In May 2003, the National Heart, Lung, and Blood Institute's Seventh Joint National Committee on High Blood Pressure (JNC 7) released its recommendations for the most current diagnosis and management of hypertension.1In both its process and its aim, this iteration of the time-honored and influential JNC series differs from previous iterations in ways that matter directly to family physicians.
The foremost difference between this JNC report and previous reports is the intensely pragmatic focus of the JNC 7. Previous reports addressed the hypertension specialist audience as well as primary care physicians, and the reports covered a wide spectrum of needs, summarizing literature and pathophys-iology, and recommending treatments. It took a year or more to produce those documents. In contrast, the JNC 7 panel was charged with producing a succinct document focused explicitly on the primary care physician's need for the latest information about managing hypertension. The panel was given four months to complete its work in order that important new information from recent clinical trials could reach primary care physicians in the form of usable guidelines with the minimum of delay. The brevity and the currency of this iteration are reflected in the title, JNC 7 Express. A longer version, reviewing the evidence base and the supporting science, soon will be available for teaching and reference use.
In terms of content, JNC 7 updates some trends in previous evidence and simplifies diagnosis and treatment. The complex staging and classification systems taught in medical school have been stripped down to only those distinctions that matter in treatment decisions. Gone are many laboratory tests and other investigations of low or no decision-making use. Finally and most importantly, the trend toward evidence-based treatment, toward reliance on medications with proven benefit in real outcomes (prevention of heart failure, stroke, and coronary disease), is fully developed. For the first time, treatment recommendations are based on drug versus drug clinical trial data. These evidence-based recommendations include thiazides as the primary choice for most treatments, and they focus on systolic rather than diastolic pressure for most patients and more than one drug for the majority of patients.
JNC 7 differs from previous documents as well in its emphasis on prevention of hypertension. As the report notes, 90 percent of Americans who survive to old age will develop hypertension. The prevalence of the disease is increasing rapidly with America's intertwined increases in obesity, sedentary lifestyle, and unhealthy diet. Even with the best treatment for high blood pressure, the potential effects on our patients' health are enormous. JNC 7 strongly recommends that we intervene with lifestyle modifications that can prevent or delay the onset of hypertension in our patients. That recommendation takes on special importance in the definition of the new class of “prehypertension,” those patients who have systolic pressures between 120 and 139 mm Hg or diastolic pressures between 80 and 89 mm Hg, who are at both increased risk of bad outcomes and high risk for development of diagnosed hypertension. Further, JNC 7 emphasizes that proper lifestyle intervention in hypertension should serve as the equivalent of one drug in a multidrug regimen.
Last, but from the perspective of family medicine certainly not least, JNC 7 attends carefully to the role of the physician-patient relationship in successful treatment. Hypertension, like all chronic diseases, is ultimately controlled only to the extent that patients are willing to control it. The evidence clearly demonstrates that a positive, patient-centered relationship—one of the core beliefs of our discipline—leads to better treatment adherence and better patient satisfaction, and hence to better control of blood pressure.
JNC 7 clearly lays out the challenges for us, in improving control of hypertension and in preventing or delaying its onset. It also provides clear guidance about how to meet these challenges, with biomedical and psychosocial interventions. It is now up to us to translate this document into better health for our patients.