Is lowering the threshold for blood pressure diagnosis worth it?

Hypertension Canada recently released a new guideline for primary care in the article, “Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care,”¹ published in the July/August 2025 issue of Canadian Family Physician. We welcome the clarity about the benefits of treatment of hypertension being greater for patients at higher cardiovascular risk. The recommendation to consider initiating pharmacotherapy at 140/90 mm Hg or higher for most adults, and at 130 to 139 mm Hg for those at high cardiovascular risk encourages a more nuanced, individualized approach to treatment rather than a one-size-fits-all threshold. Unfortunately, the information about the benefits and harms associated with treatment at different risk levels is not shared. We can only hope the final guideline will provide a decision aid to facilitate discussions with patients.

We are concerned about the decision to lower the diagnostic threshold, defining hypertension as 130/80 mm Hg or higher when measured under optimal conditions. As the authors note, this change will significantly increase the number of individuals labelled as hypertensive.¹ One previous study estimated that redefining hypertension as 130/80 mm Hg or higher would nearly double the crude prevalence of hypertension among Canadian adults to 42.4% from 24.2%.² The guideline authors justify this change by the potential benefits of earlier management without discussing the smaller positive impact for individuals at low risk. While we recognize and support the emphasis on non-pharmacologic measures at these levels, this raises a broader question: Do we need a diagnostic label to discuss healthy lifestyle changes with our patients?

Knowing that diagnostic labels are not benign, we are surprised the potential harms of a definition change and its potential for overdiagnosis were not fully discussed in the Hypertension Canada guideline update. Studies have shown that a hypertension diagnosis can likely lead to unintended harms such as increased distress, loss of productivity, and the sentiment of poorer health.^3-6

As there is guidance for guideline panels contemplating modifying the definition of diseases, we asked ourselves how well the Hypertension Canada guideline panel considered these important questions in their proposal to lower the hypertension diagnosis threshold.^7,8 The benefits and harms for newly diagnosed individuals are not described, nor is the time needed to implement the new guideline.⁹

The authors provide information about the effect of life habits on the risk of hypertension, but they do not discuss whether counselling is effective. Is there any evidence to support the assertion that a diagnostic label of hypertension promotes lifestyle changes better than without a label? One study reported that physical activity decreased in individuals with a new diagnosis of hypertension.¹⁰ Sadly, the literature to inform the complex issue of counselling was not explored in the guideline update. It is not enough to suggest that practitioners counsel patients. We need to know what works and what does not.

Lowering diagnostic thresholds without robust evidence that it improves outcomes risks expanding the population of patients without clear benefit.^11,12 This recommendation disproportionately affects those at low-to-moderate cardiovascular risk who are unlikely to benefit and may be harmed from such diagnostic threshold shifts. The potential harm of a diagnostic label must be carefully weighed against the potential benefits of earlier and more aggressive management of cardiovascular risk factors. The new guideline does not present clear evidence that benefits outweigh harms. The tables that usually present such data are not available. Before suggesting a change in a diagnostic threshold, key questions should be answered. Regrettably, some answers are missing in this guideline.

In 2018, the American Academy of Family Physicians declined to endorse the American College of Cardiology and American Heart Association guidelines over similar concerns.¹³ We believe Canadian family physicians should resist expanding disease definitions without solid evidence benefits outweigh harms, thus avoiding labelling millions of patients as sick without clear gains. As primary care providers, we do not need this shift in definition to continue counselling patients about the benefits of healthy habits.

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