A suggestion for revised JNC 7 definitions.
Such work is already in progress but, in my opinion, requires greater focus (J. Clin. Hypertens. 2005;7:505-12; J. Clin. Hypertens. 2005;7:540-1). The JNC 7 guidelines, published in 2003, defined stage 1 hypertension as a systolic pressure of 140-159 mm Hg or a diastolic pressure of 90-99 mm Hg and said that the best initial treatment for most patients in this group was monotherapy with a thiazide diuretic.
More recent data indicate that the many patients who fall into stage 1 would be better served if they were subdivided into two groups, which I call 1A and 1B. (These are my own suggestions for definitions. They do not have any official approval.) Stage 1 hypertension might be reclassified in the future as systolic blood pressure of 135-139 mm Hg or diastolic pressure of 85-89 mm Hg, on the basis of results reported in April from the Trial of Preventing Hypertension, which documented the benefit of initiating treatment in patients with prehypertension.
I define group 1A as patients with pressures of 140-149 mm Hg systolic and 90-94 mm Hg diastolic. These are the patients most likely to benefit from a trial of monotherapy. I'm a strong proponent of first-line combination therapy when it's appropriate, such as for patients with stage 1B hypertension, which I define as a systolic pressure of 150-159 mm Hg and a diastolic pressure of 95-99 mm Hg. Combination therapy is especially appropriate as first-line therapy for patients who need to drop their pressure by at least 20/10 mm Hg, which is common among the patients I define as stage 1B. But patients designated as stage 1A deserve a trial of monotherapy first; this is a potentially large group, with perhaps as many as 20 million patients in the United States.
Once a patient is deemed a candidate for a trial of monotherapy, the next issue is which drug to try first. I'm a strong believer in the usefulness of the age-by-race construct that was developed by the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Evidence suggests that the age-by-race construct is at least as good as a plasma renin profile for predicting the drugs to which a patient will probably respond. Age-by-race is simple: There is no need to draw blood, collect urine, or run any other laboratory test. Just ask the patient two questions: What is your age, and what race do you consider yourself to be?
An analysis of the efficacy of several commonly used antihypertensive drugs by age and race was first reported by me and my associates in 1993 (N. Engl. J. Med. 1993;328:914-21) and slightly revised in 1995 (Am. J. Hypertens. 1995;8:189-92), based on data that we collected from 1,292 men.
For younger white patients (under 60 years), the most effective drugs as monotherapy were an ACE inhibitor, a [beta]-blocker, or a calcium antagonist. For younger black patients, a calcium antagonist was most effective. For older blacks, the most effective drugs were a calcium antagonist or a thiazide. Older whites responded well to all medications. Once combination therapy is used, the age-by-race construct no longer applies.
DR. MATERSON, professor of medicine at the University of Miami Miller School of Medicine, was a member of the JNC 7 committee.
BY BARRY J. MATERSON, M.D.
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|Title Annotation:||GUEST EDITORIAL; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure|
|Author:||Materson, Barry J.|
|Publication:||Internal Medicine News|
|Date:||Aug 1, 2006|
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