Answer Discussing Prehypertension Perpetuates a Reactionary Myth

Internal Medicine World ReportNovember 2005

Answer Discussing Prehypertension Perpetuates a Reactionary Myth

In contrast to that response, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC-7) does not “mandate the use of antihypertensive therapy” based on the presence of compelling indications. In the setting of prehypertension, most patients with compelling indications should be advised on lifestyle modifications only, according to JNC-7. Diabetes and chronic kidney disease are unique in that they trigger drug therapy at a lower blood pressure (BP) level—above 129/70 mm Hg, which is the “upper half” of prehypertension. The vast majority of prehypertensives (even those with other compelling indications, such as coronary artery disease) should be prescribed lifestyle modifications rather than pills.

Compelling indications come into play in stage 1 hypertension, when they influence the initial choice of an antihypertensive agent. They also come into play by setting a lower BP goal for patients with diabetes or kidney disease, as well as influencing the medication choice toward the renin-angiotensin blockade for these patients.

Thus the answer to question 4 perpetuates the common, and potentially dangerous, misunderstanding that prehypertension requires treatment with antihypertensive medication. This reactionary myth started during the confusion after the category of prehypertension was rolled out in “JNC-7 Express.” To reiterate, only a small subset of prehypertensive patients should receive hypertension medications, as described above. Although the patient described in the question meets these criteria, the majority of prehypertensives with other compelling indications will not.

As an aside, many of us hope the designation prehypertension will be dropped or modified in JNC-8, because of its uncanny ability to be misunderstood. Meanwhile, the American Society of Hypertension is proposing a totally new definition of hypertension, which does not depend on BP measurements at all. Using this new paradigm, the “compelling indications” of JNC-7 may actually be considered indications for antihypertensive medications regardless of BP, as suggested in the answer.

Many recent trials, including HOPE (Heart Outcomes Protection Evaluation), PROGRESS (Perindopril Protection Against Recurrent Stroke Study), EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease), CHARM (Candesartan in Heart Failure Assessment of Reduction in Morbidity and mortality), Val-HeFT (Valsartan Heart Failure Trial), and CAMELOT (Comparison of Amlodipine vs Enalapril to Limit Occurrences of Thrombosis) demonstrate benefits of antihypertensive drugs in patients with various compelling indications but with BP <140/90 mm Hg. So, while the explanation given to question 4 is technically incorrect according to JNC-7, it may be ahead of its time, and vindicated in the near future.

Randall Zielinski

, MD

Clinical Specialist in Hypertension


, NH

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