Matters of the Heart-and Other Organs

Case 1:

Prehypertension inPostmenopausalWomen: HowAggressively toIntervene?

Q:Is treatment recommended for high-normalblood pressure (BP)--say, 135/88 mm Hg--ina postmenopausal woman?

Case 1:

A

:The Seventh Report of the Joint National Committeeon Prevention, Detection, Evaluation, and Treatmentof High Blood Pressure (JNC 7) created new classificationsof BP based on the average of 2 or more properlymeasured, seated BP readings, during each of 2 or moreoffice visits.

^1,2

The category of "prehypertension" was introducedto include persons with systolic BP (SBP) of 120to 139 mm Hg or diastolic BP (DBP) of 80 to 89 mm Hg.The report recommended that most persons with prehypertension be managed with aggressivelifestyle modification--ratherthan pharmacotherapy--in the absenceof compelling indications.

The risks of hypertension

. It isimportant to recognize that acrossthe entire range of BP, from 115/75 to185/150 mm Hg, there is a continuous,consistent, and independent relationshipbetween BP and cardiovascular disease events.The higher the BP, the greater the chance of an event,such as a myocardial infarction (MI), congestive heart failure,stroke, or progressive chronic kidney disease.Furthermore, BP tends to rise with advancing age, asdoes the prevalence of hypertension. DBP is a more potentcardiovascular risk factor than SBP until the age ofapproximately 50 years, after which DBP tends to declinemodestly as SBP continues to increase. SBP becomes amore potent risk factor with advancing age. Observationalstudies have also shown that more than 40% of personswith higher levels of prehypertension--that is, SBP of 130to 139 or DBP of 85 to 89 mm Hg--may progress to sustainedhypertension over a period of 5 years.

Prevention strategies.

For these reasons, increasedpublic awareness of the health risks associated with elevatedBP is strongly encouraged in order to decrease BP levelsand prevent progression to established hypertension. Preventionstrategies, including aggressive lifestyle modification,are strongly recommended. The

Table

lists nonpharmacologicmeasures that may significantly reduce BP. Theyinclude weight reduction and, in particular, the Dietary Approachesto Stop Hypertension (DASH) eating plan, whichfocuses on a diet rich in fruits, vegetables, and low-fat dairyproducts and reduced amounts of saturated and total fat.

³

Dietary sodium restriction, in the form of a no-added-saltdiet, can also help reduce BP, as can regular aerobic physicalactivity and moderation of alcohol consumption. Thisapproach is appropriate for patients with relatively uncomplicatedhypertension.

Compelling indications

. The JNC 7 guidelines haveidentified certain conditions that are compelling indicationsfor drug therapy in patients with prehypertension.The recommendations for specific agents in this settingare based on results of clinical trials and on practice guidelines.Optimal control of complicated hypertension usuallyrequires combination therapy. The compelling indicationis managed in parallel with the hypertension.The compelling indications that merit considerationof aggressive drug therapy include:

• Ischemic heart disease or high coronary disease risk.
• Established congestive heart failure.
• History of MI.

In addition, the patient with a history of stroke canbenefit from antihypertensive treatment with selectedagents.The JNC 7 guidelines strongly recommend a targetBP goal of lower than 130/80 mm Hg for patients withdiabetes mellitus and/or chronic kidney disease. Evidencesuggests that achieving this goal can help preserve renalfunction, or at least delay the progression of renal failure,and can prevent or retard the progression of diabeticretinopathy as well as reduce the likelihood of future cardiovascularevents. The lower BP goal is also stronglysupported by the American Diabetes Association and theNational Kidney Foundation.

Management of uncomplicated prehypertension

.For a postmenopausal woman with prehypertension andno compelling indications, management consists of aggressivelifestyle modification and BP monitoring. In thepresence of selected compelling indications, aggressivepharmacologic therapy may be warranted.

References:

REFERENCES:

1.

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the JointNational Committee on Prevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure: The JNC 7 Report.

JAMA.

2003;289:2560-2571.

2.

Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint NationalCommittee on Prevention, Detection, Evaluation, and Treatment of HighBlood Pressure.

Hypertension.

2003;42:1206-1252.

3.

Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduceddietary sodium and the Dietary Approaches to Stop Hypertension (DASH)diet. DASH-Sodium Collaborative Research Group.

N Engl J Med.

2001;344:3-10.