Long-term effects of untreated hypertension are well documented. End organ damage can be irreversible and fatal. These recommendations and rationale for screening for high blood pressure (HBP) are based on the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 6) guidelines for treatment of HBP. The new JNC 7 guidelines establish several important changes as a result of new scientific evidence, available at http://www.nhlbi.nih.gov. The categories for classification of blood pressure have been revised and are noted in Table 1.

What does this mean for health care providers? Diagnose and treat HBP earlier. JNC 6 acknowledged that other factors influence cardiovascular risk and subsequent treatment options, but it negated the effects of certain therapies on reducing cardiovascular events, citing "evidence is insufficient to determine the combined impact of multiple, simultaneous nonpharmacological interventions." More recent studies have demonstrated the positive effects of reducing blood pressure by modifying lifestyles, enhancing antihypertensive drug efficacy, and decreasing cardiovascular risk. 1

Lifestyle modifications include weight loss, increased physical activity, decreased dietary sodium intake, stress management, decreased alcohol intake, and smoking cessation. Identifying these behaviors and intervening before disease is established is the cornerstone of primary care practice and primary prevention. Increased awareness and education of the public and professionals is necessary to prevent HBP and associated morbidity and mortality.

Diagnosis is the first step in managing HBP. No consensus exists among organizations with reference to the recommended frequency of HBP screening in different segments of the population. The judgment of the provider remains the deciding factor. According to the new JNC 7 guidelines, HBP is diagnosed only after two or more properly measured seated blood pressure readings during two or more office visits. Take caution to follow proper procedure.

To avoid errors in blood pressure measurement, proper technique must be followed with attention to preparation of the patient (seated for five minutes with both feet resting on the floor), using the appropriate instrument, proper arm position, palpation and auscultation, and accurate notation of measurements. 2 Another word of caution relates to patients with "white coat" HBP or elevated blood pressure readings contributed to anxiety. These individuals may have normal blood pressure readings outside the office setting. If there is any doubt, alternative methods of blood pressure measurement such as home monitoring and ambulatory monitoring should be undertaken to document real versus white coat HBP, provided the patient has no signs of target organ damage. 2-4 Ambulatory blood pressure monitoring has been found to be more predictive of risk for target organ damage than other methods.

The majority of patients with HBP will at some point require one or more medications along with lifestyle modifications. Tighter control is warranted for patients with diabetes mellitus and chronic renal failure. The new prehypertension classification affords providers the opportunity to engage patients early. JNC 7 expands the discussion of psychological well-being and encourages providers to develop trusting relationships with patients to motivate and empower them to participate fully in managing their health. Even continuous, minimal elevations in blood pressure can be detrimental. Prevention involves a partnership between the public and professionals.

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