Taskeen Tajuddin

MPHP 439

 

Overview of Hypertension: Description, Diagnosis, Treatment and Prevention.

 

What is Hypertension?

 

High blood pressure also known as hypertension, is often called the silent killer because many people unknowingly have had the disease for years.  In fact, right now approximately 50 million Americans have high blood pressure with an estimated cost of treatment around $37 billion annually, and one-third (about 15 million people) don't know it.  The NHANES III national health survey estimates the age adjusted prevalence for hypertension in the United States between 1988 and 1991 was 32 % for the African American population and 23% for the White and Mexican-American populations1.  Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries.  Increased fluid in the body causes and increase amount of fluid in the blood vessels which in turn increases blood pressure.

  Narrow or clogged blood vessels can also raise the blood pressure in a patient.  The kidneys play a key role in keeping blood pressure within the normal range.  High blood pressure, in turn, can affect the kidneys in a negative way and potentially cause renal diseases.  High blood pressure not only causes damage to the kidney, but also causes the heart to work harder which over time lead to damaged blood vessels.

If the blood vessels in the kidneys are damaged, filtration may be compromised/impaired.  The increased fluid in the blood vessels may then cause further increases in blood pressure resulting in a dangerous cycle.  Clinically, hypertension is defined as have systolic pressure greater then 140 and diastolic greater then 90 mm Hg2.

Hypertension is very important to diagnosis and treat because it increases the individual’s risk of developing other complications such as: heart disease, kidney disease and stroke3.  It is especially dangerous since it often presents no warning signs or symptoms.  Regardless of race, age, or gender, anyone can develop high blood pressure.  It is estimated that one in every four American adults has high blood pressure1.  Once high blood pressure develops, it usually lasts a lifetime.  You can prevent and control high blood pressure by taking the appropriate actions.  Of the patients diagnosed with hypertension only 34% are under control4.

            According to the seventh report of the Joint National Committee (JNC 7), normal blood pressure is classified as systolic less than 120mmHg and diastolic less than 80mmHg.  Pre-hypertension is classified as systolic between 120-139 and/or diastolic 80-89.  Hypertension is broken down into stage 1 and stage 2.  Stage 1 is systolic 140-159 and/or diastolic 90-99. Stage 2 is systolic ≥ 160 and/or diastolic ≥ 1005.  It has recently been reported that systolic pressure is a more significant predictor of hypertension in individuals over 50 to 60 years old6.

            There are many risk factors associated with hypertension, one being heredity; patients who have one or both parents diagnosed with hypertension have an increased risk of developing the condition. Genetic factors account for 30 % of the variations in blood pressure in certain populations6.  There is also a relationship between sodium intake and essential hypertension.  Excess salt intake increases the likelihood of hypertension, but alone is not sufficient enough to cause hypertension.  Excess alcohol intake clearly increases the likelihood of hypertension.  Obesity increases the chance of hypertension.  Hypertension also tends to be more severe and more common in African-Americans7.  Some of the secondary causes of hypertension are primary renal disease, use of oral contraceptives, individuals with pheochromocytoma, primary hyperaldosteronism, endocrine disorders, Cushing’s syndrome and coarctation of aorta8.

            A major complications associated with hypertension is the risk of heart failure in individuals of all ages[10].  Individuals with hypertension have a greater tendency to develop Left Ventricular hypertrophy[11].  Hypertension is the major risk factor for stroke[12].  Another serious outcome of uncontrolled hypertension is intracerebral hemorrhage[13].  Finally, chronic renal insufficiency and end-stage renal disease are poor health outcomes associated with hypertension[14].

 

Diagnosis:

According to United States Preventive Service Task Force it is recommended that individuals over the age of 21 years get their blood pressure checked at each physician office visit[15].  It is very important to have proper measurement and interpretation of blood pressure in the management and diagnosis of hypertension. Diagnosis of mild hypertension should not be made until the blood pressure has been measured at least three to six times.  These measurements have to be evenly spaced over a period of weeks to months.  Otherwise some patients that seem to be hypertensive in their initial visit may actually turn out to be normotensive[16].

