Definition of hypertension

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A survey of the literature of the past few decades shows that the definition of hypertension has changed drastically, and it seems to continue to change. It is presently recommended that antihypertensive therapy is started in patients who have "confirmed" hypertension, defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure (JNC 7) as a blood pressure (BP) level exceeding 140/90 mmHg. However, data from the Framingham Heart Study [1] make it exceedingly clear that BP is directly related to cardiovascular events, even at levels below that defined as hypertensive by the JNC 7 [2]. High normal BP was associated with a several-fold increase of cardiovascular disease in the Framingham population (Figure 1). A number of recent studies have shown that lowering BP in the so-called normotensive population reduces morbidity and mortality. These recent data indicate that any arbitrary definition of hypertension, such as BP of above 140/90 mmHg, may not be very useful. It seems time to abandon the dichotomous partition of the world population into either hypertensive or normotensive.

Target BP should be lower in certain groups ofpatients (as acknowledged by the JNC 7), such as those with diabetes, renal failure, or heart failure. The recent Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) trial has proven this concept wrong: in patients with type 2 diabetes, targeting a systolic blood pressure below 120 mmHg, as compared with less than 140 mmHg, did not reduce total or nonfatal cardiovascular events [3].

• Hypertension may best be defined as "a BP level that increases the cardiovascular risk for a given patient."

• Normotension, or the absence of hypertension, may be defined as "a BP level that has no impact on this cardiovascular risk."

• Hypotension may be defined as "a BP that causes orthostatic symptoms or leads to impairment of blood flow to target organs."

There are, of course, potential pitfalls to such pathophysiologic definitions of hypertension and hypotension. It is entirely conceivable that in some patients BP cannot be lowered to levels that would abolish all cardiovascular and renal risk before the patient experiences distinct orthostatic symptoms or repercussions from decreased blood flow to target organs, resulting in myocardial and/or renal ischemia.

Cumulative incidence of cardiovascular events in patients without hypertension

Time (years)
Number at risk

Optimal

1005

995

973

962

934

892

454

Normal

1059

1039

1012

982

952

892

520

High normal

903

879

857

819

795

726

441

Figure 1 Cumulative incidence of cardiovascular events in patients without hypertension. The

Framingham data suggest that ever within the normotensive range patients with the highest blood pressure (high normal) have a risk of cardiovascular morbidity and mortality that is several times higher than that of patients who have optimal blood pressure. Data from male patients is shown here. Reproduced from Vasan etal. [1].

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