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JICC Vol 1 Issue 1 5

*Professor, HOD, **Associate Professor of Cardiology, ***Professor of


Cardiology, ****Registar, KLE University, *****PG Student, DM Cardiology.
Correspondence: Dr. ST Yavagal, MD DM, Professor and HOD, Cardiology,
Jawahar Lal Nehru Medical College, KLES Dr. Prabhakar Kore Hospital &
MRC, Nehru Nagar, Belgaum 590010, Karnataka. Ph: +91-9845005350.
E-mail: styavagal@yahoo.co.in
next 20 years as economically developing nations improve
sanitation, infant mortality and childhood immunization rates.
1
The prevalence of hypertension in adults is expected to
grow from 26.4% (in 2000) to 29.2% in 2025, with most of the
growth from 972 million to projected 1.56 billion affected people
occurring outside of North America and Europe i.e. in the devel-
oping countries. This global epidemic of high blood pressure is
expected to shift the burden of disease so that the heart disease
will become the most common cause of death worldwide by
the year 2025.
2
In India, cardiovascular diseases caused 2.3
million deaths in 1990 and by 2020, and this number is pro-
jected double. Recent studies by using JNC criteria have shown
that hypertension is present in 25% of urban and 10% of rural
subjects in India. In addition, this percentage translates into
absolute number of 42 million persons in rural and 45 million
in urban areas.
3
The definition of hypertension changed dramatically over
time in response to better understanding of hypertension,
pathophysiology, and studies of blood pressures from the di-
verse communities; landmark studies of BP related health out-
comes. Should the usual BP in a population be considered
normal? Should the rise according to age be considered abnor-
mal? All those and other kind of questions related to blood
pressure had found answer from huge data of both clinical and
epidemiological studies. Sir George Pickering clearly articulates
in 1968, when he said, Arterial pressure is a quantity and its
adverse effect is related numerically to it. The dividing line (be-
tween normal BP and hypertension) is nothing more than an
artifact.
4
The multiple risk factor intervention trial (MRFIT),
which included more than 5,50,000 male participants, con-
firmed a continuous and graded influence of both systolic
blood pressure (SBP) and diastolic blood pressure (DBP) on
coronary heart disease mortality, extending down to SBP of
120 mmHg.
5,6
Over the time various expert panels as well as JNC have
changed their definition as more and more data became avail-
able. The most recent report of JNC-7, published in 2003, de-
fines the normal BP as lower than 120/80 mmHg. Further
JNC-7 states that individual with SBP from 120139 mmHg or
DBP 8089 mmHg should be considered pre-hypertensive and
health promoting lifestyle modifications are recommended for
those person.
7
But taking in account psychology of general
public, very word of hypertension, puts the person next to
you in panic. Once we label the person as hypertensive or pre-
hypertensive, it will have a serious negative impact on the so-
cial, personal, and family life of the patient. Various studies
which measured quality of life (QoL) index in a patient who
are labeled as hypertensive, even if adequately controlled with
drugs; have shown negative impacts.
Most of the studies, including report of a National Survey of
General Practitioners, identified serious gap in knowledge and
practice regarding diagnosis and management of hypertension.
8
Similar finding are also reported from the developed
countries.
911
In our observation, most of the general physi-
cians have a habit of writing 120/80 mmHg as normal blood
pressure, and even most of them do not give much importance
JNC-7 definition of
hypertension needs alteration
Suresh T Yavagal, MD DM*
Ravikant Patil, DM**
Prabhu C Halakatti, DM***
Suresh V Patted, DM***
Sameer Ambar, DM**
Basavprabhu Amarkhed, MD*****
PF Kotur, MD****
ABSTRACT
OBJECTIVES
By altering JNC-7 definition of hypertension as per our modified defini-
tion, we tried to find out the difference in prevalence of hypertension. Our
modified definition is 1 mmHg less than JNC-7 criteria.
METHODS
We did the analysis of data collected in Belgaum Hypertension Prevalence
Study conducted by KLE University Belgaum; to know the difference between
the JNC-7 classified group and modified classification what we thought
can change the hypertension statistics.