            When it is determined that an individual has hypertension, then evaluation needs to be done to estimate if there has been any organ damage and also to assess risk of developing cardiovascular diseases.  A laboratory workup is often used in the diagnosis of hypertension because in some cases there aren’t any external signs.  The testing that needs to be performed are electrocardiogram, hematocrit, glucose, creatinine, electrolytes, and urinalysis.  It is also very important to get a good history from the patient.  When taking a history, one should be careful about paying attention to details which might aid in the diagnosis of hypertension.  The physical examination is also a key component in the diagnosis of hypertension.  The main goal of physical examination is to look for signs of organ damage like retinopathy17.

 

Treatment:

Individuals that are afflicted with hypertension should be treated with antihypertensive medications.  Studies have shown that antihypertensive medications have been associated with a 50 % decrease in heart failure.  There is 20 % reduction in myocardial infarction and 35 to 40 reductions in stroke.  Overall there is about 56 % reduction in coronary heart disease18.  Before individuals are put on antihypertensive medications appropriate nonpharmacological modifications and lifestyle changes should be attempted.  After evaluation, if the hypertensive individual does not have organ damage then it is recommended that the individual be evaluated three to six visits over a certain period of time19.  Individuals who have a systolic pressure that is over 140mmHg and diastolic pressure that is over 90mmHg should be put on antihypertensive medication20.  Individuals with diabetes and chronic renal failure that have a blood pressure that is over 130 mmHg or a diastolic pressure over 80 mmHg21 should also be treated with antihypertensive medications.  According to the seventh Joint National Committee, it is recommended that individuals with uncomplicated hypertension should be treated with low-dose thiazide diuretics22.  These would include low dose thiazide diuretics like hydrochlorothiazide or chlorthalidone23.  Thiazides are especially recommended because they decrease urinary calcium excretion24.  If thiazide alone does not work in lowering hypertension then the patient is usually placed on angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), beta blocker, or calcium channel blocker.  Individuals can be on both diuretics and ACE inhibitors or ARB25.

            The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study showed that a low dose diuretic offers a better cardioprotection than an ACE inhibitor or calcium channel blocker for risk factors like coronary artery disease, type II diabetes, left ventricular hypertrophy, individuals which previous stroke or myocardial infraction, cigarette smokers, atherosclerosis and hyperlipidemia26.  ACE inhibitors are used in individuals with heart failure and myocardial infarction.  It also has a protective effect on the renal system.  This class of drug should be used in individuals with heart failure, myocardial infarction, type I diabetes, left ventricular dysfunction and renal failure27.  Angiotensin II receptor blockers (ARB) are used in individuals that do not tolerate ACE inhibitors.  One of the side effects of ACE inhibitor is cough, which may cause individuals to be put on ARBs28.  Beta Blockers are given to individuals after acute myocardial infarction.  Beta Blockers is given to patients for atrial fibrillation and control for angina.  It is also given to patients with heart failure or left ventricular dysfunction29.  Calcium channel blockers (CCB) are administered to individuals for control of atrial fibrillation and angina.  CCB are also given to individuals with obstructive airway disease30.

