Potential Revisions to Hypertension Guidelines

I n their article,1 Fang and colleagues use data from the National Ambulatory Medical Care Survey to describe hypertension prevalence and control in the United States in 2003 and 2004. Approximately 176 million office visits, 9.7% of the total number of visits, involved the care of high blood pressure. Among hypertension-related visits, 44% of visits documented blood pressure levels <140/90 mm Hg. Only 22% of visits that included a diagnosis of diabetes had blood pressures controlled to levels <130/80 mm Hg. Control of hypertension was associated with coronary heart disease, dyslipidemia, and visits to primary care physicians or visits to internists or cardiologists. The analysis was nicely done and provides important information from a new source of data. The findings are generally consistent with reports from other studies. Data from the National Health and Nutrition Examination Survey in 1999–2000 suggested that blood pressure was controlled to <140/90 mm Hg in about 34% of cases.2 Clinical trials achieve control rates in the range of 66–85% for randomized subjects,1 and these proportions probably represent what may be achievable in the community if intensified efforts at blood pressure control are applied as they are in the clinical trials. To achieve these goals, the Joint National Committee guidelines make a number of recommendations, not only about treatment targets but also about first-line drug treatments.2 For uncomplicated hypertension, low-dose diuretics are recommended as the first-line drug treatment.2 As Cutler’s analysis suggests,3 some side effects of thiazides have often been exaggerated, misunderstood, or misrepresented. Low-dose diuretics are the most effective first-line antihypertensive agent for the prevention of the occurrence of cardiovascular disease morbidity and mortality.4 Evaluations of the implementations of national guidelines should assess not only blood pressure control but also patterns of drug use in the United States. To identify patients who require treatment, the US guidelines focus largely on levels of blood pressure rather than on levels of cardiovascular risk. Other factors such as smoking, diabetes, dyslipidemia, and clinical disease affect future cardiovascular risk and the numbers of those who need to be treated in order