CALL TO ACTION
Hypertension detection, treatment and control
A call to action for cardiovascular specialists1
Daniel Levy, MD, FACC, (lead author)*    ||,
C. Noel Bairey Merz, MD, FACC* ||,
Robert J. Cody, MD, FACC*,1,
Fetnat M. Fouad-Tarazi, MD, FACC,
Charles K. Francis, MD, FACC,
Marc A. Pfeffer, MD, FACC,
Neal A. Scott, MD, PhD, FACC||,
H. J. C. Swan, MD, PhD, FACC* ||,
Malcolm P. Taylor, MD, FACC* || and
Myron H. Weinberger, MD, FACC¶
* University of Michigan Health System, Ann Arbor, Michigan, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
Cardiovascular Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
|| Emory University Hospital, Atlanta, Georgia, USA
¶ Indiana University Medical Center, Indianapolis, Indiana, USA
Reprint requests and correspondence: Dr. Daniel Levy, Director, Framingham Heart Study, National Heart, Lung, and Blood Institute, 5 Thurber Street, Framingham, Massachusetts 01702
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Magnitude of the problem
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Hypertension affects about 25% of the adult population in the United States, or about 50 million people (1,2). Over the past 30 years great strides have been made in improving awareness, treatment and control of high blood pressure (1). These advances in blood pressure control have contributed to dramatic declines in morbidity and mortality attributed to hypertension. Over this period of time, death rates from stroke have fallen by about 60%, and death rates from coronary heart disease have fallen by over 50% (3,4). Unfortunately, recent evidence suggests that in the last few years the improvements in awareness, treatment and control of high blood pressure have leveled off and only about a quarter of adults with hypertension are currently controlled (Table 1) (5). In a parallel manner, the national declines in stroke and heart disease mortality also have flattened (3,4).
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Defining hypertension and hypertension control
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Hypertension is defined as a systolic blood pressure  140 mm Hg or a diastolic pressure 90 mm Hg or the current use of medication for treatment of high blood pressure (5). The classification of blood pressure stages is summarized in Table 2. Hypertension control is defined as achieving and maintaining blood pressure levels below 140 mm Hg systolic and 90 mm Hg diastolic. Even lower levels are recommended for patients with heart failure, diabetes and renal disease (5).
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Causal role of hypertension in cardiovascular disease
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Observational data have long indicated that cardiovascular disease risk increases as levels of blood pressure advance (6–9). The association of hypertension with risk is especially notable for stroke (6), heart failure (8) and endstage renal disease (9). Although clinical practice and guidelines on hypertension treatment once focused primarily on elevation of diastolic blood pressure, the risks associated with systolic hypertension have now been well established. This is especially important in older persons in whom isolated systolic hypertension is the most common form of hypertension (10).
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Benefits of hypertension control
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The causal role of blood pressure in the pathogenesis of cardiovascular disease is confirmed by the results of clinical trials documenting reductions in risk for stroke, heart failure and myocardial infarction in hypertensive patients whose blood pressure is lowered (11,12). Meta-analyses of clinical trials have indicated reductions in risk for stroke by more than 40% (11) and heart failure by about 50% (13,14). Clinical trials of blood pressure treatment in patients with isolated systolic hypertension also have shown dramatic reductions in cardiovascular risk in response to treatment (15,16).
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What’s new in JNC VI
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The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) (5) is an update of the previous guideline (JNC V) (17) and contains important new information for clinicians. JNC VI was developed using evidence-based medicine and expert consensus to make recommendations to clinicians. It provides a contemporary approach to hypertension prevention and control. New information incorporates data from phase 2 of the third National Health and Nutrition Examination Survey, updated information on the year 2000 objectives for the nation, a discussion of new pharmacologic therapies (including combination drugs), the role of managed care in the treatment of high blood pressure and information from recently completed randomized controlled trials on hypertension prevention and treatment. In addition, the report contains a guide to help clinicians individualize treatment by stratifying patients’ risks. A revised treatment algorithm, as well as detailed and updated strategies for special populations and situations, is provided to guide clinicians.
