Current Hypertension Reports

, Volume 10, Issue 5, pp 359–366

Prehypertension: Risk stratification and management considerations



Approximately 37% of US adults are prehypertensive; about 31 million have blood pressures in the range of 130–139/85–89 mm Hg. These stage 2 prehypertensives have threefold greater risk for developing hypertension and twofold higher risk for cardiovascular events than normotensives. Lifestyle changes only are recommended for most prehypertensives, but evidence for community-wide effectiveness is limited. Projected numbers needed to treat to prevent a cardiovascular event are similar for stage 2 prehypertension and stage 1 hypertension when both groups are matched for concomitant risk factors. However, no clinical trials document that pharmacotherapy reduces cardiovascular events in stage 2 prehypertension. The Trial of Preventing Hypertension demonstrated that angiotensin receptor blockade safely lowers blood pressure and prevents or delays progression to hypertension in stage 2 prehypertensives. We believe it is reasonable for clinicians to identify stage 2 prehypertensives at high absolute risk for progression to hypertension and cardiovascular events, and to treat them with a renin-angiotensin system blocker when life-style changes alone are ineffective.


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References and Recommended Reading

  1. 1.
    Robinson SC, Brucer M: Range of normal blood pressure: A statistical and clinical study of 11,383 persons. Arch Intern Med 1939, 64:409–444.Google Scholar
  2. 2.
    Chobanian AV, Bakris GL, Black HR, et al.: National High Blood Pressure Education Program Coordinating Committee: Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003, 42:1206–1252.PubMedCrossRefGoogle Scholar
  3. 3.
    Greenlund KJ, Croft JB, Mensah GA: Prevalence of heart disease and stroke risk factors in persons with prehypertension in the United States, 1999–2000. Arch Intern Med 2004, 164:2113–2118.PubMedCrossRefGoogle Scholar
  4. 4.
    Neaton JD, Kuller L, Stamler J, Wentworth DN: Impact of systolic and diastolic blood pressure on cardiovascular mortality. In Hypertension, Pathophysiology, Diagnosis, and Management, edn 2. Edited by Laragh JH, Brenner BM. New York: Raven Press; 1995:127–144.Google Scholar
  5. 5.
    Levy RL, Hillman CC, Stoud WD, et al.: Transient tachycardia: prognostic significance alone and in association with transient hypertension. JAMA 1945, 129:585–588.Google Scholar
  6. 6.
    Julius S, Schork MA: Borderline hypertension—a critical review. J Chron Dis 1971, 23:723–754.PubMedCrossRefGoogle Scholar
  7. 7.
    Julius S, Jamerson K, Mejia A, et al.: The association of borderline hypertension with target organ changes and higher coronary risk. JAMA 1990, 264:354–358.PubMedCrossRefGoogle Scholar
  8. 8.
    Giles TD, Berk BC, Black HR, et al.; for the Hypertension Writing Group: Expanding the definition and classification of hypertension. J Clin Hypertens 2005, 7:505–512.CrossRefGoogle Scholar
  9. 9.
    Wang Y, Wang QJ: The prevalence of prehypertension and hypertension among US adults according to the new Joint National Committee Guidelines: new challenges of the old problem. Arch Intern Med 2004, 164:2126–2134.PubMedCrossRefGoogle Scholar
  10. 10.
    Ostchega Y, Yoon SS, Hughes J, Louis T: Hypertension Awareness, Treatment, and Control—Continued Disparities in Adults: United States, 2005–2006. Hyattsville, MD: National Center for Health Statistics; January 2008. [NCHS data brief no. 3]Google Scholar
  11. 11.
    Qureshi AI, Suri MF, Kirmani JF, Divani AA: Prevalence and trends of prehypertension and hypertension in United States: National Health and Nutrition Examination Surveys 1976 to 2000. Med Sci Monit 2005, 11:CR403–CR409.PubMedGoogle Scholar
  12. 12.
    Leitschuh M, Cuppies LA, Kannel W, et al.: High-normal blood pressure progression to hypertension in the Framingham Study. Hypertension 1991, 17:22–27.PubMedGoogle Scholar
  13. 13.
    Winegarden CR: From “prehypertension” to hypertension? Additional evidence. Ann Epidemiol 2004, 15:720–725.CrossRefGoogle Scholar
  14. 14.
    Julius S, Nesbitt SD, Egan BM, et al.: Trial of Preventing Hypertension (TROPHY) Investigators: Feasibility of treating prehypertension with an angiotensin receptor blocker. N Engl J Med 2006, 354:1685–1697.PubMedCrossRefGoogle Scholar
