several cohort studies showed mixed effects on rates of absenteeism, and the causes of absenteeism were not well established.36,37 In children, too few studies have examined the potential harms of screening to draw conclusions.
Potential adverse effects of drugs—some sufficiently bothersome to interfere with adherence to the medication regimen—are common, but serious adverse drug reactions are rare. Physicians should take adverse effects into consideration when deciding whether to treat and which treatment to use.
Recommendations of the Joint National Committee (JNC) 6 call for routine blood pressure measurement at least once every 2 years for adults with a DBP below 85 mm Hg and a SBP below 130 mm Hg.3 JNC-7 guidelines that update the JNC-6 guidelines for the treatment of high blood pressure can be accessed at www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm. Similar recommendations have been issued by the American Heart Association (AHA) for adults beginning at age 20.38 The Canadian Task Force on Preventive Health Care is currently updating its recommendations on screening for elevated blood pressure. The American Academy of Family Physicians strongly recommends periodic measurement of blood pressure in patients older than 21.39 The American College of Obstetricians and Gynecologists recommends measuring blood pressure annually or as appropriate for women 13 and older.40 The American Academy of Pediatrics,41 the National Heart, Lung, and Blood Institute,42 the AHA,43 Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents,44 and the American Medical Association45 recommend regular blood pressure measurements starting at the age of 3 years. The AAP further recommends against universal neonatal blood pressure screenings.46
1. Sheridan S, Pignone M, Donahue K. Screening for high blood pressure: A Review of the Evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2003;25:151-8.
2. U.S. Preventive Services Task Force. Screening for high blood pressure. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996. p. 39-51.
3. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157:2413-46.
4. Padwal R, Straus SE, McAlister FA. Evidence based management of hypertension. Cardiovascular risk factors and their effects on the decision to treat hypertension: evidence based review. BMJ 2001;322(7292):977-80.
5. Klein R, Klein BE, Moss SE. The relation of systemic hypertension to changes in the retinal vasculature: the Beaver Dam Eye Study. Trans Am Ophthalmol Soc 1997;95:329-48; discussion 348-50.
6. Lederle FA, Johnson GR, Wilson SE, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 1997;126:441-9.
7. Hodgson TA, Cai L. Medical care expenditures for hypertension, its complications, and its comorbidities. Med Care 2001;39:599-615.
8. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990;335:827-38.
9. Adrogue HE, Sinaiko AR. Prevalence of hypertension in junior high school-aged children: effect of new recommendations in the 1996 Updated Task Force Report. Am J Hypertens 2001;14(5 Pt 1):412-4.
10. Bradley CB, Harrell JS, McMurray RG, et al. Prevalence of high cholesterol, high blood pressure, and smoking among elementary schoolchildren in North Carolina. N C Med J 1997;58:362-7.
11. Feld LG, Springate JE. Hypertension in children. Curr Probl Pediatr 1988;18:317-73.
12. Reeves RA. Does this patient have hypertension? How to measure blood pressure. JAMA 1995;273:1211-8.
13. McAlister FA, Straus SE. Evidence based treatment of hypertension. Measurement of blood pressure: an evidence based review. BMJ 2001;322:908-11.
14. Myers MG, Haynes RB, Rabkin SW. Canadian hypertension society guidelines for ambulatory blood pressure monitoring. Am J Hypertens 1999;12(11 Pt 1):1149-57.
15. Verdecchia P, Porcellati C, Schillaci G, et al. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994;24:793-801.
16. Khattar RS, Swales JD, Banfield A, Dore C, Senior R, Lahiri A. Prediction of coronary and cerebrovascular morbidity and mortality by direct continuous ambulatory blood pressure monitoring in essential hypertension. Circulation 1999;100:1071-6.
17. Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA 1999;282:539-46.
18. Appel LJ, Robinson KA, Guallar EG, et al. Utility of Blood Pressure Monitoring Outside of the Clinic Setting. Evidence Report/Technology Assessment Number 63. AHRQ Publication No. 03-E004, November 2002. Agency for Healthcare Research and Quality, Rockville, MD.
19. The ALLHAT officers and coordinators for the ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2000;283(15):1967-75.
20. The ALLHAT officers and coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981-97.
21. Gueyffier F, Froment A, Gouton M. New meta-analysis of treatment trials of hypertension: improving the estimate of therapeutic benefit. J Hum Hypertens 1996;10(1):1-8.
22. Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000;355:865-72.
23. UK Prospective Diabetes Study Group.Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703-13.
24. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998;351(9118):1755-62.
25. Leiter LA, Abbott D, Campbell NR, Mendelson R, Ogilvie RI, Chockalingam A. Lifestyle modifications to prevent and control hypertension. 2. Recommendations on obesity and weight loss. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada. CMAJ 1999;160(9 Suppl):S7-12.
26. Cleroux J, Feldman RD, Petrella RJ. Lifestyle modifications to prevent and control hypertension. 4. Recommendations on physical exercise training. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada. CMAJ 1999;160(9 Suppl):S21-8.
27. Cutler JA, Follmann D, Allender PS. Randomized trials of sodium reduction: an overview. Am J Clin Nutr 1997;65(2 Suppl):643S-51S.
28. Midgley JP, Matthew AG, Greenwood CM, Logan AG. Effect of reduced dietary sodium on blood pressure: a meta-analysis of randomized controlled trials. JAMA 1996;275(20):1590-7.
29. Whelton PK, He J, Cutler JA, et al. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA 1997;277(20):1624-32.
30. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38(5):1112-7.
31. Ameling EH, de Korte DF, Man in 't Veld A. Impact of diagnosis and treatment of hypertension on quality of life: a double-blind, randomized, placebo-controlled, cross-over study of betaxolol. J Cardiovasc Pharmacol 1991;18(5):752-60.
32. Mann AH. The psychological effect of a screening programme and clinical trial for hypertension upon the participants. Psychol Med 1977;7(3):431-8.
33. Ambrosio GB, Dissegna L, Zamboni S, Santonastaso P, Canton G, Dal Palu C. Psychological effects of hypertension labeling during a community survey. A two-year follow-up. J Hypertens Suppl 1984;2(3):S171-3.
34. Rudd P, Price MG, Graham LE, et al. Consequences of worksite hypertension screening. Differential changes in psychosocial function. Am J Med 1986;80(5):853-60.
35. Rudd P, Price MG, Graham LE, et al. Consequences of worksite hypertension screening. Changes in absenteeism. Hypertension 1987;10(4):425-36.
36. Rastam L, Ryden L. Work absenteeism and well-being in patients treated for hypertension. Eur Heart J 1987;8(9):1024-31.
37. Alderman MH, Davis TK. Hypertension control at the work site. J Occup Med 1976;18(12):793-6.
38. Pearson TA, Blair SN, Daniels SR, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update. Circulation 2002;106:388-91.
39. American Academy of Family Physicians (AAFP). Age Charts for Periodic Health Examinations. Revision 5.1 ed. Vol. 2002; 2001.
40. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. 2nd ed. Washington, DC: ACOG; 2002. p. 121-34.
41. Recommendations for preventive pediatric health care. Committee on Practice and Ambulatory Medicine. Pediatrics 1995;96(2 Pt 1):373-4.
42. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics 1987;79(1):1-25.
43. American Heart Association (AHA). High Blood Pressure in Children. Vol. 2002; 2002.
44. Bright Futures: guidelines for health supervision of infants, children, and adolescents. Arlington: National Center for Education in Maternal and Child Health; 2002.
45. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS). Vol. 2002; 1997.
46. American Academy of Pediatrics Committee on Fetus and Newborn: Routine evaluation of blood pressure, hematocrit, and glucose in newborns. Pediatrics 1993;92(3):474-6.
Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.PH., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, MD); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H.* (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Professor of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H.* (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); C. Tracy Orleans, Ph.D. (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H.* (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N.* (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H. (Professor and Chairman, Brookdale Department of Geriatrics, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine and Director of Research Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).
*Members of the USPSTF at the time this recommendation was finalized.
Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: uspstf@ahrq.gov.
This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.preventiveservices.ahrq.gov.
Current as of July 2003
Internet Citation:
U.S. Preventive Services Task Force. Screening for High Blood Pressure: Recommendations and Rationale. July 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/highbloodsc/hibloodrr.htm
USPSTF Topic Index
USPSTF Clinical Categories
U.S. Preventive Services Task Force (USPSTF)
Clinical Information
AHRQ Home Page