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Experts Talk About: Prehypertension

Dr. Roccella: The two of you were involved in a guideline called the Joint National Committee Report awhile back, and in that report you talked about a concept called "prehypertension." What does that mean and why is that so important?

Dr. Black: Prehypertension was the term that we devised back in 2002 to try to call attention to patients, health care providers, and journalists, too, that people whose blood pressures were in the 120 to 139 systolic and 80 to 89 diastolic were not free of the risks due to an elevated blood pressure, even though we had never defined that range as being definitely hypertension.

We have a large amount of observational data -- that is, watching people over time -- which shows that the risk of having a high blood pressure begins at much lower levels than where the diagnosis of hypertension occurs.

I hear people question what right do we have to call these people prehypertensives. Well, it is our responsibility to call attention to the fact that these people are not free of risk. This is the group that should get an unambiguous recommendation to adopt appropriate lifestyle modification. They should never see a healthcare provider without getting their blood pressure checked. They should buy a reliable blood pressure monitor and check it at home to try to avoid ignoring inexorable rise in blood pressure over time. This was not something we did to advocate getting more pills; quite the contrary! This is something we did to call attention to the risks. And it turned out to be a very, very appropriate suggestion and one that has stuck.

Ms. Houston Miller: I would agree, Henry, that we were very wise in making that recommendation. We did it, as you say, to remind people with blood pressures that begin at 115/75 mmHg that it is important to make lifestyle modifications in order to prevent high blood pressure and to prevent cardiovascular disease.

As you see blood pressure rise, cardiovascular disease risk really increases, and it doubles when you see a 20 mmHg increase in systolic and 10 mmHg in diastolic blood pressure. So ensuring that the people really try to carry out lifestyle changes is critically important to prevent high blood pressure. And, unfortunately, in this country today if you are at the age of 55 you have about a 90 percent lifetime risk of developing high blood pressure. It does not have to be that way. If we were to focus on achieving an ideal weight, exercising, avoiding the high consumption of alcohol, and really reducing our sodium, we would be in much better shape.

Dr. Roccella: The two of you are saying that the risk of hypertension does not start at 140/90 mmHg?

Dr. Black: Yes, it starts at a much lower number than that. We started with observational data in from 1 million volunteers in 61 studies encompassing 12 million volunteer years. I am very deliberately not calling these citizens patients. The increase in risk from blood pressure began at 115/75 mmHg and rose steeply as blood pressure rose. These were levels of blood pressure that we never worried about before and we would pat ourselves on the back if we had a blood pressure that was less than 140 mm Hg for systolic and less than 90 mmHg for diastolic. This large data set changed our mind. And now I pay much more attention to those in the prehypertensive range, 120-139 mmHg for systolic and 80-89 mm Hg for diastolic. When we begin to see blood pressure rising, as it inevitably does with age and with increasing weight, this is the time to take action to avoid the problems that an elevated blood pressure can cause. In fact, we have known for many, many years that a lot of the complications that we associate with elevated blood pressures begin or occur at levels much lower than where we diagnose hypertension.

Dr. Roccella: Are the two of you are suggesting that lifestyle modification could prevent the rise of blood pressures if we started soon enough?

Dr. Black: There are societies -- though not very many today -- where hypertension doesn't exist, the so-called un- or under-aculturated societies. Members of these populations are extremely thin and active, eat a healthier diet than we do, and don't have the type of stresses that we have. Rising blood pressure seems to be almost an inevitability of our modern life, but we can certainly do things to minimize it if we pay attention.

Dr. Roccella: Are these lifestyle modifications good for anything else?

Dr. Black: Well, they are good for overall cardiovascular health! For some people, being active and exercising can lower blood pressure, and it does reduce cardiovascular risk. Following the DASH diet has been shown to change blood pressure and has a very good effect on lipids. Keeping the sodium down is really what we focus on with blood pressure. Also, learning how to cope with stress has a lot of value above and beyond what it does to blood pressure.

Dr. Roccella: So with this DASH diet that Nancy talked about earlier, you can actually look to reduce your risk from lipids and your elevated cholesterol, too?

Ms. Houston Miller: Absolutely. There have been studies that have shown you can lower lipids with the DASH diet. I think the important thing for people to realize is the overlap between dyslipidemia, or elevated cholesterol, and hypertension is about 40 percent. So if you really adopt the lifestyle behaviors we are talking about for hypertension, you can decrease your cholesterol levels. Plus, these are important lifestyle behaviors just for overall aging, especially the whole area of the diet. Maintaining normal body weight and physical activity really relates to independence in older age.

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Click these links to read more from Sister to Sister’s Expert Roundtable on High Blood Pressure:

Introduction
Blood Pressure Basics
Symptoms & Screening
Treatment Benefits
Treatment Options
Drug Side Effects
Drug Interactions
Medication Costs
Prehypertension
Aging's Impact
High-Risk Groups
Future Goals