  15. 15.
    Julius S, Kaciroti N, Egan BM, et al.: TROPHY revisited: outcomes based on the JNC 7 definition of hypertension. JASH 2008, 2:39–43.Google Scholar
  16. 16.
    Julius S, Jamerson K, Mejia A, et al.: The association of borderline hypertension with target organ changes and higher coronary risk: Tecumseh Blood Pressure Study. JAMA 1990, 265:354–358.CrossRefGoogle Scholar
  17. 17.
    Eliasson M, Jansson JH, Nilsson P, Asplund K: Increased levels of tissue plasminogen activator antigen in essential hypertension: a population-based study. J Hypertens 1997, 15:349–356.PubMedCrossRefGoogle Scholar
  18. 18.
    Toikka JO, Laine H, Ahotupa M, et al.: Increased arterial intima-media thickness and in vivo LDL oxidation in young men with borderline hypertension. Hypertension 2000, 36:929–933.PubMedGoogle Scholar
  19. 19.
    Palombo C, Kozakova M, Magagna A, et al.: Early impairment of coronary flow reserve and increase in minimum coronary resistance in borderline hypertensive patients. J Hypertens 2000, 18:453–459.PubMedCrossRefGoogle Scholar
  20. 20.
    Millgard J, Hagg A, Sarabi M, Lind L: Endothelium-dependent vasodilation in normotensive subjects with a familial history of essential hypertension and in young subjects with borderline hypertension. Blood Pressure 2002, 11:279–284.PubMedCrossRefGoogle Scholar
  21. 21.
    Chrysohoou C, Pitsavos C, Panagiotakos DB, et al.: Association between prehypertension status and inflammatory markers related to atherosclerotic disease. The Attica Study. Am J Hypertens 2004, 17:568–573.PubMedCrossRefGoogle Scholar
  22. 22.
    Vasan RS, Larson MG, Leip EP, et al.: Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001, 345:1291–1297.PubMedCrossRefGoogle Scholar
  23. 23.
    Liszka HA, Mainous AG, King DE, et al.: Prehypertension and cardiovascular morbidity. Ann Fam Med 2005, 3:294–299.PubMedCrossRefGoogle Scholar
  24. 24.
    Kshirsagar AV, Carpenter M, Bang J, et al.: Blood pressure usually considered normal is associated with an elevated risk of cardiovascular disease. Am J Med 2006, 119:133–141.PubMedCrossRefGoogle Scholar
  25. 25.
    Egan BM: Should metabolic syndrome patients with prehypertension receive antihypertensive therapy? In Therapeutic Strategies in Hypertension. Edited by Bakris GL. Oxford: Clinical Publishing; 2006:9–25.Google Scholar
  26. 26.
    Zhang Y, Lee ET, Devereux RB, et al.: Prehypertension, diabetes, and cardiovascular disease risk in a population-based sample: the Strong Heart Study. Hypertension 2006, 47:410–414.PubMedCrossRefGoogle Scholar
  27. 27.
    Hsia J, Margolis KL, Eaton CB, et al.; Women’s Health Initiative Investigators: Prehypertension and cardiovascular disease risk in the Women’s Health Initiative. Circulation 2007, 115:855–860.PubMedCrossRefGoogle Scholar
  28. 28.
    Ogden LG, He J, Lydick E, Whelton PK: Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension 2000, 35:539–543.PubMedGoogle Scholar
  29. 29.
    Nesbitt SN, Julius S, Leonard D, et al.: the TROPHY Study Investigators: Is low-risk hypertension fact or fiction? Cardiovascular risk profile in the TROPHY Study. Am J Hypertens 2005, 18:979–984.CrossRefGoogle Scholar
  30. 30.
    Lasser VI, Raczynski JM, Stevens VJ, et al.: the Trials of Hypertension Prevention (TOHP) Collaborative Research Group: Trial of Prevention, phase II: structure and content of the weight loss and dietary sodium reduction interventions. Ann Epidemiol 1995, 5:156–164.PubMedCrossRefGoogle Scholar
  31. 31.
    The Trials of Hypertension Prevention Collaborative Research Group: Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. Arch Intern Med 1997, 157:657–667.CrossRefGoogle Scholar
  32. 32.
    Hjermann I, Velve Byre K, Holme I, Leren P: Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomised trial in healthy men. Lancet 1981, 2:1303–1310.PubMedCrossRefGoogle Scholar
  33. 33.
    Hjermann I: Smoking and diet intervention in healthy coronary high risk men. Methods and 5-year follow-up of risk factors in a randomized trial. The Oslo Study. J Oslo City Hosp 1980, 30:3–17.PubMedGoogle Scholar
  34. 34.
    Moser M: A decade of progress in the management of hypertension. Hypertension 1983, 5:808–813.PubMedGoogle Scholar
  35. 35.
    Goldman L, Cook F: The decline in ischemic heart disease mortality rates: an analysis of the comparative effective of medical interventions and changes in lifestyle. Ann Intern Med 1984, 101:825–836.PubMedGoogle Scholar
  36. 36.
    Bobrie G, Chatellier G, Genes N, et al.: Cardiovascular prognosis of ‘masked hypertension’ detected by blood pressure self-measurement in elderly hypertensive patients. JAMA 2004, 291:1342–1349.PubMedCrossRefGoogle Scholar
  37. 37.
    Mancia G, Facchetti R, Bombelli M, et al.: Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure. Hypertension 2006, 47:846–853.PubMedCrossRefGoogle Scholar
  38. 38.
    Egan BM, Papademetriou V, Wofford M, et al.: Metabolic syndrome and insulin resistance: contrasting views in patients with high normal blood pressure. Am J Hypertens 2005, 18:3–12.PubMedCrossRefGoogle Scholar
  39. 39.
    Isomaa B, Almgren P, Tuomi T, et al.: Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001, 24:683–689.PubMedCrossRefGoogle Scholar
  40. 40.
    Appel LJ, Moore TJ, Obarzanek E, et al.: the DASH Collaborative Research Group: A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997, 336:1117–1124.PubMedCrossRefGoogle Scholar
  41. 41.
    Esposito K, Marella R, Ciotaola M, et al.: Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome. JAMA 2004, 292:1440–1446.PubMedCrossRefGoogle Scholar
  42. 42.
    Katzmarzyk PT, Church TS, Blair SN: Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men. Arch Intern Med 2004, 164:1092–1097.PubMedCrossRefGoogle Scholar
  43. 43.
    Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002: 346:393–403.CrossRefGoogle Scholar
  44. 44.
    Kjeldsen SE, Lyle PA, Tershakovec AM, et al.: Targeting the renin-angiotensin system for the reduction of cardiovascular outcomes in hypertension: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Expert Opin Emerg Drugs 2005, 10:729–745.PubMedCrossRefGoogle Scholar
  45. 45.
    Yavuz D, Koc M, Toprak A, et al.: Effects of ACE inhibition and AT1-receptor antagonism on endothelial function and insulin sensitivity in essential hypertensive patients. J Renin Angiotensin Aldosterone Syst 2003, 4:197–203.PubMedCrossRefGoogle Scholar
  46. 46.
    Rosei EA, Rizzoni D, Muiesan ML, et al.: CENTRO (Candesartan atherosclerotic risk factors) study investigators: Effects of candesartan cilexetil and enalapril on inflammatory markers of atherosclerosis in hypertensive patients with non-insulin-dependent diabetes mellitus. J Hypertens 2005, 23:435–444.PubMedCrossRefGoogle Scholar
  47. 47.
    Dahlof B, Devereux RB, Kjeldsen SE, et al.: Cardiovascular morbidity and mortality in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): a randomized trial against atenolol. Lancet 2002, 359:995–1003.PubMedCrossRefGoogle Scholar
  48. 48.
    Dahlof B, Sever PS, Poulter NR, et al.: Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet 2005, 366:895–906.PubMedCrossRefGoogle Scholar
  49. 49.
    Jamerson KA, on behalf of the ACCOMPLISH investigators: Avoiding cardiovascular events in combination therapy in patients living with systolic hypertension. Presented at the American College of Cardiology Scientific Sessions. Chicago, IL; March 31, 2008.Google Scholar
  50. 50.
    Materson BJ, Reda DJ, Preston RA, et al.: Response to a second single agent used as monotherapy for hypertension after failure of the initial drug. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med 1995, 155:1757–1762.PubMedCrossRefGoogle Scholar
  51. 51.
    Nissen SE, Tuzcu EM, Libby P, et al.: Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure. The CAMELOT Study: a randomized controlled trial. JAMA 2004, 292:2217–2226.PubMedCrossRefGoogle Scholar
  52. 52.
    Wong ND, Pio JR, Franklin SS, et al.: Preventing coronary events by optimal control of blood pressure and lipids in patients with the metabolic syndrome. Am J Cardiol 2003, 91:1421–1426.PubMedCrossRefGoogle Scholar
  53. 53.
    Sever PS, Dahlof B, Poulter NR, et al.: ASCOT Investigators: Prevention of coronary and stroke events in hypertensive patients who have average or lower than average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm (ASCOTLLA): a multicentre randomised controlled trial. Lancet 2003, 361:1149–1158.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group LLC 2008

Authors and Affiliations

  1. 1.Medical University of South CarolinaCharlestonUSA

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