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New Hypertension Guidelines: JNC 7

Physicians and patients alike should pay more attention to controlling blood pressure at the newly defined "prehypertensive" stage.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) incorporates evidence published since JNC 6 was issued in 1997. JNC 7 simplifies the classification of blood-pressure levels and outlines how to use this new classification scheme for hypertension prevention and management.

BP Scheme for Adults (in mm Hg)

• Normal: systolic BP <120 and diastolic BP <80
  
• Prehypertension: SBP 120-139 or DBP 80-89
  
• Stage 1 hypertension: SBP 140-159 or DBP 90-99
  
• Stage 2 hypertension: SBP 160 or DBP 100
  

The Essential Points of JNC 7:

• For patients age 50 or older, elevated SBP is a stronger cardiovascular risk factor than elevated DBP.
  
• Within the BP range of 115/75 mm Hg to 185/115 mm Hg, each increment of 20/10 mm Hg doubles cardiovascular risk.
  
• Prehypertension warrants management with lifestyle modification (e.g., low-salt diet, regular physical activity).
  
• For patients with hypertension, the basic BP-control target is <140/<90 mm Hg, but the target is <130/<80 mm Hg for patients with diabetes or renal disease.
  
• Thiazide diuretics are recommended as initial therapy for uncomplicated hypertension, either alone or in combination with other agents. This recommendation is supported by an accompanying meta-analysis of 42 clinical trials (192,478 participants) done by researchers who were independent of the guideline authors; the meta-analysis showed that low-dose diuretics were significantly better than placebo for preventing coronary heart disease, heart failure, stroke, and all-cause mortality. No other drug class was significantly better than low-dose diuretics for preventing these outcomes.
  
• Most hypertensive patients will require 2 or more medications to achieve BP goals. When initial BP is more than 20/10 mm Hg above goal, clinicians should consider initiating therapy with 2 agents, usually including a diuretic.
  
• The authors emphasize the importance of the physician-patient relationship and patient motivation in fostering treatment adherence.
  

Comment: Using JNC 7 as a point of departure, an editorialist argues that hypertension control will improve only with substantial changes in the delivery of chronic-disease care and in how the public views lifestyle changes. Hypertension is an easily diagnosed and (potentially) easily treated problem. Nevertheless, despite more than 30 years of guidelines exhorting physicians and physicians exhorting patients, primary care physician behavior and patient lifestyle modification have not changed enough to result in appropriate levels of detection and control of hypertension.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine May 30, 2003

Citation(s):

Chobanian AV et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003 May 21; 289:2560-72.

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• Medline abstract (Free)

Psaty BM et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: A network meta-analysis. JAMA 2003 May 21; 289:2534-44.

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• Medline abstract (Free)

Kottke TE et al. JNC 7 -- It's more than high blood pressure. JAMA 2003 May 21; 289:2573-5.

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• Medline abstract (Free)