The four stages of hypertension

Hypertension is a common medical condition where the blood pressure in your arteries is high. Untreated hypertension can increase your risk of developing cardiovascular diseases like a heart attack or stroke. The higher your blood pressure is, the greater the danger of getting serious complications.

Hypertension can be divided into stages. Different countries count and label the stages differently. The American College of Cardiology has redefined blood pressure into four levels, whereas the British National Institute of Health and Care Excellence (NICE) only uses three.

In this article, we’ll discuss every stage of hypertension, what they’re called, and the impacts they could have on your future health.

How to measure and record your blood pressure

Your nurse, doctor or pharmacist will measure your blood pressure using a sphygmomanometer. They will wrap an inflatable cuff around your upper arm. The cuff will inflate then gradually deflate; a digital monitor will show the pressure in your arteries when your heart beats and relaxes.

Your blood pressure measurement is given in millimetres of mercury or mmHg. You will see two figures separated by a slash, for example, 120/80 mmHg.

• systolic pressure: The first figure is the pressure when your heart beats to pump blood around your body. It is the higher value, for example, 120 mmHg if your blood pressure is 120/80 mmHg.
• diastolic pressure: The second figure is when your heart relaxes between heartbeats. It is the lower value, for example, 80 mmHg if your blood pressure is 120/80 mmHg

What is normal blood pressure?

“Blood pressure of 120/80 mmHg or below, with systolic pressure at or below 120 mmHg and diastolic pressure at or below 80 mmHg, is within the normal range. However, if you are over 80, measurements of 130/90mmHg may be considered normal,” explains consultant cardiologist, Professor Stuart Rosen.

“It’s good news if you have normal blood pressure – but it’s still essential to protect your heart by eating a balanced diet, exercising regularly and avoiding smoking.”

You should also keep an eye on your blood pressure: All adults over 40 should have blood pressure checks at least every five years, and you should try and get annual reviews if you have one or more hypertension risk factors.

American College of Cardiology stages of hypertension

The American College of Cardiology defined the four stages of hypertension. They include:

1. Normal blood pressure: The first stage in the American College of Cardiology classification. It’s exactly as described – a blood pressure that is considered healthy and normal.
2. Elevated blood pressure or pre-hypertension: Pre-hypertension is the second stage in the American College of Cardiology classification system. It is defined as when your systolic blood pressure is consistently between 120 and 129 mmHg, but your diastolic blood pressure remains in the normal range of less than 80 mmHg. If you have elevated blood pressure, you are at risk of developing hypertension if you don’t make lifestyle changes to reduce your blood pressure.
3. Stage 1 hypertension (American Classification): The American College of Cardiology defines hypertension stage 1 as blood pressure levels consistently between 130 and 139 mmHg systolic or 80 to 89 mmHg diastolic. At these levels of hypertension, doctors may recommend lifestyle changes. However, they may add medication based on your overall risk of heart disease or stroke.
4. Stage 2 hypertension (American Classification): Hypertension stage 2 is defined as blood pressures consistently at a level of 140/90 mmHg or above. If you have blood pressure this high, your doctor will usually prescribe one or more blood pressure medications and recommend lifestyle changes.

NICE hypertension stages

The British National Institute of Health and Care Excellence has also classified hypertension stages. However, the names, values and stages are significantly different from the American stages.

Currently, normal blood pressures and blood pressure levels between 120/80mmHg and 140/90mmHg aren’t included in the NICE staging, but the NHS website says:

‘Blood pressure readings between 120/80mmHg and 140/90mmHg could mean you’re at risk of developing high blood pressure if you do not take steps to keep your blood pressure under control.’

If your blood pressure is elevated, it’s important to keep an eye on it and make lifestyle changes to reduce your risk of developing hypertension.

Lifestyle changes to treat pre-hypertension

• stop smoking
• eat a healthy balanced diet
• cut down on dietary salt
• cut down on alcohol
• reduce coffee, tea and other caffeinated drinks
• exercise regularly
• if you’re overweight, try to achieve and maintain a healthy BMI
• get enough sleep
• manage stress in your life

Stage 1 hypertension

NICE defines stage 1 hypertension as blood pressures measured in the clinic between 140/90 mmHg and 159/99 mmHg.

If your home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) shows average blood pressure ranging between 135/85 mmHg to 149/94 mmHg, your medical team will diagnose stage 1 hypertension.

“The treatment of your stage 1 hypertension will depend on your overall cardiovascular risk. Your doctor will check your medical history and do some blood and urine tests. If your risk of other problems is low, your doctor may recommend lifestyle changes to control your blood pressure. If your risk is high, they may also prescribe medication,” explains Professor Rosen.

Stage 2 hypertension

NICE defines stage 2 hypertension as blood pressures measured in the clinic between 160/100 mmHg and 180/120 mmHg.

If your home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) shows average blood pressure of 150/95 mmHg or higher, your medical team will diagnose stage 2 hypertension.

If you have stage 2 hypertension, your medical team should recommend lifestyle changes and prescribe medication to control your blood pressure regardless of your age and other risk factors.

Stage 3 or severe hypertension

Stage 3, severe hypertension or hypertensive crisis, is defined as a systolic blood pressure of 180 mmHg or higher or diastolic blood pressure of 120 mmHg or above.

This stage of hypertension needs urgent medical attention. Contact your doctor if you record your blood pressure at over 180/120 mmHg. If you have no symptoms or signs of organ damage, they will check your blood pressure, perform a range of blood tests and arrange a review in seven days.

Call 999 or attend your nearest Accident and Emergency department, if you have stage 3 hypertension and symptoms such as:

• chest pain
• breathlessness
• back pain
• numbness or weakness
• confusion
• visual changes
• difficulty speaking

For more information about high blood pressure and the treatments available, please read our article ‘What Is Hypertension?’.

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