Blood Pressure Problems Are Back on Rise, U.S. Warns

Federal health officials warned Thursday that new findings indicate a disturbing reversal in the dramatic improvements seen in recent years in identifying and controlling high blood pressure in Americans, and they called upon physicians to take greater action to curb this potentially life-threatening trend.

“New data show a slight rise in the rate of stroke, increases in both end-stage [kidney-related] disease and heart failure,” said Dr. Claude Lenfant, director of the National Heart, Lung and Blood Institute. Additionally, declines in the death rate for people with coronary heart disease have leveled off, he said.

“These statistics signal the need for a renewed effort by physicians and patients to prevent and treat hypertension,” Lenfant said.

The institute’s National High Blood Pressure Education Campaign issued new guidelines for classifying patients by different risk factors to determine the appropriate treatment for the malady, also known as hypertension.

The campaign also recommended dietary and other lifestyle changes as a first-line attack against this silent killer. The guidelines will be published in the Nov. 25 issue of the Archives of Internal Medicine, a journal of the American Medical Assn.

An estimated 50 million U.S. adults have hypertension, which has no obvious symptoms. The condition is a major cause of heart disease and stroke--which are the first- and third-leading causes of death in this country--and it also can lead to serious kidney damage.

Blood pressure is the amount of force exerted by the blood against the walls of the arteries. It is expressed in two numbers, usually one above the other, such as 120/80.

The first number--the systolic pressure--represents the force used when the heart beats. The second number--the diastolic pressure--is the pressure within the arteries between heartbeats. Anything above 140/90 is considered high.

The heart institute, part of the National Institutes of Health, said patient surveys indicated that between 1991 and 1994, the percentage of Americans who were unaware they had high blood pressure increased by almost 5% after having decreased substantially during the previous 15 years.

Similarly, those suffering from high blood pressure and undergoing treatment for it decreased by 1.4% between 1991-94, after having increased steadily in the years before.

Also, the percentage of Americans with hypertension who brought it under control, that is, below 140/90, decreased during this most recent period to 27.4%, from 29% between 1988 and 1991. The figure had risen from just 10% between 1976 and 1980.

Lenfant attributed this reversal in the control of hypertension to increasing obesity and decreasing physical activity in the population. Another factor, he said, is that “people are becoming more complacent” about treating the condition.

“Treatment requires a lifelong commitment,” he said.

One of the most significant changes in the new guidelines, compared to past recommendations, is the concept of stratifying hypertension patients by three stages of blood pressure and into risk groups--A, B and C--based on the presence of risk factors, such as high blood cholesterol, organ damage or other conditions, such as diabetes.

For example, a person in the lowest risk group, A, with Stage 1 hypertension (between 140-159/90-99) with no other risk factors would be instructed to implement specific lifestyle changes for one year before being put on blood pressure-controlling medication. Earlier guidelines suggested behavior changes only for three to six months before beginning drug therapy.

In the highest risk category--patients with hypertension 160/100 or higher who also have diabetes with or without other risk factors--the panel recommended immediate drug therapy.

In addition, the panel said all patients with hypertension should lose weight, if necessary; limit alcohol intake to less than one-half ounce to 1 ounce daily; engage in regular aerobic physical activity, 30 to 45 minutes on most days; limit sodium intake to 2.4 grams a day (which is about 1 teaspoon of salt, including that in processed foods); and increase potassium, which should be done cautiously by those with kidney problems or who are taking certain drugs.

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Risk Groups and Treatments

These new guidelines for controlling high blood pressure emphasize lifestyle modification over drug therapy.

Blood pressure stages: High-normal (130-139/85-89)

Risk Group A (No risk factors or signs of organ or cardiovascular disease): Lifestyle modification

Risk Group B (At least one risk factor not including diabetes; no signs of disease): Life style modification

Risk Group C (Signs of disease of organ or cardiovascular disease): Drug therapy, lifestyle modification

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Blood pressure stages: Stage 1 (140-159/90-99)

Risk Group A (No risk factors or signs of organ or cardiovascular disease): Lifestyle modification (up to 12 months)

Risk Group B (At least one risk factor not including diabetes; no signs of disease): Lifestyle modification (up to 6 months)*

Risk Group C (Signs of disease of organ or cardiovascular disease): Drug therapy, lifestyle modification

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Blood pressure stages: Stages 2 and 3 (160 and above/100 and above)

Risk Group A (No risk factors or signs of organ or cardiovascular disease): Drug therapy, lifestyle modification

Risk Group B (At least one risk factor not including diabetes; no signs of disease): Drug therapy, lifestyle modification

Risk Group C (Signs of disease of organ or cardiovascular disease): Drug therapy, lifestyle modification

* For those with multiple risk factors, drugs should be considered as initial therapy