Blood Pressure Guidelines

Blood Pressure (BP) Classification Guidelines (Adults): UK vs USA vs Europe

This document compares adult BP classification terminology and thresholds across three major guideline sources:

UK: NICE NG136 (Hypertension in adults: diagnosis and management; Aug 2019)
USA: ACC/AHA (High Blood Pressure Guideline; 2017, published in JACC 2018)
Europe: ESC/ESH (Arterial Hypertension Guideline; 2018)

NICE (UK): Clinic readings are used to identify possible hypertension, but diagnosis (and thus staging) should be confirmed using out-of-office averages with ABPM (ambulatory BP monitoring) or HBPM (home BP monitoring), except where immediate treatment is indicated (for example, severe hypertension, or where there is target organ damage/complications).
ACC/AHA (USA) and ESC/ESH (Europe): The categories in their classification tables are office/clinic BP categories (with out-of-office measurements used in diagnosis/management and to detect white-coat or masked hypertension).

Category	UK (NICE NG136, 2019)	USA (ACC/AHA, 2017) (office/clinic)	Europe (ESC/ESH, 2018) (office/clinic)
Optimal / Normal	Not formally defined as “Optimal/Normal” categories in NG136	Normal: <120 and <80 mmHg	Optimal: <120 and <80 mmHg
Normal (Europe-specific category)	Not defined as a NICE category	Not a separate category	Normal: 120–129 and/or 80–84 mmHg
High-normal / Elevated	NICE does not define a formal “High-normal” category in NG136	Elevated: 120–129 and <80 mmHg	High-normal: 130–139 and/or 85–89 mmHg
Hypertension Stage 1 / Grade 1	Stage 1 hypertension: Clinic 140–159 or 90–99 mmHg and ABPM/HBPM average ≥135 and/or ≥85 mmHg	Stage 1 hypertension: 130–139 or 80–89 mmHg	Grade 1 hypertension: 140–159 and/or 90–99 mmHg
Hypertension Stage 2 / Grade 2	Stage 2 hypertension: Clinic ≥160 and/or ≥100 mmHg and ABPM/HBPM average ≥150 and/or ≥95 mmHg	Stage 2 hypertension: ≥140 or ≥90 mmHg	Grade 2 hypertension: 160–179 and/or 100–109 mmHg
Stage 3 / Severe / Grade 3	Severe hypertension (NICE term): Clinic SBP ≥180 or DBP ≥120 mmHg	No Stage 3 category	Grade 3 hypertension: ≥180 and/or ≥110 mmHg
Isolated systolic hypertension	SBP ≥140 with DBP <90 (concept recognised)	Defined similarly (concept recognised)	Defined similarly (concept recognised)

UK: NICE NG136 (Aug 2019)
- Does not present “Optimal/Normal” or “High-normal” as formal classification categories in the way ESC/ESH does.
- Uses clinic BP to identify possible hypertension, and typically requires ABPM/HBPM average confirmation for diagnosis/staging.
- Uses the term “severe hypertension” (clinic SBP ≥180 or DBP ≥120).
- Source: NICE NG136: nice.org.uk.
- Original PDF: PDF-August 2019.
- Updated PDF: PDF-March 2022.
USA: ACC/AHA 2017 (office/clinic category table)
- Categories: Normal, Elevated, Stage 1, Stage 2; no Stage 3.
- Source: Whelton PK, et al. J Am Coll Cardiol. 2018;71(19):e127–e248. DOI: 10.1016/j.jacc.2017.11.006
  jacc.org.
Europe: ESC/ESH 2018 (office/clinic category table)
- Includes Optimal, Normal, and High-normal categories prior to hypertension grades.
- Grade thresholds begin at 140/90, with Grade 3 ≥180 and/or ≥110.
- Source: Williams B, et al. Eur Heart J. 2018;39(33):3021–3104. DOI: 10.1093/eurheartj/ehy339
  academic.oup.com.

Measurement approach
- NICE: staging is not based on clinic BP alone; it typically requires ABPM/HBPM averages for confirmation.
- ACC/AHA and ESC/ESH: the listed categories are office/clinic classifications.
Hypertension threshold
- ACC/AHA: hypertension begins at 130/80 (Stage 1).
- NICE and ESC/ESH: hypertension classification starts at 140/90 in clinic/office context (with NICE typically requiring out-of-office confirmation).
Category structure
- ESC/ESH uniquely separates Normal (120–129 and/or 80–84) from High-normal (130–139 and/or 85–89).
- ACC/AHA uses Elevated (120–129 and <80) instead.
- NICE does not mirror “optimal/normal/high-normal” as formal categories.