 

 

 

Prevention:

One of the well known prevention method is to reduce the intake of dietary sodium and the Dietary Approaches to stop hypertension (DASH) Diet.  The result of this study was published in New England Journal of Medicine.  This study observed 412 individuals that were randomly assigned to eat a control diet that is typical of Americans or the DASH diet30.1.  The participants ate their assigned diet for 30 days.  This study included males and females and individuals from different races.  The results from this study showed that in the control group reducing sodium from high to intermediate levels decreased systolic blood pressure by 2.1 mm Hg and by an additional 4.6 mm Hg when decreasing to low levels.  Within the DASH group reducing sodium from high to intermediate levels decreased systolic blood pressure by 3.4 mm Hg and by an additional 1.7 mm Hg if the participants reached a low level of sodium.  The effect of sodium was observed in the individuals with hypertension and also individuals without hypertension.  The DASH diet significantly lowered systolic blood pressure at each sodium levels.  In comparison to the control diet, DASH diet led to lower systolic blood pressure by 7.1 mm Hg in individuals without hypertension and 11.5 mm Hg in individuals with hypertension30.4.  This study showed that reducing sodium intake to levels that are below the current recommendation of 100 mmol per day and the DASH diet lowers blood pressure31.

Another study that was published in the Annals of Internal Medicine titled “Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials,” showed evidence that aerobic exercise reduces blood pressure in both hypertensive and normotensive individuals.  The study was a meta-analysis of randomized, controlled trial to determine the effect of aerobic exercise on blood pressure. This study included 2419 participants32.  The intervention and control group differed only in aerobic exercise.  The results from this study showed that aerobic exercise was associated with a significant reduction in mean systolic blood pressure.  There was a reduction of about 4 mm Hg33.  The reduction of blood pressure was associated with aerobic exercise in both hypertensive and normotensive individuals and in individuals that were overweight and normal weight. This data suggests that physical aerobic exercise should be considered an important component of lifestyle modification for the prevention and treatment of hypertension34.

The National High Blood Pressure Education Program Coordinating Committee develops programs for the Primary Prevention of Hypertension.  Their current guidelines were published recently in JAMA34.5. This articles talks about the current recommendations for primary prevention of hypertension which included population based approach and an intensive targeted strategies focused on individuals that are at high risk for developing hypertension. According to this report both of these strategies are complementary and emphasize six approaches with proven efficacy for prevention of hypertension. These include maintain normal body weight, limit alcohol consumption, maintain adequate intake of potassium, reduce sodium intake, increase physical activity, have a diet that is rich is fruits, vegetable, and low fat diary products. Finally reduce the intake of saturated and total fats. According to this report applying these standards to the general population as part of public health and clinical practice can aid in preventing hypertension from developing and can aid in the reduction of blood pressure35.

The public health sector needs to have prevention and intervention programs that aid in decreasing the prevalence of hypertension among all Americans. Public health efforts in particular need to develop education programs especially for individuals from the lower socioeconomic group and individuals that are at high risk of develop hypertension. If an impact is to be made in improving hypertension, then comprehensive programs that include early education and prevention tips to individuals about hypertension need to be developed. Another component would be to have better adherence and compliance among patient already afflicted with hypertension. By having these individuals better manage their hypertension; they will be able to improve their overall health and quality of life. This, in return, would have positive effect in the overall health and well being of the community as a whole.

From the public health point of view, developing and investing in education, prevention and intervention programs for those individuals that are afflicted with hypertension or at a higher risk of developing hypertension, can reap benefits.  There could be large savings of resources in the long term36.  Further, these types of programs will result in citizens in the community who are healthier. This is an important initial step to reaching the goals set by Healthy People 2010, particularly around increasing quality and years of healthy life and beginning to eliminate health disparities in the United States.

 

 

 

 

Consulted Reference:

Appel, Lawerence J. The Verdict From ALLHAT - Thiazide Diuretics Are the Preferred Intial Therapy for Hypertension. JAMA 288 (2002): 3039-3044. 

Burke V, Mori TA, Giangiulio N, Gillam HF, Beilin LJ, Houghton S, Cutt HE, Mansour J, Wilson A., An innovative program for changing health behaviors. Asia Pac J Clin Nutr. 2002; 11 Suppl 3:S586-97

 

Burt, VL, Whelton, P, Roccella, EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995; 25:305.

 

Chalmers, John All hats off to ALLHAT: a massive study with clear messages. Journal of Hypertension 2003 Feb; 21(2):225-8. 

