A significant number of masked, sustained, and nighttime hypertension may not be detected when using the conventional home blood pressure (BP) threshold of 135/85 mm Hg, suggests a study.
However, using the 130/80-mm Hg threshold, or designating 130/80–134/84 mm Hg as a diagnostic “gray zone” warranting ambulatory BP monitoring (ABPM), may improve diagnosis and allow earlier identification of hypertension in clinical practice, according to the investigators led by Dr Jaehoon Chung, Division of Cardiology, Dongguk University Ilsan Hospital, Dongguk University, Goyang, South Korea.
“[L]owering the diagnostic threshold of home hypertension from 135/85 to 130/80 mm Hg significantly enhances the diagnostic sensitivity and accurately identifies individuals who otherwise remain untreated despite an elevated cardiovascular risk,” Chung said.
The study included 646 untreated participants (mean age 52 years, 310 men) with valid 3-day office BP, 7-day home BP, and 24-h ABPM data and preserved renal function. Chung and colleagues classified hypertension phenotypes as normotension, white-coat, masked, and sustained hypertension according to office BP and ABPM criteria.
Lower threshold
A home BP threshold of 130/80 mm Hg improved sensitivity from 72.3 percent to 89.5 percent but reduced specificity from 81.8 percent to 69.1 percent, which then enhanced the overall diagnostic accuracy from 73.1 percent to 87.8 percent and the kappa coefficient from 0.238 to 0.427. [J Hypertens 2026;44:778-786]
When applying the conventional threshold of 135/85 mm Hg, 63.2 percent of individuals with masked hypertension and 15.1 percent of those with sustained hypertension were misclassified as having normotension, but using the 130/80-mm Hg threshold reduced these rates to 30.3 percent and 3.4 percent, respectively.
Intermediate office and ambulatory BP values were observed among individuals with home BP between 130/80 and 134/84 mm Hg, with a high prevalence of masked (32.9 percent) and sustained hypertension (11.7 percent). This subgroup also showed isolated nighttime and daytime–nighttime hypertension in 35.7 percent and 13.5 percent of participants, respectively.
“We suggest lowering the diagnostic threshold of home BP to 130/80 mm Hg or designating the home BP range between 130/80 and 134/84 mm Hg as a diagnostic ‘gray zone’ requiring ABPM confirmation,” Chung and colleagues said.
Existing guidelines
Discrepancies exist in current guidelines in their recommended thresholds for diagnosing hypertension using home BP monitoring (HBPM). For instance, the 2019 Japanese Society of Hypertension Guidelines had a threshold of at least 135/85 mm Hg for home BP, while the European version retained the 135/85-mm Hg threshold. [J Hypertens 2023;41:1874-2071; Eur Heart J 2024;45:3912-4018]
On the other hand, the 2017 American College of Cardiology/American Heart Association guidelines recommended considering the 135/85-mm Hg threshold as equivalent to stage 2 hypertension by lowering the office BP threshold of stage 1 hypertension to at least 130/80 mm Hg. [Hypertension 2018;71:e13-e115]
Furthermore, the 2020 Brazilian guidelines set 130/80 mm Hg as the threshold for a home BP diagnosis. [Arq Bras Cardiol 2021;116:516-658]
“[The current] study proposes such a progressive approach, demonstrating that an HBPM diagnostic threshold of at least 130/80 mm Hg correlates significantly better with ambulatory hypertension than traditional criteria,” Chung said.
Previous studies found hypertension to be the leading modifiable risk factor for stroke and ischaemic heart disease. [JAMA Cardiol 2019;4:1194-1202; Lancet 2016;388:761-775]
"Out-of-office measurements facilitate proper identification and management of masked and white-coat hypertension,” Chung said. “HBPM offers convenience and lower costs than ABPM.”