Tuesday, June 13, 2006

More insights on hypertension

I had always had problems with hurriedly prepared guidelines. The JNC-7 guidelines on Hypertension is one clear example. Sad to say, many who didn't understand much about hypertension quickly lapped it up and almost went to town with it, swallowing it wholesale. One of my biggest problem was the JNC-7 placed too much emphasis on a number. The authors of JNC-7 tried to make management of hypertension a numbers game, making the target "the lower, the better". Obviously the American Hypertension Society (ASH) also had reservations. They subsequently (after the publication of the JNC-7 guidelines), formed a Working Group of ASH or WG-ASH to restudy the definition of hypertension, and they came out with this

ClassificationBlood Pressure Elevations
Cardiovascular Disease*Cardiovascular Risk FactorsEarly Disease MarkersTarget Organ Disease
NormalNormalorNoneNone or fewNoneNone

Stage 1Occasional or intermittentorEarlySeveralUsually present None
Stage 2SustainedorProgressiveManyOvertly presentEarly signs present
Stage 3Marked and sustainedorAdvancedManyOvertly present with progressionOvertly present with or without cardiovascular disease events

See, no numbers. Management of hypertension is not a management of numbers. It is the management of CVS and vascular risk, including neurovascular risk. Let us begin to think in terms of CVS risk and target organ damage, and not on numbers. Hypertension and diabetes are all part of the cardiovascular continumm. Management of hypertension is the management of CVS risk and target organ damage.

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