RESULTS
According to JNC-7, only 16.3% population in our study were in normal
group while 41.1% had come in pre-hypertension group and 42.6% were in
hypertensive group. According to our proposed modified definition, nearly
double the populations i.e. 37.4% were in normal group, 40.2% remained
in pre-hypertension group and only 22.4% were in hypertension group.
CONCLUSION
This statistics significantly altered prevalence of hypertension from
42.6% to 22.4% indicating that by making 1 mmHg alteration in number,
the prevalence could be brought down by 20.2%. This simple alteration
of figure by 1 mmHg can put more than 20% of people in normal group as
compared to pre-hypertensive group of JNC-7, thereby reducing the agony
and psychological torture.
INTRODUCTION
Hypertension, is the most important public health problem world-
wide till date and its impact is expected to increase over the
Yavagal, et al
JICC Vol 1 Issue 1 6
or are ignorant about making genuine effort of beat-by-beat
blood pressure measurement and error of 12 mmHg is present
in most of reading. Even as recommended by JNC more than
one reading is taken in very few cases.
12
So, if we alter the definition of JNC by just 1 mmHg, higher
limit definition of pre-hypertension will include BP 121/
81 mmHg and similarly for stage 1 or stage 2 hypertension,
there could be a significant difference in the statistics of the
hypertension.
So, we did the analysis of data collected in Belgaum
Hypertension Prevalence Study conducted by KLE University,
Belgaum to know the difference between the JNC-7 classified
group and modified classification, what we thought can change
the hypertension statistics (Table 1).
MATERIAL AND METHODS
Aim of Study
To find out difference in the prevalence of hypertension by altering
JNC-7 definition of hypertension, as per our modified definition.
Methods
We decided to derive our data from KLE University Belgaum
Hypertension Detection Study. In this study, it was decided
to screen all persons above 30 years of Belgaum city for any
hypertension. To collect correct figures it is ideal to go door to
door and screen the people. But it is a difficult task. Therefore,
it was decided to have around 225 centers covering the entire
city of Belgaum, and people were requested to come to one of
the center and get their BP checked. All staff members of
Jawaharlal Nehru Medical and Dental College, staff and doctors
of KLE Hospital, and Ayurvedic Colleges participated. Each
center had 5 doctors. Thus, around 1100 doctors were involved
in recording blood pressure and screening of public. The program
was organized on Sunday, April 6, 2008 on the eve of World
Health Day (April 7, 2008). Since April 7 marked the Ugadi
festival, the camp was organized on April 6, 2008. All doctors of
Belgaum city participated in this camp. Indian Medical Asso-
ciation (Belgaum), Cardiological Society of India, north-west
Karnataka chapter and Indian College of Cardiology participated
as co-sponsors of the project. All students of KLE University
formed mobilizing teams to bring public to the screening centers.
Other KLE institutions (non-medical) students worked as volun-
teers. All together nearly, 2000 students worked as volunteers to
mobilize public. All city corporators and their party workers
also participated in mobilizing work.
The following data was collected, name, age, sex, previous
history of hypertension, diabetes, cerebrovascular accidents, vis-
ual assessment of obesity, height, weight, abdominal girth at the
level of umbilicus, etc. Blood pressure was recorded in sitting
posture. Appearance of the sounds was taken as systolic pressure
and disappearance of sounds was taken as diastolic pressure.
When the pulse pressure was more than 60 then muffling of
the sound was taken as diastolic pressure, written instructions
were given in the data-collecting book.
RESULTS OF THE STUDY
Data operators entered all data collected into computer and
with their help, data was analyzed. In total 56302 people
attended the camp, 35582 (63.20%) were males and 20720
(36.80%) were females. All though the camp was organized to
screen all people above 30 years yet 4106 (7.30%) were below
30 years. Only persons above 30 years i.e. 52196 were taken for
analysis (Tables 2, 3, 4).
