Editorials

Current Hypertension Control Is Just Not Good Enough

Am Fam Physician. 1998 Oct 15;58(6):1292-1296.

  Related Article

Dramatic decreases in hypertension-related mortality from strokes and heart attacks have occurred in the 25 years since the National High Blood Pressure Education Program (NHBPEP) began: a 59.0 percent reduction for stroke mortality and a 53.2 percent reduction for coronary heart disease (CHD) mortality. These decreases resulted from a concerted effort to encourage physicians to conduct blood pressure screening in their patients and treat hypertension and to inform the general population about the importance of knowing their own blood pressure values and seeking treatment for hypertension.

Among educational methods used by NHBPEP are periodic guidelines from the Joint National Committee (JNC) on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. The Sixth Report of the JNC (JNC-VI) has recently been published1; it details some unsettling trends, as discussed in the article by Kaplan.2 The first trend can be found in U.S. death rates for strokes and CHD from 1972 to 1994. The stroke curve is practically level, and the rate of decline of the age-adjusted mortality rates from CHD has slowed. Also, the incidence of end-stage renal disease related to hypertension continues to increase (Figure 1), as does the prevalence of CHD (Figure 2).

FIGURE 1.

Incidence rates of reported hypertensive end-stage renal disease therapy, 1978–1995.

View Large


FIGURE 1.

Incidence rates of reported hypertensive end-stage renal disease therapy, 1978–1995.


FIGURE 1.

Incidence rates of reported hypertensive end-stage renal disease therapy, 1978–1995.

FIGURE 2.

Prevalance of heart failure by age, 1976 to 1980 and 1988 to 1991.

View Large


FIGURE 2.

Prevalance of heart failure by age, 1976 to 1980 and 1988 to 1991.


FIGURE 2.

Prevalance of heart failure by age, 1976 to 1980 and 1988 to 1991.

Finally, findings from the recent Third National Health and Nutrition Examination Survey (NHANES III, phase 2)1  show that awareness, treatment rates and control of hypertension are lower than expected from previous trends (Table 1). In addition, recent reports show that blood pressure control had deteriorated in patients in a Minnesota survey3 and in a cohort of elderly persons in Iowa.4 These various trends, although unexplained, suggest that physicians should be more vigilant in controlling hypertension.

TABLE 1

Trends in the Awareness, Treatment and Control of High Blood Pressure in Adults, United States, 1976–1994

NHANES II (1976–1980)* NHANES III, phase 1 (1988–1991)* NHANES III, phase 2 (1991–1994)*

Awareness

51

73

68

Treatment

31

55

53

Control†

10

29

27


NHANES = National Health and Nutrition Examination Survey.

*—Data are percentage of adults aged 18 to 74 years with systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking anti-hypertensive medication.

†—Systolic blood pressure less than 140 mm Hg and diastolic blood pressure less than 90 mm Hg.

Used with permission from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413–46.

TABLE 1   Trends in the Awareness, Treatment and Control of High Blood Pressure in Adults, United States, 1976–1994

View Table

TABLE 1

Trends in the Awareness, Treatment and Control of High Blood Pressure in Adults, United States, 1976–1994

NHANES II (1976–1980)* NHANES III, phase 1 (1988–1991)* NHANES III, phase 2 (1991–1994)*

Awareness

51

73

68

Treatment

31

55

53

Control†

10

29

27


NHANES = National Health and Nutrition Examination Survey.

*—Data are percentage of adults aged 18 to 74 years with systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking anti-hypertensive medication.

†—Systolic blood pressure less than 140 mm Hg and diastolic blood pressure less than 90 mm Hg.

Used with permission from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413–46.

The goal for the treatment of hypertension is a blood pressure level of less than 140/90 mm Hg or as low as tolerated.1 The latter goal is important for patients with renal disease and hypertension because a reduction in blood pressure to 130/85 mm Hg or lower (125/75 mm Hg) in those who also have proteinuria (defined as over 1 g per 24 hours) is recommended to slow the progressive decline in the glomerular filtration rate.5 That hypertension itself without preexisting renal disease is a risk factor for end-stage renal disease was found in the long-term follow-up of several thousand men who were screened for the Multiple Risk Factor Intervention Trial6; this was particularly true among African Americans.

Another group deserving heightened attention is elderly persons, because they have a higher incidence of hypertension. For example, NHANES III7 found that the prevalence of hypertension was 60 percent in non-Hispanic whites, 71 percent in African Americans and 61 percent in Mexican Americans 60 years of age or older. Not only is the prevalence of hypertension among elderly persons an important consideration, but the number of elderly persons with hypertension is also important. These numbers have increased greatly, and increases will continue. By 2030, the number of U.S. citizens 65 years of age or older is expected to be 70 million—up from 33 million in 1994.8 Thus, unless hypertension can be prevented, millions of additional people will need treatment for high blood pressure.

