Classifying and managing hypertension: Which guidelines are appropriate?

For the past decade, the recommendations of the Joint National Committee (JNC) on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure have been the accepted guidelines for the general physician’s approach to the classification and management of hypertension in the United States. The European medical community, however, has followed the guidelines of the European Society of Hypertension (ESH) since 1989.1 JNC 7 recommendations2 are now being called into question, especially in light of the recent publication of the ESH 2003 recommendations. There is a clear difference of opinion reported in these two documents regarding the most appropriate approach to the classification and treatment of the hypertensive patient. Because of this dissimilarity, a closer examination of the JNC 7 and ESH guidelines is warranted.

Comparing the guidelines

ESH was created in the vacuum of its downsizing predecessor, the International Society of Hypertension. The goals of ESH are similar to those of JNC, which are to formulate a set of basic guidelines by which the general health care community may classify and treat hypertension based on scientific data and the current literature.

Defining and classifying hypertension. ESH and JNC 7 guidelines differ on the definition and classification of hypertension. The ESH recommendations state that the optimal range of systolic blood pressure is below 120 mm Hg, and the optimal range of diastolic blood pressure is below 80 mm Hg. They also state that normal systolic blood pressure ranges from 120 to 129 mm Hg, normal diastolic blood pressure ranges from 80 to 84 mm Hg, high normal systolic blood pressure ranges from 130 to 139 mm Hg, and high normal diastolic blood pressure ranges from 85 to 89 mm Hg. The high-normal category includes values that would be considered hypertensive in high-risk patients but that are acceptable in lower risk populations. A different approach is taken by JNC.

JNC 7 has included the new category of “prehypertensive” in its classification of blood pressure. This designation is given to patients (without renal disease or diabetes) with systolic blood pressures of 120 to 139 mm Hg or diastolic blood pressures of 80 to 89 mm Hg. The treatment recommendation for this group is lifestyle modification. The classifications of blood pressure ranges set forth in the JNC 7 and ESH 2003 guidelines are shown in table 1.