DISCUSSION
There are multiple single center studies on prevalence of
hypertension available across the country. However, there is
no multicentric national prevalence data. Over the years with
changing definition, a lower level of pressure (140/90 mmHg)
is being used as a cut-off point to define hypertension as com-
pared to earlier studies, which used higher levels of pressure
(160/95 mmHg). This vitiates any assessment of trends of hyper-
tension prevalence over the past few decades. Nevertheless,
there appears to be a steady increase in hypertension prevalence
over the last 50 years, more in urban than in rural areas.
Using cut-off 160/95 mmHg for diagnosis of hypertension,
studies conducted in 1950s in urban Indian populations revealed
that the prevalence of hypertension ranged between 3.03% and
6.19%. Using the same criteria, the prevalence increased to 6.43%
and 10.912.8% in 1990. Based on the revised diagnostic BP
criteria of 140/90 mmHg studies from Mumbai have reported a
prevalence rate of 26.936.4% while in Jaipur it was 36.9%.
Therefore, changing definition has definitely increased preva-
lence of hypertension.
Table 1 Criteria of blood pressure classification.
JNC-7 Classification Proposed Classification
Normal < 120/80 mmHg Normal < 121/81 mmHg
Pre-hypertension 120139/8089 mmHg Pre-hypertension 121140/8190 mmHg
Stage I hypertension 140159/9099 mmHg Stage I hypertension 141160/91100 mmHg
Stage II hypertension 160/100 mmHg Stage II hypertension > 160/100 mmHg
JNC-7 definition of hypertension needs alteration
JICC Vol 1 Issue 1 7
Table 2 Age and sex distribution.
Age group Male Female Total
3039 11056 21.2% 6592 12.6% 17648 33.8%
4049 8500 16.3% 5016 9.6% 13516 25.9%
5059 6886 13.2% 3706 7.1% 10592 20.3%
6069 4214 8.1% 2684 5.1% 6898 13.2%
7079 1852 3.5% 996 1.9% 2848 5.5%
8089 422 0.8% 208 0.4% 630 1.2%
9099 42 0.1% 18 0.0% 60 0.1%
100 and above 4 0.0% 00 0% 4 0.0%
Total 32976 63.2% 19220 36.8% 52196 100%
Total population screened = 56302
Total population screened (30 years and above) = 52196
4106 were below 30 years hence, not included in the analysis.
Table 3 Distribution of blood pressure according to JNC-7 definition.
Blood pressure Male Female Total
Normal (< 120/80 mmHg) 4656 8.9% 3838 7.4% 8494 16.3%
Pre-hypertensive 120/80139/89 mmHg 13542 25.9% 7948 15.2% 21490 41.1%
Hypertensive 140/90 mmHg and above 14778 28.4% 7434 14.2% 22212 42.6%
Total 32976 63.2% 19220 36.8% 52196 100%
According to JNC-7 only 16.3% population in our study was in
normal groups while 41.2% had come in pre-hypertension group
and 42.6% were in hypertensive group (Figure 1). According to
our modified definition nearly double the population i.e. 37.4%
was in normal group, 40.2% remained in pre-hypertension group
and only 22.4% were remained in hypertension group (Figure 2).
This statistics significantly altered prevalence of hypertension
from 42.6% to 22.4%. That means just making 1mm alteration in
number can bring down the prevalence by 20.2%, which is con-
sidering worldwide epidemic of hypertension is a very big number.
Therefore, this 20.2% population, which needs drug treatment
for hypertension according to JNC-7, our modified definition rec-
ommends only lifestyle modification. Even only 16.3% were nor-
mal according to JNC-7, but our modified definition converts that
number to 37.4%. Therefore, JNC-7 labels this extra 21.1% popu-
lation as pre-hypertensive and setting them in panicky situation.
Our proposed definition by altering 1 mmHg calculation in
JNC-7 definition had made the big difference to the population
screened in our study. This study certainly augurs good news
to the treating physicians.
Next question arises immediately after considering this
modified JNC-7 classification, whether ignoring 1 mmHg rise in
BP translates into fatal cardiac and non-cardiac adverse effects of
hypertension. Framingham Heart Study investigators devel-
oped the risk calculators for chronic heart disease (CHD). The
simplest of these was adopted by the third adult treatment
panel of the National Cholesterol Education Program
15
which
states that cardiovascular disease risk is increased 2.5-folds in
women and 1.6-folds in men with high normal BP (SBP 130
139 mmHg or DBP 8589 mmHg).
