COVER STORY
The new blood pressure guidelines
A digest
MICHAEL GLICK, D.M.D.
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ABSTRACT
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Background. In December 2003, the National High Blood Pressure Education Program of the National Heart, Lung, and Blood Institute finalized the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, called JNC 7.
Overview and Conclusions. On the basis of new trials and observational studies, and the need for clear and concise guidelines, the JNC implemented changes in blood pressure classification, nomenclature, treatment and prevention in the JNC 7 report. One of the key messages of the report is that systolic blood pressure higher than 140 millimeters of mercury in people older than 50 years of age is a more important risk factor than diastolic blood pressure. Another finding is that people with normal blood pressure at the age of 55 to 65 years have an 80 to 90 percent risk of developing hypertension by the age of 80 to 85 years.
Clinical Implications. JNC 7 emphasizes that health care professionals besides physicians, including dentists, need to help patients by reinforcing hypertension-related lifestyle modifications, pharmacological therapies and adherence to treatment.
In December 2003, the National High Blood Pressure Education Program finalized the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, or JNC 7.1 This report is the latest in a series of reports initiated in 1972 that outline the standards of care and prevention for patients with high blood pressure and hypertension. When enough new information with clinical ramifications has accumulated, new guidelines are generated.
Dentists need to help patients with hypertension by reinforcing lifestyle modifications, pharmacological therapies and adherence to treatment.
In December 2002, the JNC recognized that JNC VI, published in 1997, needed to be revised. This decision was based on a couple of seminal studies regarding new directions for care and new data on hypertension and risk for developing cardiovascular disease.2,3 The resulting new guidelines contain four key messages:
- – The risk of dying of ischemic heart disease and stroke increases progressively and linearly when blood pressure exceeds 115/75 millimeters of mercury.
- – The risk of developing cardiovascular disease doubles for every increment of 20 mm Hg of systolic blood pressure or 10 mm Hg of diastolic blood pressure.
- – Systolic blood pressure higher than 140 mm Hg in people older than 50 years of age is a more important risk factor than diastolic pressure.
- – People with normal blood pressure at age 55 to 65 years have an 80 to 90 percent risk of developing hypertension by the age of 80 to 85 years.
On the basis of new trials and observational studies, and the need for clear and concise guidelines, the JNC implemented changes in blood pressure classification, nomenclature, treatment, and prevention in the JNC 7 report.
The "normal" and "borderline" stages in JNC VI have been replaced by a "pre-hypertension" stage. The rationale behind this change was to emphasize that people at this level of blood pressure are at some risk of developing cardiovascular disease.
What were called "Stage 2" and "Stage 3" in JNC VI have been replaced by one stage ("Stage 2") in JNC 7. Management of the medical care of patients with blood pressure of 160/100 mm Hg or higher versus patients with blood pressure of 180/110 mm Hg or higher will not change significantly. Thus, two levels are not necessary.
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CHANGES IN TREATMENT AND PREVENTION
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The primary goal of hypertensive therapy is to control blood pressure at a level of less than 140/90 mm Hg. For patients with diabetes or renal disease, this level is even lower: less than 130/80 mm Hg. The majority of patients will require two or more antihypertensive medications to achieve these control rates. The preferred initial medication is a thiazide-type diuretic (Table
).
Lifestyle modifications—such as weight loss; reduced sodium intake; adoption of the Dietary Approaches to Stop Hypertension, or DASH, diet; regular aerobic physical activity; and limited alcohol intake—are beneficial for both prevention and treatment of hypertension.
Monitoring blood pressure is an integral part of hypertension control. JNC 7 emphasizes that health care professionals besides physicians, including dentists, need to help patients by reinforcing lifestyle modifications, pharmacological therapies and adherence to treatment.
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DENTAL ISSUES
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The recommendation in JNC 7 for treatment of dental patients with hypertension addresses two concerns. The use of epinephrine in local anesthetic solutions is not contraindicated, as this will result in only a minimal adverse cardiovascular response. However, when general anesthetic is used with patients taking antihypertensive medications, there is a potential for wide fluctuations in blood pressure and a risk of hypotension.
The changes in JNC 7 do not alter previously published dental protocols for treatment of patients with hypertension,4 which were based on JNC VI.
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FOOTNOTES
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Dr. Glick is professor and chairman, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey, 110 Bergen Street, Room D860, Newark, N.J. 07103-2400, e-mail "glickmi{at}umdnj.edu". Address reprint requests to Dr. Glick.
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REFERENCES
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- Chobanian AV, Bakris GL, Black HR, et al.; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206–52.[Abstract/Free Full Text]
- Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies (Published correction appears in Lancet 2003;361[9362]:1060). Lancet 2002;360(9349):1903–13.[Medline]
- The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (published correction appears in JAMA 2003;289:178). JAMA 2002;288:2981–97.[Abstract/Free Full Text]
- Glick M. New guidelines for prevention, detection, evaluation and treatment of high blood pressure. JADA 1998;129:1588–94.[Medline]
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320 - 321.
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CHANGES IN TREATMENT AND...
