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Hypertension standards reveal more patients at risk

New findings warn that blood pressure will inevitably reach the danger level unless patients lose weight, the salt shaker and sedentary habits.

By Susan J. Landers, AMNews staff. June 2/9, 2003.

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Washington -- Could new hypertension guidelines released May 14 by the National Heart, Lung and Blood Institute perhaps raise everyone's blood pressure a notch or two?

At least figuratively, yes.

With this article   Key rule changes   New BP classifications   See related content

Physicians may face new challenges convincing patients with blood pressure formerly considered normal to high-normal that they are actually in a higher risk category -- that of "prehypertension." An estimated 45 million Americans fall into this grouping.

The updated guidelines reflect a growing body of science indicating that cardiovascular damage begins at much lower blood pressure levels than previously thought. The change has very real implications for physicians who will now have to decide how much weight to give the recommendations and how to adjust their efforts to educate a larger patient population about the importance of lifestyle in preventing heart disease.

"The first thing that's going to happen will be a wailing and gnashing of teeth," said Raymond Townsend, MD, director of the University of Pennsylvania's hypertension program.

"Physicians are also going to ask, 'Is this really necessary? Is this a good idea?' " he added. "Eventually, as they scratch at the data, people are going to come around to the idea that maybe we should be doing more at an earlier point."

Even if only a few people decide to skip the ice cream cone, walk a little more and put the salt shaker away, it will go a long way toward preventing cardiovascular illness, he said.

Henry Black, MD, chair of the Dept. of Preventive Medicine at Rush Presbyterian Medical Center in Chicago, and an author of the guidelines, said he would be disappointed if the guidelines didn't generate some controversy.

"We wanted them to be a not-so-gentle reminder to [physicians], patients and people who aren't patients yet to pay attention to their blood pressure," Dr. Black said.

The new category of prehypertensives is the most visible change advanced in the "Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure."

The guidelines were published in the May 21 JAMA but were posted a week earlier on the JAMA Web site.

A physician's job should now include notifying these patients -- with empathy -- of their high risk for developing hypertension and the serious diseases that often accompany it, the guidelines' authors said.

Studies show that the risk of death from heart disease and stroke begins to rise at blood pressures as low as 115/75 and it doubles for each 20-over-10 mmHG increase, said Claude Lenfant, MD, director of the NHLBI, which sponsored the study.

"At age 55, those who do not have high blood pressure have a 90% chance of developing it at some point in their lives," said Aram V. Chobanian, MD, dean of Boston University's School of Medicine and chair of the panel that developed the guidelines.

Optimal blood pressure readings have dropped over the years. "At one point we thought the proper blood pressure reading should be your age plus 100," said Edward J. Roccella, PhD, MPH, coordinator of the National High Blood Pressure Education Program. Low blood pressures were thought to be dangerous. Those days are long gone.

Additional ammunition

The new guidelines might help primary care physicians with one of their more difficult tasks -- convincing patients to start often-postponed diet or exercise programs.

"The guidelines do give me another tool to say this is why it's so important that you come back at this regular interval to check your blood pressure," said Michael Fleming, MD, president-elect of the American Academy of Family Physicians.

While pleased that the guidelines support such lifestyle changes as better diet and exercise habits, Dr. Fleming said he didn't think they would change the way he counsels patients. "One of the things family physicians do as a matter of course is to monitor people at high risk, such as those with family history of heart disease and those who have complicating factors like diabetes or high lipids."

"I think prevention is always the best policy, and making lifestyle recommendations is always a good idea," agreed Vincenza Snow, MD, an internist who is also senior medical associate for scientific policy at the American College of Physicians.

Dr. Fleming, who is in private practice in Shreveport, La., also favored the evidence-based outcomes measures employed by the guidelines regarding medications. "There is not a lot of anecdotal stuff in there."

The guidelines do not suggest that any medications be prescribed for most members of the prehypertensive set, relying instead on lifestyle changes to hold off the upward progression. But for those with readings of 140/90 mmHG or higher, the guidelines recommend that diuretics, either alone or in combination with another class of drugs, be tried first.

The guidelines also note that most patients will need two and sometimes three or more medications to lower blood pressure to the desired level.

"I think what's important to understand is that this is a recommendation that is solidly based on what the evidence is right now," Dr. Black said. "It's not about using more drugs. On the contrary, it is about paying serious attention to lifestyle."

The recommendation for lifestyle changes is a familiar one to most doctors, said Lawrence Appel, MD, MPH, a professor of medicine at Johns Hopkins University in Baltimore.

"We had recommended in the past that people make lifestyle changes, it's just a little more graphic the way the guidelines present it," he said.

The basic problem of getting patients to make these changes remains. "Physicians can give advice but they are swimming up a very swift stream right now," he added, pointing to the supersizing of foods and the axing of school-based physical education.

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 ADDITIONAL INFORMATION: 

Copyright 2003 American Medical Association. All rights reserved.
 

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