Draft Recommendation Statement
Hypertension in Adults: Screening
June 23, 2020
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.
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- Update in Progress for Hypertension in Adults: Screening
|Adults age 18 years or older||The USPSTF recommends screening for hypertension in adults age 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.||A|
|Table of Contents||PDF Version and JAMA Link||Archived Versions|
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.
Hypertension is a prevalent condition, affecting approximately 45% of the adult U.S. population.1 It is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor to heart failure, heart attack, stroke, and chronic kidney disease.
In 2015, the USPSTF reviewed the evidence for screening for hypertension in adults and issued an A recommendation.2 The USPSTF has decided to use a reaffirmation deliberation process to update this A recommendation. The USPSTF uses the reaffirmation process for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify a change in the grade of the recommendation.3 In its deliberation of the evidence, the USPSTF considers whether any new evidence is of sufficient strength and quality to change its previous conclusions about the evidence.
Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that the net benefit of screening for hypertension in adults is substantial.
Patient Population Under Consideration
This recommendation applies to adults age 18 years or older without known hypertension.
Increasing blood pressure predicts an increased risk of cardiovascular disease.4,5 Generally, the threshold that has been used to define hypertension vs. normal blood pressure by various organizations ranges from 130/80 mm Hg or greater to 140/90 mm Hg or greater.6,7 For the purposes of this recommendation, the USPSTF reviewed evidence from studies that included any threshold used to define hypertension.8 Hypertension (also referred to as “sustained hypertension”) is when a person has repeatedly high blood pressure measurements over time and in various settings.
Assessment of Risk
Although all adults should be screened for hypertension, risk factors that increase a person’s risk for the condition include older age, African American race, family history, excess weight and obesity, lifestyle habits (lack of physical activity, stress, and tobacco use), and dietary factors (diet high in fat or sodium, diet low in potassium, or excessive alcohol intake).8,9
Initial screening for hypertension should be performed with OBPM. OBPM is most commonly performed using a manual or automated sphygmomanometer.8 There are various OBPM protocols available; however, in the studies reviewed by the USPSTF, OBPM was most commonly taken in a seated position after 5 minutes of rest with medical personnel present during measurement.8 Ambulatory blood pressure measurement (ABPM) and home blood pressure monitoring (HBPM) can provide a diagnosis of hypertension outside of a clinical setting after initial screening. ABPM involves wearing a programmed device that automatically takes frequent blood pressure measurements over the course of a day (or day and night); HBPM involves patients measuring their own blood pressure at home with an HBPM device.
Available evidence on optimal screening intervals for hypertension remains limited.8 The USPSTF suggests annual screening for hypertension in adults age 40 years or older and for adults at increased risk for hypertension (such as persons with high-normal blood pressure, who are overweight or obese, or who are African American). Screening less frequently (i.e., every 3 to 5 years) is appropriate for adults ages 18 to 39 years not at increased risk for hypertension and with a prior normal blood pressure reading.
The benefits of treatment of hypertension in preventing important health outcomes such as stroke, heart failure, and coronary heart disease events are well documented.10 Treatment can include lifestyle changes, pharmacotherapy, or both. Selection of treatment can vary depending on severity of elevated blood pressure measurement, age, and other risk factors.
ABPM offers the most evidence-based risk information for future cardiovascular events. ABPM devices are small portable machines that record blood pressure noninvasively at typically 20- to 30-minute intervals over 12 to 24 hours while patients go about their normal activities and are sleeping. HBPM devices are fully automated oscillometric devices that record measurements taken from the patient’s brachial artery. HBPM devices are activated by patients or caregivers and measurements are taken much less frequently than with ABPM (e.g., one to two times a day or week, although they can be spread out over more time).
Additional Tools and Resources
Hypertension resources for health professionals are available through the Centers for Disease Control and Prevention at: https://www.cdc.gov/bloodpressure/educational_materials.htm.
The Community Preventive Services Task Force has several resources related to community-focused interventions for blood pressure monitoring, management, and control available at https://www.thecommunityguide.org/topic/cardiovascular-disease.
