The Moment of Truth on Hypertension

Article excerpt

At least 122 million Americans are overweight or obese. (1) Mean sodium intake is approximately 4,100 mg per day for men and 2,750 mg for women, 75 percent of which comes from processed foods. (2, 3) Fewer than 20 percent of Americans engage in regular physical activity, (4) and fewer than 25 percent consume five or more servings of fruits and vegetables daily. (5) The prevalence of these characteristics is high. The prevention and management of hypertension are major public health challenges for the United States.

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For more than three decades, the National Heart, Lung, and Blood Institute (NHLBI) has administered the National High Blood Pressure Education Program (NHBPEP) Coordinating Committee, a coalition of major professional, public, and voluntary organizations and federal agencies to issue guidelines and advisories designed to increase awareness, prevention, treatment, and control of hypertension (high blood pressure [BP]).

Since inception, there were several published joint reports. The current Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) published in May 2003 was based on the premise that there were many new hypertension observational studies and clinical trials since the last report was published in 1997, (6) the need for a new, clear, and concise guideline that would be useful to clinicians; the need to simplify the classification of BP; and a clear recognition that the JNC reports did not result in maximum benefit to the public.

The purpose of JNC 7 is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are as follows: (7)

* in those older than age 50, systolic blood pressure (SBP) of > 140 mmHg is a more important cardiovascular disease (CVD) risk factor than the diastolic BP (DBP);

* beginning at 115/75 mmHg, CVD risk doubles for each increment of 20/10 mm Hg;

* those who are normotensive at 55 years of age will have a 90 percent lifetime risk of developing hypertension;

* prehypertensive individuals (SBP120-139 mmHg or DBP 80-89 mmHg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD;

* for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes;

* two or more antihypertensive medications will be required to achieve goal BP (<140/90 mmHg, or <130/80 mmHg for patients with diabetes and chronic kidney disease);

* for patients whose BP is > 20 mmHg above the SBP goal or 10 mmHg above the DBP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered.

Regardless of therapy or care, hypertension will only be controlled if patients are motivated to stay on their treatment plan. As the report states, the Committee continues to recognize that the responsible physician's judgment remains paramount.

Substantial Improvements

Fifty million or more Americans have high BP warranting some form of treatment according to the National Health and Nutrition Examination Survey (NHANES). (8, 9)

Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals, and approximately 7.1 million deaths per year may be attributable to hypertension. The World Health Organization (WHO) reports that suboptimal BP (>115 mmHg SBP) is responsible for 62 percent of cerebrovascular disease (CVD) and 49 percent of ischemic heart disease (IHD), with little variation by sex. In addition, suboptimal BP is the number one attributable risk factor for death throughout the world. (10)

Considerable success has been achieved in the past in meeting the goals of the program. The awareness of hypertension among Americans has improved from a level of 51 percent in the period of 1976-1980 to 70 percent in 1999-2000 (Table 1). …