Ample evidence now shows that drug therapy for elderly patients with hypertension can reduce the incidence of stroke and heart attack. The NHBPEP recently reviewed data from seven trials9; in all, benefit was achieved with drug therapy for stroke, CHD and cardiac failure. Isolated systolic hypertension was the focus of the Systolic Hypertension in the Elderly Program (SHEP) Trial.10 This trial was randomized and placebo controlled, and enrolled 4,736 participants 60 years of age or older. The patients in the trial first received chlorthalidone, then received atenolol, if necessary. Average pretreatment blood pressure values in the drug- and placebo-treated groups were 171/77 mm Hg and 170/76 mm Hg, respectively. Blood pressure values in the subjects who received treatment averaged 142/68 mm Hg over five years, and blood pressure values in the placebo group averaged 155/74 mm Hg (Figure 3). Strikingly, the difference of 13.6 mm Hg resulted in a reduced stroke rate of 36 percent and a reduced myocardial infarction rate of 27 percent. If such benefits can be achieved with minor decreases in blood pressure, imagine what might be gained by a tolerated reduction to even lower levels.

FIGURE 3.

Average systolic blood pressure and diastolic blood pressure during the Systolic Hypertension in the Elderly Program Follow-up.

View Large


FIGURE 3.

Average systolic blood pressure and diastolic blood pressure during the Systolic Hypertension in the Elderly Program Follow-up.


FIGURE 3.

Average systolic blood pressure and diastolic blood pressure during the Systolic Hypertension in the Elderly Program Follow-up.

It seems wise, therefore, that all physicians pay close attention to the blood pressure values that they achieve with treatment of their patients—be it with nonpharmacologic modalities or antihypertensive drugs—and aim for strictly normal levels if such are well tolerated.

Current hypertension control is just not good enough. We can do much better.

Dr. Dustan spent most of her professional career in hypertension research and care. For 26 years she was a staff member in the Research Division of the Cleveland Clinic. In 1977, she became director of the Cardiovascular Research and Training Center, University of Alabama School of Medicine, a position she held for 10 years. After three years as Veterans Administration Distinguished Physician, she retired to Vermont. She is now visiting professor of Pharmacology and Medicine at the University of Vermont College of Medicine, Burlington. Dr. Dustan has participated in the preparation of all six Joint National Committee Reports. She was chair of JNC III and an executive committee member of JNC VI.


Figure 1 is from the U.S. Renal Data System. USRDS 1997 annual report. Bethesda, Md.: U.S. Department of Health and Human Services, National Institute of Diabetes and Digestive and Kidney Diseases, 1997. Figure 2 was used with permission from Levy D, Larson MG, Vasan RS, Kannel WB, Ho KKL. The progression from hypertension to congestive heart failure. JAMA 1996;275:1557-62. Figure 3 was used with permission from the 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). JAMA 1991;265:3255–64.

REFERENCES

1. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Arch Intern Med. 1997;157:2413–46.

2. Kaplan NM. Treatment of hypertension: insights from the JNC-VI report. Am Fam Physician. 1998;58:1323–30.

3. Meissner I, Whisnant JP, Sheps S, Schwartz G, O'Fallon WM, Coralt J, et al. Stroke prevention: assessment of risk in a community: the SPARC study, part 1: blood pressure trends, treatment and control (abstract). Ann Neurol. 1997;42:433.

4. Glynn RJ, Brock DB, Harris T, Havlik RJ, Chrischilles EA, Ostfeld AM, et al. Use of antihypertensive drugs and trends in blood pressure in the elderly. Arch Intern Med. 1995;155:1855–60.

5. Lazarus JM, Bourgoigne JJ, Buckalew VM, Greene T, Levey AS, Milas NC, et al. Achievement and safety of a low blood pressure goal in chronic renal disease: the Modification of Diet in Renal Disease Study Group. Hypertension. 1997;29:641–50.

6. Klag MJ, Whelton PK, Randall BL, Neaton JD, Brancati FL, Stamler J. End-stage renal disease in African-American and white men: 16-year MRFIT findings. JAMA. 1887;227:1293–8.

7. National Center for Health Statistics. Health United States, 1996. Hyattsville, Public Health Service, 1997.

8. American Association of Retired Persons and the Administration on Aging. U.S. Department of Health and Human Resources. Profiles of older Americans, 1995.

9. National High Blood Pressure Education Program Working Group report on hypertension in the elderly. Hypertension. 1994;23:275–85.

10. 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). JAMA. 1991;265:3255–64.


Copyright © 1998 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in AFP

More in Pubmed

Navigate this Article