This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force (USPSTF). Screening for high blood pressure: recommendations and rationale. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2003 Jul 14. 12 p. [46 references].

High blood pressure (hypertension)

Prevention
Screening

Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physician Assistants
Physicians

• To summarize the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for high blood pressure and the supporting evidence
• To update the 2003 USPSTF recommendations for screening for high blood pressure

Adults aged 18 and older without known hypertension

Blood pressure measurement with sphygmomanometer

Note: Assessment of risk, screening intervals, pharmacological treatment, and nonpharmacological treatment were also considered.

• Benefits and harms of screening adults for high blood pressure
• Harms of early treatment of high blood pressure

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC): A targeted review of the literature was prepared by the Agency for Healthcare Research and Quality (AHRQ) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Availability of Companion Documents" field).

In 2006, USPSTF decided to reexamine the evidence in order to reaffirm its 2003 recommendation on screening for high blood pressure (or hypertension). The Task Force issues a reaffirmation update for a topic that the USPSTF decides to keep current because the topic is one of its priorities, is within its scope, and is a topic for which there is a compelling reason to make a recommendation. Topics in this category are well-established evidence-based standards of current medical practice. The USPSTF decided to perform a reaffirmation update because the evidence base on hypertension is strong and only large, high-quality studies would overturn such a recommendation. Such recommendations would previously have been an A or D recommendation. Therefore, a literature search for new, substantial evidence that would be sufficient to change the 2003 recommendation was performed.

Data Sources and Searches

AHRQ staff performed nonsystematic literature searches of PubMed and the Cochrane Library. They used the following search terms: hypertension, mass screening, adverse effects, and false positive results. The searches were limited to English-language studies of adult humans (age >18 years) that were published in core clinical journals between 1 October 2001 and 31 March 2006. "Core clinical journals" are a subset of 120 English language journals defined by the National Library of Medicine; it was previously known as the Abridged Index Medicus. AHRQ staff also checked reference lists of systematic reviews and other studies for possibly relevant studies.

Study Selection

In this review, studies on benefits and harms of screening and treatment of "early hypertension" were included "Early hypertension" was understood to be a blood pressure elevation that screening could reasonably identify. For this review, "early hypertension" was defined as prehypertension (systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg), hypertension detected through screening, or untreated or newly diagnosed mild to moderate hypertension (systolic blood pressure of 140 to 180 mm Hg or diastolic blood pressure of 90 to 110 mm Hg, when information was not given about how hypertension was detected). Studies in very high-risk or special populations, including patients with preexisting cardiovascular disease were excluded.

Studies of non-pregnant adults older than 18 years were included. AHRQ staff also included studies from the United States and from countries with patient populations that are generalizable to the United States. For the literature on benefits, meta-analyses; systematic reviews; and randomized, controlled trials were included. For harms, meta-analyses; systematic reviews; randomized, controlled trials; cohorts; case--control studies; and case series of large, multisite databases were included. Editorials, case reports, nonsystematic reviews, and guideline reports were excluded.

No new studies on the benefits or harms of screening for high blood pressure met inclusion criteria. Five studies evaluated the harms of early treatment of hypertension and met inclusion criteria.

Expert Consensus

Not applicable

Review

Expert Consensus

When the overall quality of the evidence is judged to be good or fair, the U.S. Preventive Services Task Force (USPSTF) proceeds to consider the magnitude of net benefit to be expected from implementation of the preventive service. Determining net benefit requires assessing both the magnitude of benefits and the magnitude of harms and weighing the two.

In making its determinations of net benefit, the USPSTF strives to consider what it believes are the general values of most people. It does this with greater confidence for certain outcomes (e.g., death) about which there is little disagreement about undesirability, but it recognizes that the degree of risk people are willing to accept to avert other outcomes (e.g., cataracts) can vary considerably. When the USPSTF perceives that preferences among individuals vary greatly, and that these variations are sufficient to make trade-off of benefits and harms a 'close-call', then it will often assign a C recommendation (see the "Recommendation Rating Scheme" field). This recommendation indicates the decision is likely to be sensitive to individual patient preferences.

