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Adults should continue undergoing routine hypertension screening, according to the U.S. Preventive Services Task Force (USPSTF), which specified office blood pressure (BP) measurements for initial screening.

It is reasonable for adults 40 years and older and those at increased risk for hypertension to undergo screening every year. Young people not at risk, or those with a prior normal BP reading, may get screened every few years instead, said Alex Krist, MD, MPH, of Virginia Commonwealth University in Richmond, and colleagues of the task force.

Thus, the USPSTF reaffirms its 2015 grade A recommendation for hypertension screening -- citing its potential to reduce cardiovascular events, with few major harms -- while clarifying that this should be performed with office readings, leaving measurements outside the clinical setting (i.e., ambulatory BP monitoring [ABPM] or home BP measurement [HBPM]) for diagnostic confirmation before starting treatment.

The finalized recommendations were after a draft version had been made public last summer. Also published was the , commissioned for the USPSTF, that found that office BP measurement alone was associated with low sensitivity for detecting hypertension.

"With its rigorous evidence standards for high-grade recommendations, the USPSTF recommendation for BP screening provides an appropriate floor condition, setting the minimum standard expected for BP measurement in the diagnosis and confirmation of elevated BP levels consistent with hypertension," commented Yuichiro Yano, MD, PhD, of Duke University in Durham, North Carolina, and Yokohama City University in Japan, and Donald Lloyd-Jones, MD, ScM, of Northwestern University Feinberg School of Medicine in Chicago.

In contrast, "both the U.S. and European professional society guidelines support more intensive screening and confirmation strategies, especially with regards to detecting patients with the higher-risk masked hypertension phenotype," Yano and Lloyd-Jones wrote in an in JAMA Cardiology.

"The association of masked hypertension and white coat hypertension with increased cardiovascular risk has been well documented; however, more evidence is needed to understand whether early detection and treatment of these hypertension types lead to an improvement in health," Krist's group argued.

"Given the substantial evidence generated over the past several decades, the focus on office and out-of-office BP measurements by the 2021 USPSTF recommendation statement is appropriate," said Daichi Shimbo, MD, and colleagues of Columbia University Irving Medical Center, in a .

Like Yano and Lloyd-Jones, Shimbo's group suggested HBPM as an alternative to ABPM, owing to its wider availability in out-of-office BP monitoring.

USPSTF has issued an A recommendation for BP screening in adults since 1996. In 2015, the group updated its stance to call for measurements outside of the clinical setting for diagnostic confirmation before treatment.

Now, the designation of office BP measurements as the entry point for hypertension screening could lead to issues such as the underdetection of individuals with masked hypertension.

"Additionally, [office screening] may not be possible for many patients, especially those with adverse social determinants of health. The COVID-19 pandemic also has severely limited in-patient office visits for all patients. Thus, initial BP screening may more commonly have to occur within patients' homes or community settings," wrote Eric Peterson, MD, MPH, of UT Southwestern Medical Center in Dallas, and colleagues in another .

"Although we applaud the increased recognition of the significant impact of undiagnosed or untreated hypertension on CVD [cardiovascular disease], it is necessary to question whether the recommended two-stage screening method will further worsen or will decrease racial/ethnic disparities in BP control," said Keith Ferdinand, MD, of Tulane University School of Medicine in New Orleans, and Angela Brown, MD, of Washington University School of Medicine in St. Louis, in their .

In any case, ABPM is still not widely available, and it poses its own problems for access.

"Until reimbursement improves, self-measured BP remains a luxury that may contribute to the already persistent, longstanding, and unacceptable disparities in hypertension outcomes, specifically among racial/ethnic minority groups, such as Black and Hispanic/Latinx individuals, and disadvantaged populations," Ferdinand and Brown wrote.

"We reported in a 2017 study that clinician-level barriers to ABPM include the need for staff training, time constraints in patient preparation, and inaccessibility of equipment and specialists to whom clinicians could refer their patients for ABPM. There are also patient-level barriers, including low patient tolerability to ABPM and sleep disturbance," noted Shimbo's group.

"Therefore, without effective strategies for the implementation of ABPM, the well-intentioned 2021 USPSTF recommendation statement, which considers ABPM the reference standard for out-of-office BP monitoring, will have little impact on hypertension screening among U.S. adults," they continued.

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