Normal† - < 120/80

Prehypertension: 120-139/80-99

Stage 1: < 140-159/90-99

Stage 2:  ≥ 160/100

*Based on the average of 2 or more readings taken at each of 2 or more visits after initial screening

†Normal blood pressure with respect to cardiovascular risk is less than 120/80 mm Hg. However, unusually low readings should be evaluated for clinical significance.

Prehypertension, a new category designated in the JNC VII report, emphasizes that patients with prehypertension are at risk for progression to hypertension and that lifestyle modifications are important preventive strategies.

Hypertension may be either essential or secondary. Essential hypertension is diagnosed in the absence of an identifiable secondary cause. Approximately 95% of American adults have essential hypertension, while secondary hypertension accounts for fewer than 5% of the cases.

Cardiac

LVH
left atrial enlargement
aortic root dilatation
atrial and ventricular arrhythmias
systolic and diastolic heart failure, and
ischemic heart disease

LVH is associated with an increased risk of premature death and morbidity. A higher frequency of cardiac atrial and ventricular dysrhythmias and sudden cardiac death may exist. Possibly, increased coronary arteriolar resistance leads to reduced blood flow to the hypertrophied myocardium, resulting in angina despite clean coronary arteries. Hypertension, along with reduced oxygen supply and other risk factors, accelerates the process of atherogenesis, thereby further reducing oxygen delivery to the myocardium.

Hypertension remains the most common cause of congestive heart failure.

• Renal parenchymal disease
• Polycystic kidney disease
• Urinary tract obstruction
• Renin-producing tumor
• Liddle syndrome

Renovascular hypertension (0.2-4%)

• Coarctation of aorta
• Vasculitis
• Collagen vascular disease

Endocrine (1-2%) - Oral contraceptives

• Primary aldosteronism
• Cushing syndrome
• Pheochromocytoma
• Congenital adrenal hyperplasia

Hyperthyroidism and hypothyroidism

Hypercalcemia

Hyperparathyroidism

Acromegaly

• Brain tumor
• Bulbar poliomyelitis
• Intracranial hypertension

Pregnancy-induced hypertension

JNC VII recommendations to lower blood pressure and decrease cardiovascular disease risk include the following:

• Lose weight if overweight.
• Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (ie, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100-proof whiskey) per day or 0.5 (15 mL) ethanol per day for women and people of lighter weight.
• Increase aerobic activity (30-45 min most days of the week).
• Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium or 6 g sodium chloride).
• Maintain adequate intake of dietary potassium (approximately 90 mmol/d).
• Maintain adequate intake of dietary calcium and magnesium for general health.
• Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

Initial therapy based on the JNC VII report recommendations is as follows:

• Prehypertension (< 120-139/ 80-89): No antihypertensive drug is indicated.
• Stage 1 hypertension (systolic 140-159, diastolic 90-99): Thiazide-type diuretics are recommended for most. ACE inhibitor, angiotensin II receptor blocker (ARB), beta-blocker, calcium channel blocker, or combination may be considered.
• Stage 2 hypertension (systolic more than 160, diastolic more than 100): Two-drug combination (usually thiazide-type diuretic and ACE inhibitor or ARB or beta-blocker or calcium channel blocker) is recommended for most.
• For the compelling indications, other antihypertensive drugs (eg, diuretics, ACE inhibitor, ARB, beta-blocker, calcium channel blocker) may be considered as needed

Considerations in the Individualization of Antihypertensive Therapy

Key messages of the JNC VII:

• In those older than 50 years, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease risk factor than diastolic BP.
• Beginning at 115/75 mm Hg, the cardiovascular disease risk doubles for each increment of 20/10 mm Hg.
• Individuals who are normotensive at 55 years will have a 90% lifetime risk of developing hypertension.
• Prehypertension (systolic 120-139, diastolic 80-89) requires health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and cardiovascular disease.
• In uncomplicated hypertension, a thiazide diuretic, either alone or combined with drugs from other classes, should be used for the drug treatment of most.
• In specific high-risk conditions, there are compelling indications for the use of other antihypertensive drug classes (eg, ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers).
• Two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg or <130/80 mm Hg) for patients with diabetes and chronic kidney disease.
• For patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using 2 agents, one of which usually will be a thiazide diuretic, should be considered.
• Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan.