BP guidelines establish pre-hypertension diagnosis

New level to identify at-risk individuals earlier

New clinical practice guidelines for the prevention, detection, and treatment of high blood pressure have been released by the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, MD.

The guidelines, approved by the coordinating committee of the NHLBI’s National High Blood Pressure Education Program, include altered blood pressure categories, featuring a new "pre-hypertension" level, which covers about 45 million American adults. The guidelines also streamline steps by which physicians diagnose and treat patients, and recommend the use of diuretics as part of the drug treatment plan for high blood pressure in most patients.

Here are the key aspects of the guidelines:

  • Former blood pressure definitions are changed as follows: normal, less than 120/less than 80 mm Hg; pre-hypertension, 120-139/80-89; stage 1 hypertension, 140-159/90-99; stage 2 hypertension, at or greater than 160/at or greater than 100. The previous categories were optimal, normal, high-normal, and hypertension stages 1, 2, and 3.
  • Simplified and strengthened drug treatment recommendations. Use of diuretics, either alone or in combination, is recommended for most patients. The report says they currently are not being used sufficiently.
  • Use of additional drugs for severe hypertension or to lower blood pressure to the desired level. According to the report, most people will need two, and at times three or more, medications to lower blood pressure to the desired levels.
  • The recommendation that clinicians work with patients to agree on blood pressure goals and develop a treatment plan.

The guidelines do not recommend drug therapy for those with pre-hypertension unless it is required by another condition, such as diabetes or chronic kidney disease, but it advises them to make any needed lifestyle changes.

Getting to goal is emphasized

"The important thing for us is that we emphasized the need again to get to goal blood pressure. This makes it easier to follow the guidelines and to focus not so much on drugs as getting to goal," says Henry R. Black, MD, one of the co-authors of the new guidelines. Black is Roberts Professor and chairman in the department of preventive medicine at Rush-Presbyterian St. Luke’s Medical Center in Chicago, and associate vice president for research and dean for research.

"Our drug recommendations are based on clinical trials, where diuretics were unsurpassed," he continues. "It is also an enormous leap to recommend that for [blood pressure greater than] 160/ 100, two drugs should be used. A lot of clinical trial studies show you just can’t get to goal without two drugs. And if you do achieve goal, we are reasonably confident that attendant savings will come in fewer strokes, fewer heart attacks, fewer episodes of heart and renal failure, and even possibly lower mortality."

According to statistics cited in the report, about 30% of hypertensives don’t know they have hypertension, and it’s a fair guess that many more pre-hypertensives also are unaware of their condition. Some of these people will be admitted to hospitals, often for some acute condition. Do the new guidelines put extra pressure on health care professionals and quality managers in the hospital?

"We’ve been after people for a long time to recognize that hypertension is important, and that has not changed, but with the new classification, we may hopefully ring an alarm bell for people who have been complacent about it," Black says.

As for hospital professionals, Black notes that in an acute condition or when under stress, a patient’s blood pressure would naturally tend to be elevated.

"But if it is elevated when the patient is under stress, a situation like that is a reminder to go back and have the blood pressure rechecked once the patient is stable," he notes. "Although we have an opportunity there to make the diagnosis, we often ignore it and shouldn’t," Black continues. "Any time a person has contact with a health care provider and the blood pressure is not normal, he should be told about it, and arrangements should be made to follow up."

Does the hospital have a specific responsibility to follow hypertensive patients after discharge? "It depends on where they go," Black says.

"If the hospital and clinic [where the primary care provider is] are part of the same group, they do. It would be nice if we could get that [kind of follow-up] done, but here we’re just lucky if they get follow-ups at all," he adds.

Need More Information?

For more information, contact:

• Henry R. Black, MD, Department of Preventive Medicine, Rush-Presbyterian St. Luke’s Medical Center, 1700 W. Van Buren, Suite 470, Chicago, IL 60612. Telephone: (312) 942-2798.