The USPSTF uses its assessment of the evidence and magnitude of net benefit to make recommendations. The general principles the USPSTF follows in making recommendations are outlined in Table 5 of the companion document cited below. The USPSTF liaisons on the topic team compose the first drafts of the recommendations and rationale statements, which the full panel then reviews and edits. Recommendations are based on formal voting procedures that include explicit rules for determining the views of the majority.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

What the United States Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice

USPSTF Levels of Certainty Regarding Net Benefit

Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Peer Review. Before the U.S. Preventive Services Task Force (USPSTF) makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft systematic evidence review to 4 to 6 external experts and to federal agencies and professional and disease-based health organizations with interests in the topic. They ask the experts to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the Task Force in memo form. In this way, the Task Force can consider these external comments and a final version of the systematic review before it votes on its recommendations about the service. Draft recommendations are then circulated for comment from reviewers representing professional societies, voluntary organizations and Federal agencies. These comments are discussed before the whole USPSTF before final recommendations are confirmed.

Recommendation of Others. Recommendations for screening for high blood pressure from the following groups were discussed: the Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC) 7; the American Heart Association; the American Academy of Family Physicians; and the American College of Obstetricians and Gynecologists.

None provided

The type of evidence supporting the recommendation is not specifically stated.

Benefits of Detection and Early Treatment

The U.S. Preventive Services Task Force (USPSTF) found good evidence that treatment of high blood pressure in adults substantially decreases the incidence of cardiovascular events.

Harms of Detection and Early Treatment

The U.S. Preventive Services Task Force (USPSTF) found good evidence that screening and treatment for high blood pressure causes few major harms.

• The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.
• Recommendations are based on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.
• The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policy-makers should understand the evidence but individualize decision making to the specific patient or situation.
• Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

1996 (revised 2007 Dec 4)

United States Preventive Services Task Force - Independent Expert Panel

The U.S. Preventive Services Task Force (USPSTF) is a Federally-appointed panel of independent experts. Conclusions of the U.S. Preventive Services Task Force do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or its agencies.

United States Government

U.S. Preventive Services Task Force (USPSTF)

Corresponding Author: Ned Calonge, MD, MPH, Chair, U.S. Preventive Services Task Force, c/o Program Director, USPSTF, Agency for Healthcare Research and Quality

Task Force Members*: Ned Calonge, MD, MPH, Chair, USPSTF (Chief Medical Officer and State Epidemiologist, Colorado Department of Public Health and Environment, Denver, CO); Diana B. Petitti, MD, MPH, Vice-chair, USPSTF (Adjunct Professor, Keck School of Medicine, University of Southern California, Sierra Madre, CA); Thomas G. DeWitt, MD (Carl Weihl Professor of Pediatrics and Director of the Division of General and Community Pediatrics, Department of Pediatrics, Children's Hospital Medical Center, Cincinnati, OH); Leon Gordis, MD, MPH, DrPH (Professor, Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); Kimberly D. Gregory, MD, MPH (Director, Women's Health Services Research and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA); Russell Harris, MD, MPH (Professor of Medicine, Sheps Center for Health Services Research, University of North Carolina School of Medicine, Chapel Hill, NC); Kenneth W. Kizer, MD, MPH (President and CEO, National Quality Forum, Washington, DC); Michael L. LeFevre, MD, MSPH (Professor, Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO); Carol Loveland-Cherry, PhD, RN (Executive Associate Dean, Office of Academic Affairs, University of Michigan School of Nursing, Ann Arbor, MI); Lucy N. Marion, PhD, RN (Dean and Professor, School of Nursing, Medical College of Georgia, Augusta, GA); Virginia A. Moyer, MD, MPH (Professor, Department of Pediatrics, University of Texas Health Science Center, Houston, TX); Judith K. Ockene, PhD (Professor of Medicine and Chief of Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA); George F. Sawaya, MD (Associate Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences and Department of Epidemiology and Biostatistics, University of California, San Francisco, CA); Albert L. Siu, MD, MSPH (Professor and Chairman, Brookdale Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, MD, MPH (Executive Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); and Barbara P. Yawn, MD, MSc (Director of Research, Olmstead Research Center, Rochester, MN)

*Members of the Task Force at the time this recommendation was finalized.

Not stated

This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force (USPSTF). Screening for high blood pressure: recommendations and rationale. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2003 Jul 14. 12 p. [46 references].

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on July 11, 2003. This NGC summary was updated by ECRI Institute on November 14, 2007. The updated information was verified by the guideline developer on November 27, 2007.