May Is National High Blood Pressure Education Month
NHLBI Issues New High Blood Pressure Clinical Practice
Guidelines
The National Heart, Lung, and Blood Institute (NHLBI) today released
new clinical practice guidelines for the prevention, detection,
and treatment of high blood pressure. The guidelines, which were
approved by the Coordinating Committee of the NHLBI’s National
High Blood Pressure Education Program (NHBPEP), feature altered
blood pressure categories, including a new “prehypertension”
level–which covers about 22 percent of American adults or
about 45 million persons.
The new guidelines also streamline the steps by which doctors diagnose
and treat patients, and recommend the use of diuretics as part of
the drug treatment plan for high blood pressure in most patients.
Called “The
Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure,” the
guidelines will appear in the May 21, 2003, issue of The Journal
of the American Medical Association (JAMA). But, due to their importance,
they will be available on May 14, 2003, on the JAMA
Web site (jama.com) in an expedited version.
The guidelines were prepared by a special committee of the NHBPEP,
which represents 46 professional, voluntary, and Federal organizations,
and reviewed by 33 national hypertension experts and policy leaders.
The NHBPEP issues new guidelines when warranted by scientific advances.
The last guidelines were issued in November 1997.
“Since 1997, much more has been learned about the risk of
high blood pressure and the course of the disease,” said NHLBI
Director Dr. Claude Lenfant. “Americans’ lifetime risk
of developing hypertension is much greater than we’d thought.
For instance, those who do not have hypertension at age 55 have
a 90 percent risk of going on to develop the condition.
“We also now know that damage to arteries begins at fairly
low blood pressure levels–those formerly considered normal
and optimal,” he continued. “In fact, studies show that
the risk of death from heart disease and stroke begins to rise at
blood pressures as low as 115 over 75, and that it doubles for each
20 over 10 millimeters of mercury (mm Hg) increase. So the harm
starts long before people get treatment.
“Unless prevention steps are taken, stiffness and other damage
to arteries worsen with age and make high blood pressure more and
more difficult to treat. The new prehypertension category reflects
this risk and, we hope, will prompt people to take preventive action
early.”
“The past six years have brought results from more than 30
clinical studies worldwide, many of which were funded by the NHLBI,”
said Dr. Aram V. Chobanian, Dean of Boston University School of
Medicine in MA and Chair of the Joint National Committee that produced
the new guidelines. “These findings have been remarkably consistent
in demonstrating the critical importance of lowering blood pressure,
irrespective of age, gender, race, or socio-economic status. The
data allow us to create a set of recommendations that are easier
to use than past guidelines, which should in turn make it easier
for clinicians to treat their patients’ hypertension.”
High blood pressure is a major risk factor for heart disease and
the chief risk factor for stroke and heart failure, and also can
lead to kidney damage. It affects about 50 million Americans–one
in four adults. Treatment seeks to lower blood pressure to less
than 140 mm Hg systolic and less than 90 mm Hg diastolic for most
persons with hypertension (less than 130 systolic and less than
80 diastolic for those with diabetes and chronic kidney disease).
The guidelines include new data on U.S. control, awareness, and
treatment rates for high blood pressure. According to a national
survey, 70 percent of Americans are aware of their high blood pressure,
59 percent are being treated for it, and 34 percent of those with
hypertension have it under control. Those percentages represent
a slight improvement over rates for 10 years ago, when 68 percent
of Americans were aware of their high blood pressure, 54 percent
were being treated for it, and 27 percent of those with hypertension
had it under control. By contrast, about 25 years ago, 51 percent
were aware of their high blood pressure, 31 percent were being treated,
and 10 percent of those with hypertension had it under control.
“Though improved, the treatment and control rates are still
too low,” said Chobanian. “The new guidelines zero in
on this problem, recommending factors that often lead to inadequate
control such as not prescribing sufficient medication. The guidelines
stress that most patients will need more than one drug to control
their hypertension and that lifestyle measures are a crucial part
of treatment.
