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Stroke risk high for prehypertensive patients, but best treatment remains uncertain


By Sabriya Rice
Posted: March 12, 2014 - 4:15 pm ET
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Patients whose blood pressure is higher than the optimal 120/80 mm Hg are 66% more likely to develop a stroke when compared to patients with normal blood pressure, regardless of other risk factors such as high cholesterol, diabetes and smoking, a study says.

Drug interventions are typically reserved for those who have been diagnosed with “high blood pressure,” but the study suggests that aggressive methods might be needed even for individuals whose BP is consistently elevated, but who are not yet considered to be hypertensive.

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The term “prehypertension” defines patients who have a systolic blood pressure between 120-139 mm Hg, and a diastolic blood pressure between 80- 89 mm Hg, higher than what is recommended, but not enough for a high blood pressure diagnosis. Since the term was proposed in 2003 by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, many have disagreed about lumping patients into this category, arguing that the risks and treatment options would be different for those on the higher end.

How to handle patients who fall in this “gray area” was the topic of new JNC 8 guidelines published in December. The recommendations brought a firestorm of criticism, when they advised against using drugs to treat blood pressure as high as 150 over 90 in people 60 or older. Some said the committee of 17 academics that formulated the new guidelines took too narrow a focus on data from randomized trials.

This latest study says the risk is high for any patient who has a BP reading above the optimal level.

Patients on the lower end of the prehypertension range were 44% more likely to develop stroke than patients with normal blood pressure, although the risk was even greater for patients on the higher end, found the meta-analysis published Wednesday in the journal Neurology. Researchers analyzed data from a total of 19 studies from Asia, Europe and the United States, a data set representing more than 760,000 patients.

“These findings, if confirmed, have important takeaways for the public,” said study author, Dr. Dingli Xu, of Southern Medical University in Guangzhou, China. “Considering the high proportion of the population who have higher than normal blood pressure, successful treatment of this condition could prevent many strokes and make a major difference in public health.”

Nearly 30% of U.S. adults have prehypertension, according to the Centers for Disease Control. In patients without other risk factors such as diabetes, high cholesterol or family history, the first line of intervention is often to encourage lifestyle adjustments—such as reducing sodium intake, increasing physical activity and losing weight. Some argue that alone may not be enough, as patients who present with these problems often have great difficulty managing the issues on their own. The Neurology study suggests more research into pharmaceutical approaches for this category of patient.

“For those of us who are trying to prevent stoke, more aggressive control of blood pressure is essential,” agreed Dr. Ralph L. Sacco, chairman of Neurology at the University of Miami School of Medicine, and past president of the American Heart Association. He says lifestyle interventions are very important, but if a patient's blood pressure remains elevated after several unsuccessful attempts, a pharmacological approach may be in order to help preclude a high blood pressure diagnosis.

“We need to do everything we can to get patients' blood pressure controlled, and that may include medication. This article provides further strong evidence in favor of controlling blood pressure at intermediate levels,” he said.

Still, experts agree more research is needed on the long-term effects of use of these medications in patients who do not have high blood pressure, in order to avoid overtreatment and unnecessary exposure to known side effects associated with the drugs.

Follow Sabriya Rice on Twitter: @MHSrice


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