BEFORE IT RISES
If your patients' blood pressure is between 120/80 and 139/89 mm Hg, don't dismiss it as normal. Rather, consider it "prehypertensive," and give strong advice on "health-promoting lifestyle modifications" to prevent the emergence and progression of cardiovascular disease.
This was just one of the new recommendations that came with the May release of the Seventh Report of the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure (JNC 7) of the National Heart, Lung, and Blood Institute (NHLBI). Published by the Journal of the American Medical Association, the seventh report was prepared in light of the growing body of knowledge on hypertension that had come since the release of the sixth report in 1997. In the past six years alone, more than 30 clinical studies had yielded significant findings on how to better deal with high blood pressure. Said Dr. Aram Chobanian, chair of the joint national committee: "These findings have been remarkably consistent in demonstrating the critical importance of lowering blood pressure, irrespective of age, gender, race, or socioeconomic status."
Dr. Claude Lenfant, NHLBI director, said that new evidence has shown that artery damage "begins at fairly low blood pressure levels, those formerly known considered normal and optimal." He added that the new prehypertension category will hopefully "prompt people to take preventive action early."
Worldwide there are about a billion hypertensive adults. Various studies have already shown that an ageing population has a higher likelihood to develop hypertension; the Framingham Heart Study, for instance, has some evidence suggestive that normotensive 55-year-olds have a 90-percent lifetime risk of developing hypertension. The link between hypertension and the development of CVD has also been widely studied, showing that increases in blood pressure translate to a direct increase in one's chance of a heart attack, heart failure, stroke, and kidney disease.
Prehypertension
Approved by the coordinating committee of the NLHBI's National High Blood Pressure Education Program, the new guidelines address 10 issues in hypertension control: a new classification of blood pressure, cardiovascular disease risk, benefits of lowering blood pressure, blood pressure control rates, accurate blood pressure measurement in the office, ambulatory blood pressure monitoring, self-measurement of blood pressure, patient evaluation, treatment, and other special considerations.
One of the major points of departure in JNC 7 is the modification in classifying hypertension. Aside from the addition of a "prehypertensive" category, what JNC 6 used to consider stage two and three are now joined. Explained Chobanian: "Stages two and three were combined because their treatment is essentially the same. The new prehypertension category should alert people to their real risk from high blood pressure."
Patients classified as "prehypertensive" are generally told about the risks they are facing, but they don't have to begin drug therapy yet-unless they suffer from such conditions as diabetes and kidney disease. Also, the report stresses that no matter the classification of hypertension-even including people considered normal-the adherence to a healthy lifestyle should be constant. Specifically, the report recommends adopting the Dietary Approach to Stop Hypertension (DASH) eating plan, which is a diet rich in fruits, vegetables, and dairy products with reduced saturated and total fat content. The shedding of unneeded pounds, reduction of dietary sodium, involvement in physical activity, moderation of alcohol consumption, and smoking cessation also have considerable positive effects on blood pressure lowering.
Drug Therapy
There have been a significant number of wide-scale clinical trials involving antihypertensive drugs in the past years. Most of them, particularly the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), show that diuretics are "virtually unsurpassed" in preventing the cardiovascular complications of hypertension. The report notes, however, that despite the findings, diueretics remain "underutilized." It further states that diuretics "enhance the antihypertensive efficacy of multidrug regimens, can be careful in achieving BP control, and are more affordable than other antihypertensive agents." Among the other drugs that have shown positive outcomes in reducing hypertension's cardiovascular complications are angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, and calcium channel blockers.
The report therefore recommends the use of thiazide-type diuretics either alone or in combination with another class of drug in hypertensive patients without comorbidities. Once drug therapy is in place, patients must return for follow-up at least once a month, until BP targets are achieved.
For patients who are seen with "compelling indications (viz., deemed high-risk)," the above-mentioned drugs may also be used, although caution must be exercised, and each treatment plan must be adjusted to the patient's specific needs.
Patient Power
Even if doctors actively do their part in lowering their patients' blood pressure, everything still lies in the patients' hands. Said Dr. Ed Roccella, executive secretary of the joint committee: "No treatment will work unless patients stay on it…The guidelines incorporate information from behavioral studies and offer advice to clinicians on how to motivate patients to stick with their treatment. It's crucial to build trust and make sure patients understand their treatment and feel able to voice their concerns."
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