“Another key factor is the need for clinicians to pay more
attention to systolic blood pressure in those age 50 and older,”
he continued. “From mid-life on, systolic hypertension is
a more important cardiovascular risk factor than diastolic. It’s
also much more common and harder to control.”
Key aspects of the new guidelines include:
- A new “prehypertension” level and merging of other
categories. The new report changes the former blood pressure definitions
to: normal, less than 120/less than 80 mm Hg; prehypertension,
120-139/80-89 mm Hg; stage 1 hypertension, 140-159/90-99 mm Hg;
stage 2 hypertension, at or greater than 160/at or greater than
100 mm Hg. The 1997 categories were optimal, normal, high-normal,
and hypertension stages 1, 2, and 3.
“Stages 2 and 3 were combined because their treatment is
essentially the same,” said Chobanian. “The new prehypertension
category should alert people to their real risk from high blood
pressure.”
The guidelines do not recommend drug therapy for those with prehypertension
unless it is required by another condition, such as diabetes or
chronic kidney disease. But the report advises them–and
encourages those with normal blood pressures–to make any
needed lifestyle changes. These include losing excess weight,
becoming physically active, limiting alcoholic beverages, and
following a heart-healthy eating plan, including cutting back
on salt and other forms of sodium. The report also recommends
that, for overall cardiovascular health, persons quit smoking.
As in the 1997 guidelines, the new report recommends Americans
follow the DASH–Dietary Approaches to Stop Hypertension–eating
plan, which is rich in vegetables, fruit, and nonfat dairy products.
Clinical studies have shown that DASH significantly lowers blood
pressure. The decreases are often comparable to those achieved
with blood pressure-lowering medication.
- Simplified and strengthened drug treatment recommendations.
The guidelines recommend use of a diuretic, either alone or in
combination with another drug class, as part of the treatment
plan in most patients. The report notes that even though many
studies have found diuretics to be effective in preventing hypertension’s
cardiovascular complications, they are currently not being sufficiently
used.
The guidelines also list other drug classes that have been shown
to be effective in reducing hypertension’s cardiovascular
complications and that may be considered to begin therapy: angiotensin
converting enzyme (ACE) inhibitors, angiotensin receptor blockers,
beta-blockers, and calcium channel blockers. The report also gives
the “compelling indications”–or high-risk conditions–for
which such drugs are recommended as initial therapy.
- Use of additional drugs for severe hypertension or to lower
blood pressure to the desired level. According to the new report,
most persons will need two, and at times three or more, medications
to lower blood pressure to the desired level.
- The guidelines also recommend clinicians work with patients
to agree on blood pressure goals and develop a treatment plan.
“No treatment will work unless patients stay on it, no matter
how careful the clinician,” said NHBPEP Coordinator Dr.
Ed Roccella. “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.”
To raise awareness about the dangers of high blood pressure, NHLBI
is developing special Web pages and educational materials for health
care professionals, patients, and the public. These include an updated
“Your Guide To Lowering High Blood Pressure” Web page,
which can be found at www.nhbli.nih.gov/hbp.
“The bottom line is that Americans must change how they think
about blood pressure,” said Roccella. “The sooner they
take action, the better. It’s vital that they adopt a heart-healthy
lifestyle early, even if their blood pressure is normal.
“May is National High Blood Pressure Education Month, a good
time for people to take stock of their heart health–along
with the steps necessary to protect it,” he added.
Information and resources regarding National High Blood Pressure
Education Month are available at http://www.nhlbi.nih.gov/hbp/index.html.
The guidelines and related information are available at http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm.
To interview an NHLBI spokesperson about the new guidelines, call
the NHLBI Communications Office at (301) 496-4236. To interview
Dr. Chobanian, call Gina DiGravio at the Boston University School
of Medicine’s Corporate Communications Office at (617) 638-8491.
NHLBI press releases and other materials, including those related
to high blood pressure, are available online at www.nhlbi.nih.gov.
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