 

Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003; 289:2560.

 

Coresh, J, Wei, L, McQuillan, G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States. Findings from the Third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001; 161:1207.

 

Cuspidi C, Sampieri L, Macca G, Fusi V, Salerno M, Lonati L, Severgnini B, Michev I, Magrini F, Zanchetti A., Short and long-term impact of a structured educational program on the patient's knowledge of hypertension. Ital Heart J. 2000 Dec;1(12):839-43.

 

Davis, Barry R., and Jackson T. Wright Jr. Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic. JAMA 288 (2002): 2981-2997. 

 

Davis, Barry R.; Cutler, Jeffrey A.; Gordon, David J.; Furberg, Curt D.; Wright Jr, Jackson T.; Cushman, William C.; Grimm, Richard H.; LaRosa, John; Whelton, Paul K.; Perry, H. Mitchell; Alderman, Michael H.; Ford, Charles E.; Oparil, Suzanne; Francis, Charles; Proschan, Michael; Pressel, Sara; Black, Henry R.; Hawkins, C. Morton, Rationale and Design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) American Journal of Hypertension Vol: 9, Issue: 4, April, 1996 342-360 

 

Duff EM, Simpson SH, Whittle S, Bailey EY, Lopez SA, Wilks R., Impact on blood pressure control of a six-month intervention project. West Indian Med J. 2000 Dec; 49(4):307-11.

 

Dusing, R Old or new antihypertensive drugs? Consequences from ALLHAT. Deutsche Medizinische Wochenschreit 2003 Jan 31; 128(5):214-6. 

 

Elliott, W.J. ALLHAT: The Largest and Most Important Clinical Trial in

Hypertension Ever Done in the USA American Journal of Hypertension Vol: 9, Issue: , April, 1996 409-411 

Englert HS, Diehl HA, Greenlaw RL., Rationale and design of the Rockford CHIP, a community-based coronary risk reduction program: results of a pilot phase. Prev Med. 2004 Apr; 38(4):432-41.

 

Epstein, Murray Antihypertensive strategies for preservation of renal function. American Journal of Hypertension Volume: 9, Issue: 4, April, 1996.198A

 

Fagard, Robert The ALLHAT trial: strengths and limitations. Journal of Hypertension 2003 Feb; 21(2):229-32. 

 

Freedman, Barry I.; Wuerth, Jean-Paul; Cartwright, Kenneth; Bain, Raymond P.; Dippe, Stephen; et. al. Design and Baseline Characteristics for the Aminoguanidine Clinical Trial in Overt Type 2 Diabetic Nephropathy (ACTION II) Controlled Clinical Trials Volume: 20, Issue: 5, October, 1999. 493-510.

Gerber, JC and Stewart, DL. Prevention and Control of hypertension and Diabetes in an underserved Population through Community Outreach and disease management: A Plan of action. Journal of the Association for Academic Minority Physicians, Vol. 9, No. 3, July 1998: 48-52.

 

Greenland, P, Knoll, Stamler, J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA 2003; 290:891.

 

Hartley, RM, Velez, R, Morris, RW, et al. Confirming the diagnosis of mild hypertension. Br Med J 1983; 286:287.

 

Hollenberg, Norman K Renal protection by antihypertensive drugs: What are the issues for the new millennium? American Journal of Hypertension Volume: 11, Issue: 4, Supplement 1, April, 1998. 244A.

Julius, Stevo The ALLHAT study: if you believe in evidence-based medicine. Journal of Hypertension 2003 Mar; 21(3):453-4. 

Kaplan, NM. Clinical hypertension, 8th ed. Philadelphia, Lippincott Williams Wilkins, 2002, p. 4.

 

Levine DM, Bone LR, Hill MN, Stallings R, Gelber AC, Barker A, Harris EC, Zeger SL, Felix-Aaron KL, Clark JM., The effectiveness of a community/academic health center partnership in decreasing the level of blood pressure in an urban African-American population., Ethn Dis. 2003 Summer;13(3):354-61

 

Levy, D, Larson, MG, Vasan, RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557.

