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CLINICIAN’S CORNER
The Seventh Report of the Joint
National Committee on Prevention,
Detection, Evaluation, and Treatment
of High Blood Pressure
The JNC 7 Report
“The Seventh Report of the Joint National Committee on Prevention, De-
tection, Evaluation, and Treatment of High Blood Pressure” provides a new
guideline for hypertension prevention and management. The following are
the key messages: (1) In persons older than 50 years, systolic blood pres-
sure (BP) of more than 140 mm Hg is a much more important cardiovascular
disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning
at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individu-
als who are normotensive at 55 years of age have a 90% lifetime risk for
developing hypertension; (3) Individuals with a systolic BP of 120 to 139
mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as pre-
hypertensive and require health-promoting lifestyle modifications to pre-
vent CVD; (4) Thiazide-type diuretics should be used in drug treatment for
most patients with uncomplicated hypertension, either alone or combined
with drugs from other classes. Certain high-risk conditions are compelling
indications for the initial use of other antihypertensive drug classes (angio-
tensin-converting enzyme inhibitors, angiotensin-receptor blockers, ␤-block-
OR MORE THAN 3 DECADES, THENational Heart, Lung, and ers, calcium channel blockers); (5) Most patients with hypertension will re-
quire 2 or more antihypertensive medications to achieve goal BP (Ͻ140/90
mm Hg, or Ͻ130/80 mm Hg for patients with diabetes or chronic kidney
disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration
should be given to initiating therapy with 2 agents, 1 of which usually should
be a thiazide-type diuretic; and (7) The most effective therapy prescribed by
the most careful clinician will control hypertension only if patients are mo-
organizations and 7 federal agencies.
One important function is to issue tivated. Motivation improves when patients have positive experiences with
and trust in the clinician. Empathy builds trust and is a potent motivator.
Finally, in presenting these guidelines, the committee recognizes that the
responsible physician’s judgment remains paramount.
publication of “The Sixth Report ofthe Joint National Committee on thePrevention, Detection, Evaluation, and Author Affiliations and Financial Disclosures are listed
Corresponding Author and Reprints: Edward J. Roc-
cella, PhD, MPH, National Heart, Lung, and Blood In- stitute, National Institutes of Health, 31 Center Dr, MSC2480, Bethesda, MD 20892 (e-mail: roccella@nih See also pp 2534 and 2573.
tee for “The Seventh Report of the Joint 2560 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted)
2003 American Medical Association. All rights reserved.
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tee members provide in writing a detailed rationale explaining the necessity to up- sidered for a new report. The JNC 7 chair plify the classification of BP; and a clear reviewed in a reiterative fashion. At its discussion and justification for the cur- Classification of BP
TABLE 1 provides a classification of BP
chaired by the director of the NHLBI, has pertension clinical trials at their bian- reviewed scientific literature from Janu- readings on each of 2 or more office vis- principal investigator of the larger stud- rectly to the Coordinating Committee.
Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older
Management*
Initial Drug Therapy
Systolic
Diastolic
Lifestyle
Classification
BP, mm Hg*
BP, mm Hg*
Modification
Without Compelling Indication
With Compelling Indications†
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; BP, blood pressure; CCB, calcium channel blocker.
*Treatment determined by highest BP category.
†See Table 6.
‡Treat patients with chronic kidney disease or diabetes to BP goal of less than 130/80 mm Hg.
§Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
2003 American Medical Association. All rights reserved.
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Table 2. Trends in Awareness, Treatment, and Control of High Blood Pressure in Adults With
National Health and Nutrition Examination Surveys, Weighted %
III (Phase 1,
III (Phase 2,
II (1976-1980)
1988-1991)
1991-1994)
1999-2000
Accurate BP Measurement
*Data for 1999-2000 were computed (M. Wolz, unpublished data, 2003) from the National Heart, Lung, and Blood Institute and data for National Health and Nutrition Examination Surveys II and III (phases 1 and 2) are from “The Sixth in the Office
Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pres-sure.”1 High blood pressure is systolic blood pressure of at least 140 mm Hg or diastolic blood pressure of at least 90 mm Hg or taking antihypertensive medication.
†Systolic blood pressure of less than 140 mm Hg and diastolic blood pressure of less than 90 mm Hg.
validated instrument should be used.16Patients should be seated quietly for at least 5 minutes in a chair rather than on floor and arm supported at heart level.
Benefits of Lowering BP
cially in those at risk for postural hypo- Cardiovascular Disease Risk
It is estimated that in patients with stage years of age have a 90% lifetime risk for Ambulatory BP Monitoring
BP Control Rates
35 million office visits as the primary di- Ͻ90 mm Hg), although improved, are with antihypertensive medications, epi- have hypertension (TABLE 2). In the ma-
usually lower than clinic readings. Awake jority of patients, controlling systolic hy- introduced in this report (Table 1), rec- ognizes this relationship and signals the toring correlates better than office mea- tolic hypertension. Recent clinical trials readings that are elevated, the overall BP load, and the extent of BP reduction dur- 2562 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted)
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ing sleep. In most individuals, BP de-creases by 10% to 20% during the night; Box 1. Cardiovascular Risk Factors*
Major Risk Factors
present are at increased risk for cardio- Self-measurement of BP
Microalbuminuria or estimated GFR Ͻ60 mL /min Age (Ͼ55 years for men, Ͼ65 years for women) Family history of premature cardiovascular disease (men Ͻ55 years Target-Organ Damage
Prior coronary revascularizationHeart failure Patient Evaluation
(1) to assess lifestyle and identify other *BMI indicates body mass index calculated as weight in kilograms divided by the square of height in meters; GFR, glomerular filtration rate.
sis and guide treatment (BOX 1); (2) to
†Components of the metabolic syndrome.
reveal identifiable causes of high BP
(BOX 2); and (3) to assess the presence
or absence of target-organ damage and
Box 2. Identifiable Causes of
Hypertension
tration rate), and calcium20; and a lipid profile (after a 9- to 12-hour fast) that with verification in the contralateral arm; lesterol, and triglycerides. Optional tests ally unless BP control is not achieved.
cultation for carotid, abdominal, andfemoral bruits; palpation of the thyroid Treatment
Goals of Therapy.The ultimate public
pulses; and neurological assessment.
