(Circulation. 1998;97:307-308.)
© 1998 American Heart Association, Inc.
New Rules for High Blood Pressure
Ruth SoRelle, Circulation Newswriter
In its sixth report, the Joint National Committee on
Prevention, Detection, Evaluation and Treatment of High Blood Pressure
had a succinct message for doctors: complacency is hurting your
patients.
Studies indicate that three-fourths of people with high blood
pressure do not have it controlled, said Sheldon G. Sheps, MD, emeritus
professor of medicine at the Mayo Clinic in Rochester, Minn, and
chairman of the committee.
"One quarter of people with high blood pressure are
controlled," he said. "One quarter are on medication but not
controlled. One half are not on medications at all," he said.
"It's important to point out that there are some signals that
things are not going as well as we thought," said Dr Sheps. "Not
enough Americans are controlling their high blood pressures. Related
diseases are not declining as they have in the past. These things
signal the need to renew our efforts to control and prevent high blood
pressure."
But if the panel had a warning for doctors, it also heeded a
previous call from physicians that the new report should be easy to
read, straightforward, and specific as to what the committee was
recommending. Dr Sheps said the committee tried to meet all these
requirements while offering an aggressive new plan for the control of
high blood pressure in stratified population groups with specific risk
factors.
The picture for high blood pressure control was good from
1976-1991. In 1988-1991 (the period of the National Health and
Nutrition Examination Survey III, phase 1), 73% of people with high
blood pressure knew of their condition compared to only 51% in
1976-1980 (NHANES II). Fifty-five percent were under treatment in the
NHANES III, phase 1 study period, as compared to only 31% in NHANES
II. And 29% of those in the latter period had their blood pressure
controlled to 
140/90 mm Hg, compared to only 10% in the
earlier group.
But by 1991-1994, phase II of NHANES III, the picture had begun
to get bleaker. Only 68.4% of patients knew of their diagnosis, only
53.6% were receiving treatment, and only 27.4% had their hypertension
under control.
The committee estimated that if previous increases had continued,
the trend established between 1976-1980 and 1988-1991, there would have
been an increase in 1991-1994 in awareness to 76.2%, in treatment to
59.6%, and in control to 31.2% instead of the levels shown in Table
1.
Associated with these changes have been age-adjusted increases in
stroke rates. The decline in age-adjusted coronary heart
disease is leveling off.
The rates of end-stage renal disease have also increased during
that period, as has the prevalence of heart failure.
Dr Sheps noted that the new treatment guidelines refer to three
stages of hypertension and three stages of risk factors as a matrix
against which physicians can determine therapy. Along with the
recognition of high normal blood pressure as problematic,
those are the new elements of the report that he described as
"succinct and user-friendly."
"These new guidelines offer aggressive new strategies to
improve the effectiveness of high blood pressure treatment," said Dr
Sheps. The strategies are based on a patient's risk status as
determined by blood pressure and co-existing risk factors, he said.
Health care providers said they wanted something contemporary and
succinct, said Dr Sheps. "If someone wants to stick something up on
the wall that says what I do, then that's all right."
For example, high normal blood pressure of between
130-139/85-89 mm Hg is included in the risk stratification.
In patients with high normal blood pressure with no or only one
concurrent risk factor that does not include diabetes, target organ, or
clinical cardiac disease, the guidelines suggest lifestyle modification
to lower blood pressure even further. But with a risk factor of target
organ or clinical cardiac disease, diabetes and/or other risk factors,
the guidelines recommend drug therapy, no matter what the patient's
blood pressure is.
Patients with stage 1 blood pressures of between
140-159/90-99 mm Hg who have no other risk factors should try
lifestyle modifications for a year before drug therapy is used. But if
these patients have one risk factor other than diabetes, target organ,
or clinical cardiac disease, their lifestyle modification should be
tried for only 6 months before initiation therapy.
For patients with blood pressure above 150/100 mm Hg,
drug therapy is recommended, no matter what the patients' risk
factors.
The report notes that most patients with diagnosed hypertension
do not make lifestyle changes or take enough medication to achieve
control. The report suggests lifestyle modifications involving diet,
weight reduction, moderation in alcohol and sodium intake, and regular
exercise for people with high blood pressure, including those who are
working to reduce pressure without medications and those taking
medications.
When medication is considered, the panel recommended that doctors
consider cost. It recommended generic formulations and advising
patients to check prices at different sources of the drugs. Physicians
should start with lowest recommended doses and go up from there.
Dr Sheps said addressing the cost issues was important. "We
wanted to give physicians ways to reduce costs by recommending generic
drugs and lower doses," he said.
For the first time, the panel recommended classes of drugs for
specific comorbidities, such as ACE inhibitors for Type 1
diabetes with proteinuria, or ACE inhibitors and
diuretics for heart failure.
Norman Kaplan, MD, of the University of Texas Southwestern
Medical School in Dallas, called the suggestions "compelling
indicators." He said that while one has to consider the competing
indicators, doctors should be innovative and work to achieve blood
pressure control. "If the goal is not reached, change the drug or add
more drugs to it. Consider referring the patient to a hypertension
specialist," he said.
Being aware of the special needs of special populations such as
children and women and minority groups is key in high blood pressure
control, said Keith Ferdinand, MD, of Heartbeats Life Center in New
Orleans. For example, African-Americans with high rates of high blood
pressure also have more end-stage renal disease, stroke, and myocardial
infarction, he said. When high blood pressure is detected in a
child, physicians should look carefully for a cause, he said.
"The main message we want to get out is `Get your blood
pressure controlled'," said Dr Sheps. "Don't be satisfied if your
blood pressure is not controlled."