 

Libby, Peter Success and predictors of blood pressure control in diverse North American settings: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).Curr Atheroscler Rep 2003 May;5(3):199-200. 

 

Lindblad, Ulf, and Melander, Arne An announcement from the ALLHAT: Thiazide diuretics are medically and economically superior Lakartidningen 2003 Feb 6; 100(6):413-4. 

 

Messerli, Franz H. Doxazosin and Congestive Heart Failure. Journal of the American College of Cardiology 38 (2001): 1295-1296. 

Nelson, Mark R The verdict from ALLHAT. Medical Journal Australia 2003 Mar 17; 178(6):304. 

 

Pasternak, Richard C. The ALLHAT Lipid Lowering Trial-Less is Less.  JAMA 288 (2002): 3042-3044. 

 

Probstfield, Jeffery L. Major Outcomes in Moderately Hypercholestrolemica, Hypertensive Patients Randomized to Pravastatin Vs. Usual Care. JAMA 288 (2002): 2998-3007. 

Psaty, BM, Furberg, CD, Kuller, LH, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality. The Cardiovascular Health Study. Arch Intern Med 2001; 161:1183.

 

Ruilope, Luis M Comments on the renal aspects of the ALLHAT study. Journal of Hypertension 2003 Feb; 21(2):235-6. 

 

Sacks F et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine 2001; 344(1):3-10

 

Seamus P et al. Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials. Annals of Internal Medicine 2002; 136:493-503.

 

Sica, D.A.; Gehr, T.W.B.; Fernandez, A Risk-Benefit Ratio of Angiotensin Antagonists versus ACE Inhibitors in End-Stage Renal Disease. Drug Safety Volume: 22, Issue: 5, 2000. 350-360.

Skybo TA, Ryan-Wenger N., A school-based intervention to teach third grade children about the prevention of heart disease. Pediatr Nurs. 2002 May-Jun; 28(3):223-9, 235.

 

Staessen, JA, Fagard, R, Thijs, L, et al. Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350:757.

Staessen, JA, Wang, J, Bianchi, G, Birkenhager, WH. Essential hypertension. Lancet 2003; 361:1629.

 

Thrift, AG, McNeil, JJ, Forbes, A, et al. Risk factors for cerebral hemorrhage in the era of well controlled hypertension. Melbourne Risk Factor Study (MERFS) Group. Stroke 1996; 27:2020.

 

Vakili, BA, Okin, PM, Devereux, RB. Prognostic implications of left ventricular hypertrophy. Am Heart J 2001; 141:334.

 

Vidt, Donald G The ALLHAT Trial. Diuretics are still the preferred initial drugs for high blood pressure. Cleveland Clinic Journal Med 2003 Mar; 70(3):263-9. 

 

Whelton, P et al., Primary Prevention of Hypertension: Clinical and Public Health Advisory from the National High Blood Pressure Education Program. JAMA 2002; 288:1882-1888

 

Williams, G Hypertensive Vascular Disease. Harrison’s Principles of Internal Medicine 15th edition. 2001; 1414-1430

 

Wong, ND, Thakral, G, Franklin, SS, L'Italien, GJ. Preventing heart disease by controlling hypertension: impact of hypertensive subtype, stage, age, and sex. Am Heart J 2003; 145:888.

 

--Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.

 

--The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. 1999. Texas Medical Center. 18 Feb. 2003

[http://allhat.sph.uth.tmc.edu/]

 

--The seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report JAMA, 2003; 289 No.18, 2560-2572.

--The Sixth Report of the Joint National Committee on Detection, Evaluation, and Diagnosis of High Blood Pressure (JNC VI). Arch Intern Med 1997; 157:2413.

 

--1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens 1999; 17:151.