16,17
Thus, the studies consid-
ered the range rather than 1 mmHg change.
In both men and women, each 20 mmHg difference of SBP
or approximately 10 mmHg diastolic BP was associated with more
than two-folds difference in stroke death rates and with a two-
folds difference in death rates from ischemic heart disease (IHD),
each 10 mmHg lower SBP is associated with 33% decreased risk
of stroke.
18
As all the studies, showed associated risk of hypertension when
measured in range and not with 1 mmHg difference, so altering
definition will not definitely change the end measurements.
Table 4 Distribution of blood pressure (with modified definition).
Age group Male Female Total
Normal (< 121/81 mmHg) 11474 22% 8038 15.4% 19512 37.4%
Pre-hypertensive 121/81140/90 mmHg 13798 26.4% 7200 13.8% 20998 40.2%
Hypertensive 141/90 mmHg and above 7704 14.8% 3982 7.6% 11686 22.4%
Total 32976 63.2% 19220 36.8% 52196 100%
Yavagal, et al
JICC Vol 1 Issue 1 8
However, why a new definition? The public health services
in developing countries particularly Asia and Africa including
China, are dysfunctional.
19,20
The vast majority of the popula-
tion in these countries seek care from allopathic doctors, as
well as their traditional branches of medicine like Unani,
Ayurveda, Homeopathy, etc.
21,22
Most of the studies from these countries reported marked defi-
ciencies in knowledge and approach of family physicians from
these countries relating diagnosis and management of high blood
pressures and identified serious limitation in current practice.
23
Therefore, the measurement taken by most of the family
physicians in reality is not accurate. Moreover, most of these
doctors write 120/80 mmHg as a normal blood pressure, which
is a very common phenomenon worldwide. That is why epide-
miological studies, based on single measurement taken by the
family physicians, will overestimate the prevalence of hyper-
tension statistically.
The estimated cost of hypertension and its treatment in
United States alone in 2006 is 63.5 billion. Worldwide the cost is
six times the above value, which involves lifestyle modification
100
P
e
r
c
e
n
t
a
g
e

(
%
)
Normal
(< 120/80 mmHg)
8.90%
7.40%
16.30%
Pre-hypertensive
120/80 mmHg
139/89 mmHg
Hypertensive
140/90 mmHg
and above
Total
90
80
70
60
50
40
30
20
10
0
25.90%
15.20%
41.20%
28.30%
14.20%
42.60%
63.20%
36.80%
100.00%
Male
Female
Total
Figure 1 Graph showing distribution according to JNC-definition.
120
P
e
r
c
e
n
t
a
g
e

(
%
)
Normal
(< 121/81 mmHg)
22.00%
15.40%
37.40%
Pre-hypertensive
121/81 mmHg
140/90 mmHg
Hypertensive
141/90 mmHg
and above
Total
100
80
60
40
20
0
26.40%
13.80%
40.20%
14.80%
7.60%
22.40%
63.20%
36.80%
100.00%
Male
Female
Total
Figure 2 Graph showing distribution of blood pressure according to modified definition.
JNC-7 definition of hypertension needs alteration
JICC Vol 1 Issue 1 9
to drug treatment. Even in United States over the last 15 years,
the cost of antihypertensive drugs has increased more than
7 times the inflation rates.
24
Our modified definition will prevent
the use of antihypertensive treatment in nearly half the JNC-7
population treated as hypertensive group, which can nearly bring
down the cost involved by 50% to ease the already overburdened
world economies.
25
So logistically speaking, if we consider the hard and ground
level facts of measuring diagnosing and treating hypertension, our
modified definition of JNC-7 will bring down the proposed prev-
alence of the hypertension in the population. This will in turn
decrease the agony and psychological torture of significant
number of population who have been labeled as pre-hypertensive
or hypertensive. In addition, we recommend to Indian Cardi-
ology Society as well as World Cardiology Society to initiate
a comprehensive program for physician and family physicians
to become aware about measurement of blood pressure in
more careful and correct way.
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