Other Related USPSTF Recommendations
The USPSTF has several recommendations addressing cardiovascular health.
- Risk assessment for cardiovascular disease with nontraditional risk factors11
- Screening for atrial fibrillation with electrocardiography12
- Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention:
- Statin use for the primary prevention of cardiovascular disease in adults15
- Aspirin use to prevent cardiovascular disease and colorectal cancer16
- Screening for primary hypertension in children and adolescents17
This recommendation is a reaffirmation of the 2015 recommendation statement on screening for high blood pressure in adults (“A” recommendation). The USPSTF has issued an A recommendation on screening for high blood pressure in adults since 1996 (updated in 2003, reaffirmed in 2007, and then updated in 2015). In 2015, the USPSTF recommended screening for high blood pressure in adults age 18 years or older and obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. The USPSTF found no new substantial evidence that could change its recommendation and therefore reaffirms its recommendation. The current reaffirmation clarifies that initial screening should be performed with OBPM, updates language to be more consistent with current evidence, and clarifies implementation strategies.
Scope of Review
The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of OBPM for initial screening, and the accuracy of various confirmatory blood pressure measurement methods.
Accuracy of Screening Tests
The USPSTF reviewed evidence from 20 studies (n=12,614) on the test accuracy of OBPM for initial screening for hypertension.8 All studies used ABPM as the reference standard. Studies reflected a wide range of clinical characteristics and most commonly included community-based samples; mean ages of participants ranged from 25.6 to 70 years and 37.9% to 72.3% of participants were female.8 Although reported less frequently, race/ethnicity was predominately white in those studies that did report it.8 Meta-analyses of 15 studies (n=11,309) showed a pooled sensitivity of 0.54 (95% confidence interval [CI], 0.37 to 0.70) and a pooled specificity of 0.90 (95% CI, 0.84 to 0.95) when using an OBPM threshold of 140/90 mm Hg compared to a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg.
Eighteen studies (n=57,128) provided evidence on the accuracy of various methods to evaluate adults who initially screened positive for hypertension by OBPM. Again, ABPM was used as the reference standard in all studies. The mean age of study participants was generally older (46.9 to 60 years), reflecting the preselected study populations. Zero to 66.7% of study participants were female. Again, few studies reported race/ethnicity of participants and those that did included predominantly white participants. Meta-analysis of eight studies (n=53,183) of repeat OBPM showed a pooled sensitivity of 0.80 (95% CI, 0.68 to 0.88) and pooled specificity of 0.55 (95% CI, 0.42 to 0.66) using an OBPM threshold of 140/90 mm Hg compared to a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg. Meta-analysis of four studies (n=1,001) on HBPM found a pooled sensitivity of 0.84 (95% CI, 0.76 to 0.90) and a pooled specificity of 0.60 (95% CI, 0.48 to 0.71) using an HBPM threshold of 135/85 mm Hg compared to a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg.
Benefits of Early Detection
No trials compare the effectiveness of solely screening for hypertension vs. no screening. However, a Canadian community-based, cluster randomized clinical trial8 evaluated a multicomponent cardiovascular disease health promotion program that assessed cardiovascular disease outcomes of 140,642 community members in 39 clusters.21 Community residents (targeted age of 65 years or older) were invited to pharmacy-based blood pressure screening and a cardiovascular disease risk assessment. Risk-specific educational materials were provided and results communicated back to the participant’s clinician. At 1 year of followup, a 9% reduction in the number of hospital admissions for acute myocardial infarction, congestive heart failure, or stroke was found; however, no differences in all-cause mortality were noted.21 Although there is limited direct trial evidence on benefits of screening for hypertension on health outcomes, based on the available indirect evidence on the accuracy of screening tests for hypertension and robust, foundational evidence showing that treatment of hypertension (detected in office-based settings) improves health outcomes,10 the USPSTF found convincing evidence that screening for hypertension in adults provides health benefits.