 

--U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed, Williams Wilkins, Baltimore, 1996.

ALLHAT

[http://www.allhat.org] 

 

Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate Online 12.1 [http://www.uptodate.com]

 

Hypertension: BlackHealthCare.Com Addressing the health care of African Americans. . [http://www.blackhealthcare.com/BHC/Hypertension/Description.asp]

 

Interventions to improve hypertension control rates in African Americans. NIH Guide: Interventions to improve Hypertension control rates.

[http://www.nih.gov]

Material well-being Income and Poverty. Left Business Observer. 1998 [http://www.panix.com/~dhenwood/Stats_incpov.html.] 

 

 

 

 

 

 

 

 

 

 

 

 



1Burt, VL, Whelton, P, Roccella, EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995; 25:305.

2 Kaplan, NM. Clinical hypertension 8th ed. Philadelphia, Lippincott Williams Wilkins, 2002, p. 4.

3 Greenland, P, Knoll, MD, Stamler, J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA 2003; 290:891.

 

4 Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003; 289:2560.

5 Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003; 289:2560.

6 Psaty, BM, Furberg, CD, Kuller, LH, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality. The Cardiovascular Health Study. Arch Intern Med 2001; 161:1183.

6 Staessen, JA, Wang, J, Bianchi, G, Birkenhager, WH. Essential hypertension. Lancet 2003; 361:1629.

7 Burt, VL, Whelton, P, Roccella, EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995; 25:305.

8 The Sixth Report of the Joint National Committee on Detection, Evaluation, and Diagnosis of High Blood Pressure (JNC VI). Arch Intern Med 1997; 157:2413.

[10] Levy, D, Larson, MG, Vasan, RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557.

[11] Vakili, BA, Okin, PM, Devereux, RB. Prognostic implications of left ventricular hypertrophy. Am Heart J 2001; 141:334.

[12] Staessen, JA, Fagard, R, Thijs, L, et al. Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350:757.

[13] Thrift, AG, McNeil, JJ, Forbes, A, et al. Risk factors for cerebral hemorrhage in the era of well controlled hypertension. Melbourne Risk Factor Study (MERFS) Group. Stroke 1996; 27:2020.

[14] Coresh, J, Wei, L, McQuillan, G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States. Findings from the Third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001; 161:1207.

[15] U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed, Williams Wilkins, Baltimore, 1996.

[16] Hartley, RM, Velez, R, Morris, RW, et al. Confirming the diagnosis of mild hypertension. Br Med J 1983; 286:287.

17 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

18 Wong, ND, Thakral, G, Franklin, SS, L'Italien, GJ. Preventing heart disease by controlling hypertension: impact of hypertensive subtype, stage, age, and sex. Am Heart J 2003; 145:888.

19 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

20 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens 1999; 17:151.

21 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

22 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.

23 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.

24 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

25 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

26 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.

27 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

28 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

29 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

30 Domino, FJ and Kaplan NM Overview of Hypertension.2004 UpToDate online 12.1 www.uptodate.com

30.1 Sacks F et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine 2001; 344(1):3-10

30.4 Sacks F et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine 2001; 344(1):3-10

31 Sacks F et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine 2001; 344(1):3-10

32 Seamus P et al. Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials. Annals of Internal Medicine 2002; 136:493-503.

33 Seamus P et al. Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials. Annals of Internal Medicine 2002; 136:493-503.

34 Seamus P et al. Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials. Annals of Internal Medicine 2002; 136:493-503.

34.5 Whelton, P et al., Primary Prevention of Hypertension: Clinical and Public Health Advisory from the National High Blood Pressure Education Program. JAMA 2002; 288:1882-1888

35 Whelton, P et al., Primary Prevention of Hypertension: Clinical and Public Health Advisory from the National High Blood Pressure Education Program. JAMA 2002; 288:1882-1888

36 Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003; 289:2560.