Prehypertension: An Important Preventive Medicine Concept—or Marketing Ploy ?

One of the first and easiest decisions of the members of the executive committee preparing the Seventh Report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC 7)1 was to abolish the term high normal that had been used in earlier classifications. The evidence base strongly demonstrated that systolic blood pressure (SBP) in the range of 130–139 mm Hg was high, but not normal. We also agreed that the term normal used in JNC VI for SBP 120–129 mm Hg was inappropriate in view of the mounting evidence that SBP above 115 mm Hg conferred some increasing risk of cardiovascular morbidity and mortality. JNC 7 assigned the term normal to SBP <120 mm Hg, although some members of the committee argued for reducing this to <115 mm Hg. The committee then had to deal with what to call SBP in the range of 120–139 mm Hg (and corresponding diastolic BPs) that was neither normal nor hypertensive. With the skillful facilitation of Ed Roccella, the term prehypertension was eventually adopted. The concept was to use a term analogous to prediabetes or precancerous. That is, early identification of the problem provided an opportunity to institute measures designed to prevent diabetes, cancer—or hypertension. Those recommended measures for prehypertension were for the initiation and maintenance of a healthy life-style; drug therapy was not specifically indicated except for those persons who had diabetes mellitus or chronic kidney disease. Focus group testing demonstrated that prehypertension was understood by patients and primary care practitioners. Insurance companies indicated that a designation of prehypertension would not impact a person's insurability because they relied on decades of actuarial data and not JNC guidelines. It was not supported by specialists, particularly nephrologists. The term was soundly lampooned by James Berlin writing in the Arizona Republic.2 He opined that thin people were simply preobese, folks with teeth were pre-edentulous, and living people were, sadly, predead. Despite this opposition, the term seemed to gain general acceptance, particularly among the primary care practitioners for whom it was intended. I make a special effort to point out that the term prehypertension, which had been used much earlier by others to indicate the time during which genetic and environmental forces were interacting to cause hypertension, was promulgated by JNC 7, a part of the National High Blood Pressure Education Program (NHBPEP), a program of the National Heart, Lung, and Blood Institute (NHLBI), which is part of the National Institutes of Health (NIH). Said more pointedly, the federal government—not the pharmaceutical industry—decided on the use of both the concept and the term. This is very much in contrast to the purport of a recent New York Times article.3 Data from the recently published Trial of Preventing Hypertension (TROPHY)4 lend support to the abandonment of “high normal” and the adoption of the concept of prehypertension by JNC 7. A simplified precis of the first part of that trial is that 53 of 391 (13.6%) subjects whose BP was 130–139 mm Hg and who were randomly allocated to treatment with an angiotensin receptor blocker developed fixed hypertension after 2 years of treatment. In contrast, 154 of the 381 (40.4%) people allocated to placebo became hypertensive in the same period. Treatment had effected a definite risk reduction. Thus, not only is SBP of 130–139 mm Hg not benign, but there is now some evidence that single-drug therapy can reduce the risk of developing hypertension over 2 years. Tom Giles, who has been a leader of a group advocating a reclassification of BP, has also used the TROPHY data to support definitional changes.5 He pointed out that most of the TROPHY subjects had cardiovascular risk factors in addition to hypertension. I have supported the need for changing the classification and guidelines. Where we differ is in the use of specific BP ranges to help guide practitioners.6 I am now personally inclined to label SBP of 130–139 mm Hg and diastolic BP of 85–89 mm Hg as stage 1 hypertension and revise the terms for the higher BP levels. This would not mandate drug therapy. That decision would be based on the comorbidities and risk factors discussed by Giles. Eventually, all of this will be worked out. Will the pharmaceutical industry use these concepts and data as a basis to increase the marketing of antihypertensive medications? I certainly hope so! Can industry and the medical profession work together for the betterment of the health of people with hypertension worldwide? Of course they can; they have been doing it for years. The point is that it is the medical profession, based on data—and not industry—that is driving this shift in the therapeutic paradigm. The concept of prehypertension is valid. The term prehypertension may or may not be retained as guidelines are rewritten and improved. That is not important. What is important is that the concept will remain and the well-being of people with BP readings in this range will be improved.