Harms of Early Detection
The USPSTF reviewed 13 studies (n=5,150) that reported on harms of screening for hypertension.8 Results from five studies (n=1,321) suggest that screening is not associated with any substantial short-term quality of life changes or adverse psychological outcomes. Evidence from two worksite studies (n=502) reported mixed findings on whether absenteeism increased with screening. Seven studies (n=3,505) reported minor adverse events such as sleep disturbance, pain/discomfort, bruising, and skin irritation with ABPM. Overall, the USPSTF determined that the harms of screening for hypertension are minor.
How Does Evidence Fit With Biological Understanding?
There are different types of hypertension, including “sustained” hypertension (blood pressure measurements that are high when obtained both in a clinical office setting and outside the office, referred to as “hypertension” in the current recommendation), “white coat” hypertension (blood pressure measurements that are high only when obtained in a clinical office setting but normal when obtained outside the office), and “masked” hypertension (blood pressure measurements that are high only when obtained outside the office but normal when obtained in clinical office settings). Cardiovascular disease risk is highest among persons with sustained hypertension, followed by those with masked hypertension, followed by those with white coat hypertension.19-24 The prevalence of white coat and masked hypertension in the United States is unknown, but estimates based on data from international cohorts25 are 8% and 14%, respectively.8 Analyses of participants of a U.S.-based study estimates a prevalence of 12.3% for masked hypertension.26
White coat hypertension can be detected by obtaining an out-of-office blood pressure measurement (either through HBPM or ABPM) after an elevated blood pressure measurement is detected in the office. Masked hypertension is more difficult to identify and can only be detected when out-of-office blood pressure measurements are obtained. Current screening algorithms that focus on performing OBPM first, then following up with ABPM or HBPM only in persons with elevated blood pressure on OBPM are not able to identify persons with masked hypertension. The USPSTF hypothesizes that screening strategies that use OBPM for both initial screening and confirmation with traditional thresholds would miss a greater number of cases of sustained hypertension and would lead to overtreatment of a greater number of cases of white coat hypertension. Followup ABPM or HBPM after an initial positive OBPM screening result would result in fewer cases of sustained hypertension being missed and fewer cases of white coat hypertension being overtreated. Confirmation with ABPM would result in the greatest number of cases of sustained hypertension being identified without any cases of white coat hypertension being treated (by definition considered the “gold standard”). Importantly, cases of masked hypertension would be missed with all three of these screening strategies, at least when using OBPM with traditional thresholds.
Although the association of masked hypertension and white coat hypertension with increased cardiovascular risk has been well documented, it is unclear whether treatment of either of these types of hypertension improves health outcomes. The USPSTF considers this a critical evidence gap.
The association of masked hypertension and white coat hypertension with increased cardiovascular risk has been well documented; however, more evidence is needed to understand whether early detection and treatment of these hypertension types leads to an improvement in health. More research is needed on the following.
- The benefits and harms of early detection and treatment of masked hypertension and white coat hypertension:
- Does early detection of masked hypertension and white coat hypertension lead to improved health outcomes?
- Does treating masked hypertension improve cardiovascular health outcomes?
- Does treating white coat hypertension cause harms?
- How frequently do adults transition between the different types of hypertension, and how long is the length of time it takes to transition (e.g., what percent of persons with masked hypertension transition to sustained hypertension, and how long does that transition take)?
- Identification of feasible methods for early detection of masked hypertension.
- Inclusion of diverse and underrepresented persons in all of the above studies is needed to determine optimal screening for all types of hypertension.
