JNC VII: the more things change …

Journal of Family Practice, June, 2003 by Jeff Susman

Imagine you are Rip Van Winkle, MD, waking from a 20-year sleep to hear that the Joint National Committee on & Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has released its 7th report. (1) You wouldn't be surprised to learn that diuretics are first-line therapy for hypertension, a systolic blood pressure of > 140 mm Hg is a more important risk factor than elevated diastolic blood pressure, and that patients will achieve goal blood pressure only if they are motivated.

Moreover, you probably wouldn't be surprised to learn that hypertension has now been characterized as a "lifestyle syndrome" (2) associated with our insatiable appetites for too many calories, too much alcohol, too much salt, too much fat, too much tobacco--simply too much!

Speaking of excess, JNC VII informs us that people who are normotensive at age 55 have a 90% lifetime risk for developing hypertension, and that those with a blood pressure of 120-139 mm Hg systolic or 80-89 mm Hg diastolic blood pressure are now "prehypertensive" and should adopt lifestyle modifications. Such figures are downright depressing. I have a hard enough time getting patients to lose weight, reduce dietary sodium, and engage in physical activity when they have a disease, let alone a "predisease."

Commenting on JNC VII in JAMA, Dr Thomas Kottke and colleagues state that "technologies are available to detect, treat, and control hypertension ... delivery systems are also available. What is unclear is the degree of the will to succeed...." I hope they are correct: that hypertension control is simply a "problem of technology transfer." I remain suspicious, however, about such blithe pronouncements. Sure, interventions in North Karelia, Finland, and Olmstead County, Minnesota, where a managed care environment prevails, can be successful. I just wish I felt more optimistic about replicating these outcomes in the typical family practice while seeing 6 patients hourly.

Perhaps as Dr Kottke suggests, it's simply a matter of "the will to succeed, which requires devoting the resources, organizing the treatment systems, and creating the environments that allow patients and clinicians to cross the hypertension quality chasm."

And your next thought as Dr Van Winkle, just before you curl up for another 20 years, might be "I've heard this all before."

REFERENCES

(1.) Chobanian AV, Bakris GL, Black HR. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. JAMA 2003; 289:2560-2573.

(2.) Kottke TE, Stroebel RJ, Hoffman RS. JNC 7--It's more than high blood pressure. JAMA 2003; 289:2573-2575.