Managing prehypertension

Current situation

  • There has been a lot of work done demonstrating the benefits of patients with ‘prehypertension’ being treated with medication to lower their BP.
  • Patients with prehypertension, or high-normal BP, are at increased risk of cardiovascular disease (CVD) and MI.

What is the evidence?

  • Compared with patients who had optimal BP, the relative risk of developing CVD is 2.49 for those with prehypertension, after adjustment for recognised cardiovascular risk factors (Am J Med 2006; 119: 133–41).
  • Another study used data from Framingham Heart Study participants to examine the association between prehypertension, hypertension and the incidence of CVD. It reported that patients with prehypertension were 3.5 times more likely to experience MI and 1.7 times more likely to develop heart disease than people with normal BP (Stroke 2005; 36: 1,859).
  • Metabolic syndrome, obesity, overweight, impaired fasting glucose and elevated triglycerides to HDL ratio have been shown to be independent risk factors for the progression from normotension to prehypertension (Am J Hypertens 2006; 19: 189–96).
  • Another study has shown that there is a high prevalence of prehypertension in diabetic patients and it is associated with higher risks of CVD in these patients (Hypertension 2006; 47: 410–14).
  • One report found that patients with BP below 120/80mmHg had the slowest progression of atherosclerosis. Patients with prehypertension had some increase in their atheroma in this study (J Am Coll Cardiol 2006; 48: 833–8).
  • Analysis of the Women’s Health Initiative data has shown that prehypertension is associated with an increased risk of MI, stroke, heart failure and cardiovascular death in postmenopausal women (Circulation 2007; 115: 855–60).
  • One study has demonstrated that giving patients with prehypertension candesartan for two years reduced the relative risk of progression to hypertension by 66 per cent (New Engl J Med 2006; 354: 1,685–97)

Implications for practice

  • Patients with prehypertension are more likely to develop hypertension than people with normal BP.
  • These studies raise the question of whether patients with prehypertension should be treated with antihypertensive medication to reduce their risk of future CVD.

Available guidelines

  • The current British Hypertension Society guidelines state that patients with  high–normal systolic BP or diastolic BP should have their BP measured annually.
  • It recommends that patients with high–normal BP should initiate lifestyle measures and have other risk factors corrected.

Useful websites

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners’ PasTest 2006

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