Prehypertension: should we be treating with pharmacologic therapy?

Prehypertension, defined by Seventh Joint National Committee (JNC 7) as a blood pressure (BP) 120-139/80-89 mm Hg, was controversial. Approximately 31-37% of US adults are prehypertensive, and approximately 12-14% have BP of 130-139/85-89 mm Hg or ;Stage 2' prehypertension, is associated with approximately 3-fold greater likelihood of developing hypertension and roughly twice the cardiovascular events than BP <120/80 mm Hg. Lifestyle change is the only intervention recommended for most prehypertensives. When fully implemented, lifestyle changes lower BP and prevent cardiovascular events, but evidence for community-wide effectiveness is limited. The Trial of Preventing Hypertension (TROPHY) documented that angiotensin receptor blockade safely lowers BP and prevents and/or delays hypertension in Stage 2 prehypertensives. Prehypertensives with diabetes or nephropathy are at high risk and should receive antihypertensive treatment according to JNC 7. Epidemiological data suggest that the number needed to treat to prevent a cardiovascular event in these at-risk Stage 2 prehypertensives is similar to Stage 1 hypertensives when both groups have one or more concomitant risk factors. Clinical trials are urgently needed to address this question. In the absence of clinical trials data, we believe it is prudent for the concerned clinician to consider initiating antihypertensive pharmacotherapy in selected Stage 2 prehypertensive patients at significant absolute risk for progression to hypertension and cardiovascular events.