Initial assessment
The assessment of arterial hypertension begins with correct office blood pressure measurement, following standardised technical criteria. The patient should be seated, comfortable, after at least five minutes of rest, avoiding physical exercise, caffeine and smoking in the previous thirty minutes. A validated device should be used, with an appropriately sized cuff, and the arm supported at heart level. Three consecutive measurements are taken, recording the average of the last two. At the first assessment, blood pressure should be measured in both arms, using the arm with the higher values as reference.
Classification of blood pressure values
Values below 120/70 millimetres of mercury define non-elevated blood pressure, with reassessment in three to five years being sufficient. Values between 120 and 139 for systolic pressure and 70 to 89 for diastolic pressure correspond to elevated or high-normal blood pressure, with reassessment recommended within one year. In these cases, masked hypertension should be considered, using home blood pressure monitoring or ambulatory blood pressure monitoring.
Diagnostic confirmation
When blood pressure is equal to or above 140/90 millimetres of mercury, the diagnosis of arterial hypertension should be confirmed, ideally by repeated office measurements or by out-of-office methods, preferably home or ambulatory blood pressure monitoring. In very high values, namely ≥180/110 mmHg, associated with symptoms or target-organ damage, treatment initiation should not be delayed, and formal confirmation may be performed subsequently.
Global clinical assessment and target-organ damage
Once the diagnosis is confirmed, a comprehensive clinical assessment should be performed, including cardiovascular risk factors, personal and family history, and lifestyle-related factors such as smoking, alcohol consumption, salt intake and level of physical activity. Signs and symptoms suggestive of target-organ damage at neurological, cardiac, renal and peripheral vascular levels should also be actively assessed.
Suspicion of secondary hypertension
The possibility of secondary hypertension should be considered in cases of onset at a young age, grade 2 or 3 hypertension, rapid progression or difficulty achieving blood pressure control. Renal, endocrine, pharmacological causes and causes associated with obstructive sleep apnoea syndrome should be investigated.
Initial complementary assessment
The initial work-up includes full blood count, fasting glucose and/or haemoglobin A1c, complete lipid profile, electrolytes, serum creatinine with estimated glomerular filtration rate, urinalysis with albumin-to-creatinine ratio, and electrocardiogram. Additional tests, such as echocardiography, carotid Doppler ultrasound or fundoscopy, may be performed in selected situations.
Cardiovascular risk stratification
Global cardiovascular risk stratification is based on an integrated approach that considers blood pressure grade, risk factors, the presence of target-organ damage and associated comorbidities. This assessment is essential to guide therapeutic decisions and treatment intensity.
Non-pharmacological treatment
Lifestyle intervention is recommended for all patients and includes a balanced diet, reduced salt intake, smoking cessation, moderation of alcohol consumption, weight control and regular physical exercise, ideally thirty to sixty minutes, four to seven days per week.
Pharmacological treatment
The decision to start pharmacological therapy depends on blood pressure values and cardiovascular risk. In grade 1 hypertension, in patients with low or moderate risk, three to six months of non-pharmacological measures may be awaited. In grade 2 hypertension, treatment should be started immediately. In grade 3 hypertension, starting with a two-drug combination in a single pill is recommended, except in frail older adults or patients with low risk.
Therapeutic targets
Blood pressure targets should be individualised. Between the ages of eighteen and sixty-four years, the target is systolic pressure close to 130 millimetres of mercury, if tolerated, avoiding values below 120. In individuals aged 65 years or older, the target is between 130 and 139 for systolic pressure and 70 to 79 for diastolic pressure.
Approach in special situations and follow-up
Treatment choice should be adapted to comorbidities, such as coronary artery disease, chronic kidney disease, heart failure with reduced ejection fraction or atrial fibrillation. If, despite treatment optimisation, blood pressure remains uncontrolled with three pharmacological classes, resistant hypertension should be considered and hospital referral should be assessed. Regular follow-up is essential to evaluate treatment efficacy, adherence and tolerability.