The Eighth Joint National Committee does not address the diagnosis of hypertension in its 2014 guidelines.10 The Seventh Joint National Committee recommends screening for high blood pressure at least once every 2 years in adults with blood pressure less than 120/80 mm Hg and every year in adults with blood pressure of 120 to 139/80 to 89 mm Hg.6 The American College of Cardiology and the American Heart Association recommend proper measurement methods be used for diagnosis and management of high blood pressure and that out-of-office blood pressure measurement be performed to confirm the diagnosis of hypertension.7,27 They also suggest screening for masked hypertension with ABPM or HBPM in adults who consistently have systolic blood pressure measurements of 120 to 129 mm Hg or diastolic blood pressure measurements of 75 to 79 mm Hg in the office7,27 and screening for white coat hypertension in adults who consistently have systolic blood pressure measurements of 130 to 160 mm Hg or diastolic measurements of 80 to 100 mm Hg in the office. Additionally, in 2019, the Centers for Medicare & Medicaid Services added coverage of ABPM to diagnose patients with suspected white coat and masked hypertension.28 The American Academy of Family Physicians supports the 2015 USPSTF recommendation statement on screening for high blood pressure.29
1. Ostchega Y, Fryar C, Nwankwo T, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018.2020. https://www.cdc.gov/nchs/products/databriefs/db364.htm. Accessed May 26, 2020.
2. U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(10):778-786.
3. U.S. Preventive Services Task Force. Procedure Manual. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual. Accessed May 26, 2020.
4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903-1913.
5. Flint AC, Conell C, Ren X, et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N Engl J Med. 2019;381(3):243-251.
6. National High Blood Pressure Education Program. The Seventh Report on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Washington, DC: National Institutes of Health; 2004.
7. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115.
8. Guirguis-Blake JM, Evans CV, Webber EM, Coppola EL, Perdue LA, Weyrich MS. Screening for Hypertension in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 197. AHRQ Publication No. 20-05265-EF-1. Rockville, MD; Agency for Healthcare Research and Quality; 2020.
9. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603.
10. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
11. US Preventive Services Task Force. Risk assessment for cardiovascular disease with nontraditional risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(3):272-280.
12. US Preventive Services Task Force. Screening for atrial fibrillation with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(5):478-484.
13. US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(8):587-593.
14. US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2017;318(2):167-174.
15. US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(19):1997-2007.
16. U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(12):836-845.
17. U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:613-619.
18. Kaczorowski J, Chambers LW, Dolovich L, et al. Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP). BMJ. 2011;342:d442.
19. Briasoulis A, Androulakis E, Palla M, Papageorgiou N, Tousoulis D. White-coat hypertension and cardiovascular events: a meta-analysis. J Hypertension. 2016;34(4):593-599.
20. Huang Y, Huang W, Mai W, et al. White-coat hypertension is a risk factor for cardiovascular diseases and total mortality. J Hypertension. 2017;35(4):677-688.
21. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertension. 2011;24(1):52-58.
22. Asayama K, Thijs L, Li Y, et al. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Hypertension. 2014;64(5):935-942.
23. Cohen JB, Lotito MJ, Trivedi UK, Denker MG, Cohen DL, Townsend RR. Cardiovascular events and mortality in white coat hypertension: a systematic review and meta-analysis. Ann Intern Med. 2019;170(12):853-862.
24. Shimbo D, Muntner P. Should out-of-office monitoring be performed for detecting white coat hypertension? Ann Intern Med. 2019;170(12):890-892.
25. Conen D, Aeschbacher S, Thijs L, et al. Age-specific differences between conventional and ambulatory daytime blood pressure values. Hypertension. 2014;64(5):1073-1079.
26. American Academy of Family Physicians. Clinical Preventive Services Recommendation: Hypertension. https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html. Accessed May 26, 2020.
27. Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35-e66.
28. Centers for Medicare & Medicaid Services. Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM) (CAG-00067R2). 2019. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=294. Accessed May 26, 2020.
29. American Academy of Family Physicians. Clinical Preventive Services Recommendation: Hypertension. https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html. Accessed May 26, 2020.
|Benefits of Early Detection and Intervention and Treatment||The USPSTF found convincing evidence that screening for hypertension with office blood pressure measurement and treatment of hypertension in adults substantially reduces the incidence of cardiovascular events.|
|Harms of Early Detection and Intervention and Treatment||The USPSTF found convincing evidence that screening for and treatment of hypertension detected in clinical office settings has few major harms.|
|USPSTF Assessment||Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that the net benefit of screening for hypertension in adults is substantial.|