There are four stages of hypertension: elevated, stage 1, stage 2, and hypertensive crisis. There are also different types: primary, secondary, resistant, malignant, and isolated.

“Hypertension” is the medical term for high blood pressure.

The 2023 European Society of Hypertension guidelines for hypertension define it as a blood pressure reading of 140/80 or higher. The 2017 American College of Cardiology/American Heart Association guidelines define hypertension as a blood pressure reading of 130/80 or higher.

In addition to these definitions of elevated blood pressure, doctors further classify hypertension into different stages and types.

This article reviews the four stages or classifications of hypertension as well as the different types.

Understanding blood pressure readings

Blood pressure readings are given in two numbers. The first number is the systolic pressure, which indicates the pressure in your arteries when your heart beats in and pumps out blood.

The second number is your diastolic pressure, which indicates the pressure in your arteries between heartbeats.

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Under the most recent guidelines for hypertension, blood pressure measurements are categorized as follows:

  • Normal: systolic pressure less than 120 millimeters of mercury (mm Hg) and diastolic less than 80 mm Hg
  • Elevated: systolic pressure of 120 to 129 mm Hg and diastolic less than 80 mm Hg
  • Stage 1: systolic pressure of 130 to 139 mm Hg or diastolic of 80 to 89 mm Hg
  • Stage 2: systolic pressure of at least 140 mm Hg or diastolic of at least 90 mm Hg
  • Hypertensive crisis: systolic pressure above 180 mm Hg and/or diastolic above 120 mm Hg (This is considered a medical emergency.)

The new classification system puts more people in the “elevated” category who were previously considered prehypertensive.

Under the new guidelines, an estimated 46% of U.S. adults are categorized as having high blood pressure.

Treatment is recommended at the elevated stage if you have heart disease or other risk factors, such as diabetes or a family history of hypertension.

If your blood pressure reading is elevated, discuss with your doctor what steps you can take to lower it.

Chart showing blood pressure rangesShare on Pinterest
Chart Design by Maya Chastain

Primary hypertension

Primary hypertension is also known as essential hypertension. Most adults with hypertension have this type.

Despite years of research on hypertension, the specific cause isn’t known. It’s thought to be a combination of:

  • genetics
  • diet
  • lifestyle
  • age

Lifestyle factors that may contribute to hypertension include:

Changes in your diet and lifestyle can lower your blood pressure and your risk of complications from hypertension.

Secondary hypertension

If you have secondary hypertension, it means your high blood pressure has an identifiable — and potentially reversible — cause.

Only 5% to 10% of cases of hypertension are the secondary type.

Secondary hypertension is more prevalent in younger people. An estimated 30% of people ages 18 to 40 years old who have hypertension have the secondary type.

The underlying causes of secondary hypertension include:

Subtypes that fit within the categories of primary or secondary hypertension include:

  • resistant hypertension
  • malignant hypertension
  • isolated hypertension

Resistant hypertension

Resistant hypertension is high blood pressure that’s difficult to manage and requires multiple medications.

Hypertension is considered resistant when your blood pressure stays above your treatment target even though you’re taking three different types of blood pressure-lowering medications, including a diuretic.

An estimated 10% of people in Western countries who have high blood pressure have resistant hypertension.

People with resistant hypertension may have secondary hypertension with a cause that hasn’t yet been identified, prompting their doctor to search for secondary causes.

In most cases, resistant hypertension can be successfully treated with multiple drugs or by identifying a secondary cause.

Malignant hypertension

Malignant hypertension is high blood pressure that causes damage to your organs. This is an emergency condition.

Malignant hypertension is the most severe type, involving elevated blood pressure that is usually higher than 180 mm Hg systolic or higher than 120 to 130 mm Hg diastolic plus damage to multiple organs.

The prevalence of malignant hypertension is low — about 1 to 2 cases in 100,000. But rates may be higher in Black populations.

Malignant hypertension is a medical emergency

Malignant hypertension is a life threatening condition because high blood pressure can damage essential organs or cause complications such as an aortic dissection or tear or bleeding in your brain.

Seek immediate emergency medical attention if you think you may be having a hypertensive emergency.

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Isolated systolic hypertension

Isolated systolic hypertension is defined as systolic blood pressure above 140 mm Hg and diastolic blood pressure below 90 mm Hg.

It’s the most frequent type of hypertension in older adults. An estimated 15% of people ages 60 years or older have isolated systolic hypertension.

The cause is thought to be the stiffening of arteries with age.

Younger people can also develop isolated systolic hypertension. Some research suggests that isolated systolic hypertension appears in 2% to 8% of younger people. According to a 2005 study from the United Kingdom, isolated systolic hypertension is the most common form of hypertension in people 17 to 27 years old.

A large study published in 2015 with an average of 31 years of follow-up found that adults 18 to 49 years old who had isolated systolic hypertension were at a higher risk of stroke and heart attack than those with normal blood pressure levels.

A hypertensive emergency, also called malignant hypertension, is when your blood pressure suddenly rises above 180/120 and you have symptoms as a result of this sudden increase. Symptoms include:

  • chest pain
  • headache
  • shortness of breath
  • dizziness
  • vision changes

However, it is possible to have no obvious symptoms and still have a hypertensive emergency. Hypertensive emergency can occur with blood pressure above 180/120 and signs of end-organ damage that only a doctor could detect.

As an example, someone could have no symptoms, but then blood work could reveal acute kidney injury due to decreased blood flow to their kidneys.

Only 1% to 3% of people with hypertension are likely to experience a hypertensive emergency during their lifetime. Be sure to take your prescribed blood pressure medications and to avoid drugs that stimulate your nervous system, as these are common causes of hypertensive emergency.

Hypertensive urgency is when your blood pressure is above 180/120, but you have no other symptoms.

Hypertensive urgency is most often treated by adjusting your medications. It’s important to treat hypertensive urgency quickly so it doesn’t become a hypertensive emergency.

Although fewer than 1% of people with hypertensive urgency are referred to a hospital and few of those people experience major negative effects, it’s still a serious condition, and you should call your doctor’s office immediately or seek medical care if you have hypertensive urgency.

White coat hypertension (also known as white coat syndrome) is a temporary increase in blood pressure that you experience when you’re in a doctor’s office or in another stress-inducing situation, such as being stuck in traffic.

Previously, this condition was found to be benign. But more recently it has been associated with increased cardiovascular risk. Often, people with white coat hypertension will progress to having a diagnosis of hypertension.

Usually, before you start taking a medication for hypertension, a doctor will monitor your blood pressure over a period of time in different settings. Your diagnosis won’t be based on one reading, but if you have any reading that’s out of range, you should discuss it with your doctor.

Hypertension is called the “silent killer” because it doesn’t usually have identifiable symptoms.

Most cases of hypertension don’t have a known cause. It may be inherited or related to diet and sedentary lifestyle. Also, blood pressure typically tends to increase with age.

If you have risk factors for high blood pressure, such as a heart condition or diabetes, it’s a good idea to monitor your blood pressure regularly and take preventive measures.

Often, lifestyle changes can greatly improve your chances of avoiding hypertension medications and complications, including heart attack or stroke. If lifestyle changes aren’t enough, a variety of prescription medications can help treat your hypertension.