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The role of cardiologists in managing hypertension
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The new recommendations for hypertension treatment are based on not only the level of blood pressure but also on the level of other risk factors (Table 3). Hypertensive patients with heart disease or target organ damage, who are often in the care of a cardiologist, fall into a high risk category (Risk Group C). Because of their high risk, hypertensive patients with heart disease have a lower treatment threshold and a lower target blood pressure. These are patients in whom blood pressure control is crucial for ensuring cardiovascular wellness. Because hypertensive target organ damage is preventable and predisposes to the development of clinical cardiovascular disease, early and aggressive treatment of hypertension remains an important public health challenge that must be addressed by cardiologists.
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A call to action
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The risks associated with high blood pressure are clear. The evidence that hypertension treatment can reduce risk for cardiovascular disease complications is irrefutable. Nevertheless, rates of awareness, treatment and control of high blood pressure remain unacceptably low (1). Cardiologists provide primary and consultative care to the highest risk hypertensive patients, who benefit most from blood pressure control. JNC VI is an invaluable desktop resource that can assist cardiologists in achieving far higher rates of blood pressure control in their patients with high blood pressure.
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Footnotes
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1 The above is an editorial written by the Members of Hypertensive Diseases Committee, American College of Cardiology. 
1 Robert J. Cody, MD, FACC, Chair, Hypertensive Diseases Committee of the American College of Cardiology.
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References
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1. Burt VL, Culter JA, Higgins M, et al. Trends in the prevalence, awareness, treatment and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension. 1995;26:60–69[Abstract/Free Full Text]
2. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension. 1995;25:305–313[Abstract/Free Full Text]
3. National Center for Health Statistics, Division of Vital Statistics, Public Use Data Tapes for U.S. mortality, 1970 to 1996. Hyattsville (MD): National Center for Health Statistics, 1997.
4. National Heart, Lung and Blood Institute. Morbidity and Mortality: 1998 Chartbook of Cardiovascular, Lung and Blood Diseases. Bethesda (MD): National Institutes of Health, 1998.
5. Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413–2446[Abstract/Free Full Text]
6. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke and coronary heart disease. Part 1. Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765–774[CrossRef][Medline]
7. O’Donnell CJ, Ridker PM, Glynn RJ, et al. Hypertension and borderline isolated systolic hypertension increase risks of cardiovascular disease and mortality in male physicians. Circulation. 1997;95:1132–1137[Abstract/Free Full Text]
8. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to congestive heart failure: insights into the time course of and risk factors for hypertensive left ventricular dysfunction. JAMA. 1996;275:1557–1562[Abstract/Free Full Text]
9. Klag MJ, Whelton PK, Randall BI, et al. Blood pressure and end-stage renal disease in men. N Engl J Med;334:13–8.
10. Sagic A, Larson MG, Levy D. The natural history of borderline isolated systolic hypertension. N Engl J Med. 1993;329:1912–1917[Abstract/Free Full Text]
11. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke and coronary heart disease. Part 2. Short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet. 1990;335:827–838[CrossRef][Medline]
12. Gueyffier F, Boutitie F, Boissel JP, et al. Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men. A meta-analysis of individual patient data from randomized controlled trials. The INDANA Investigators. Ann Intern Med. 1997;126:761–767[Abstract/Free Full Text]
13. Moser M, Herbert PR. Prevention of disease progression, left ventricular hypertrophy and congestive heart failure in hypertension treatment trials. J Am Coll Cardiol. 1996;27:1214–1218[Abstract]
14. Cutler J, Psaty BM, MacMahon S, Furberg CD. Public health issues in hypertension control: what has been learned from clinical trials. In: Laragh JH, Brenner BM, editors. Hypertension: Pathophysiology, Diagnosis and Treatment. New York: Raven Press, 1995:253–70.
15. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP): SHEP Cooperative Research Group. JAMA. 1991;265:3255–3264[Abstract/Free Full Text]
16. Staessen JA, Fagard R, Thijs L, et al. Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757–764[CrossRef][Medline]
17. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154–183[Abstract/Free Full Text]
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Magnitude of the problem
Defining hypertension and...