When is High Blood Pressure Hypertension?

Frederick R. Jelovsek MD

If your blood pressure is 140/85 at the doctor's office, do you have hypertension? If it's repeated at that level several times do you need treatment for high blood pressure? With primary care doctors under pressure to keep costs down, when should they start you on medical treatment with medications and which ones to start with? A recent report by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure tried to answer these questions by consensus.

William F. Rayburn M.D. has summarized those recommendations in Rayburn, WE: Sixth report of the joint national committee on prevention, detection, evaluation and treatment: A Summary. J Reproduc Med 1998 43:444-50.. Hypertension is defined as a systolic blood pressure of 140 mmHg or more, a diastolic blood pressure of 90 mm Hg or more, or the taking of antihypertensive medicines. Different blood pressure categories for adults have been defined:

Adult Blood Pressure Categories

Blood pressure (mmHg)
Category	Systolic	Diastolic	Follow-up recommendations
Optimal	<120	and	<80
Normal	<130	and	<85	Recheck in 2 years
High normal	130-139	or	85-89	Recheck in 1 year
Hypertension
Stage 1	140-159	or	90-99	Confirm within 2 months
Stage 2	160-179	or	100-109	Evaluate or refer to source of care within 1 month
Stage 3	>=180	or	>=110	Evaluate or refer to source of care immediately or within 1 week, depending upon clinical situation

Hypertension appears to be a multifactorial disorder in which the interaction of several genetic tendencies and the environment is important. Other diagnostic laboratory tests suggested include urinalysis, complete blood count, blood chemistry, and a 12 lead electrocardiogram. Lifestyle modification is the mainstay reccomendation to prevent and to treat hypertension. This includes:

weight control - keep body mass index <27 and waist circumferance less than 34 in (85 cm) for women
alcohol intake control - less than .5 oz (15 ml) of ethanol per day ( 12 oz.[360ml] beer, 5 oz [150ml] wine, 1 oz [30 ml] whiskey)
tobacco control - discontinuance
physical activity - 30-45 minutes brisk walking activity or more, most days of week
diet - sodium reduction to less than 6 grams salt (2.4 gm sodium) per day. Also an adequate daily intake of potassium, calcium and magnesium.
stress - there is no evidence that relaxation therapy or caffeine restriction is beneficial

Women who are on oral contraceptives can have a small but detectable increase in blood pressure but it is usually not enough to change them into a higher stage of increased blood pressure unless there is already a tendency present. Estrogen replacement therapy during the menopause is usually the same as with oral contraceptives, no change to a very slight increase. High blood pressure during pregnancy is an entirely different category and has it's own unique categories and treatments.

Initial treatments for hypertension depend upon the stage of blood pressure elevation and risk factors such as weight, alcohol use, physical activity, and smoking along with risk for cardiovascular disease such as diabetes, or any history of existing target organ damage to the heart, vascular system or kidneys.

Treatment by Risk Stratification of Hypertension

Blood pressure stages (mmHg)	Risk group A no risk factors, no target organ disease or diabetes	Risk group B at least one risk factor, no target organ diseases, no diabetes	Risk group C target organ disease and/or diabetes
High normal (130-139/85-90	lifestyle modification	lifestyle modification	drug therapy
Stage 1 (140-159/90-99)	lifestyle modification (up to 12 months)	lifestyle modification (up to 6 months)	drug therapy
Stages 2 and 3 (over 160/100)	drug therapy	drug therapy	drug therapy