Lifestyle Modifications. Adoption of
Laboratory Tests and
critical for the prevention of high BP and Other Diagnostic Procedures
tolic BP goal (FIGURE). Treating sys-
tolic BP and diastolic BP to targets that 2003 American Medical Association. All rights reserved.
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(TABLE 3).30 Lifestyle modifications de-
Pharmacologic Treatment. Excel-
pertension eating plan has effects similar converting enzyme (ACE) inhibitors,angiotensin-receptor blockers (ARBs), Figure. Algorithm for Treatment of Hypertension
(CCBs), and thiazide-type diuretics, willall reduce the complications of hyper- tension.10,31-37 TABLE 4 and TABLE 5 pro-
vide a list of commonly used antihy-
(<140/90 mm Hg or <130/80 mm Hg for Those With Diabetes basis of antihypertensive therapy in most outcome trials.37 In these trials, includ-ing the recently published Antihyper- to Prevent Heart Attack Trial,33 diuret-ics have been virtually unsurpassed in Pressure trial36 that reported slightly bet- ter outcomes in white men with a regi-men that began with an ACE inhibitorcompared with one starting with a di- uretic. Diuretics enhance the antihyper-tensive efficacy of multidrug regimens, Optimize Dosages or Add Additional Drugs Until Goal BP Is Achieved can be useful in achieving BP control, and Consider Consultation With Hypertension Specialist are more affordable than other antihy-pertensive agents. Despite these find- BP indicates blood pressure; ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; and CCB,calcium channel blocker.
as initial therapy for most patients with Table 3. Lifestyle Modifications to Manage Hypertension*
Approximate Systolic BP
Modification
Recommendation
Reduction, Range
Maintain normal body weight (BMI, 18.5-24.9) Consume a diet rich in fruits, vegetables, and Reduce dietary sodium intake to no more than as initial therapy are listed in TABLE 6.
If a drug is not tolerated or is contrain- Engage in regular aerobic physical activity dicated, then 1 of the other classes proven such as brisk walking (at least 30 minutes Limit consumption to no more than 2 drinks per day (1 oz or 30 mL ethanol [eg, 24 oz Achieving BP Control in Indi-
vidual Patients. Most patients with hy-
whiskey]) in most men and no more than1 drink per day in women and hypertensive medications to achieve their Abbreviations: BMI, body mass index calculated as weight in kilograms divided by the square of height in meters; BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension.
*For overall cardiovascular risk reduction, stop smoking. The effects of implementing these modifications are dose and time dependent and could be higher for some individuals.
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equate doses fails to achieve the BP goal.
tions already in use, tolerability, and de- sired BP targets. In many cases, specialist above goal, consideration should be given Ischemic Heart Disease. Ischemic
ther as separate prescriptions or in fixed- ␤-blocker; alternatively, long-acting nists have proven to be most benefi- vised in those at risk for orthostatic hy-potension, such as patients with diabe- Table 4. Oral Antihypertensive Drugs*
Usual Dose,
Drug (Trade Name)
Range, mg/d
Frequency
Follow-up and Monitoring. Once an-
frequent visits will be necessary for pa- year.60 After BP is at goal and stable, fol- treated to their respective goals, and to- Special Considerations
tention and follow-up by the clinician.
Compelling Indications. Table 6 de-
classes for high-risk conditions. The drug data from clinical trials. Combination of 2003 American Medical Association. All rights reserved.
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Heart Failure. Heart failure, in the
Diabetic Hypertension. Combina-
Chronic Kidney Disease. In pa-
filtration rate of less than 60 mL/min per tion, ACE inhibitors and ␤-blockers are tients with diabetes.33,54,63 The ACE in- µmol/L] in women)20 or (2) the pres-ence of albuminuria (Ͼ300 mg/d or 200mg albumin per gram of creatinine), Table 4. Oral Antihypertensive Drugs (cont)*
Usual Dose,
Drug (Trade Name)
Range, mg/d
Frequency
tion of renal function and prevent CVD.
betic renal disease.55-59,64 A limited in- Cerebrovascular Disease. The risks
and benefits of acute lowering of BP dur- ing an acute stroke are still unclear; con- trol of BP at intermediate levels (approxi- until the condition has stabilized or im- Other Special Situations. Minority
Populations. Blood pressure control rates Abbreviation: ACE, angiotensin-converting enzyme.
*Dosages may vary from those listed in the Physicians’ Desk Reference,38 which may be consulted for additional in- †Are now or will soon become available in generic preparations.
‡A 0.1-mg dose may be given every other day to achieve this dosage.
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est rates of BP control.68 Treatment rec- Hypertension in Older Individuals. Hy- thirds of individuals after age 65 years.1 This is also the population with the low- to monotherapy with ␤-blockers, ACEinhibitors, or ARBs compared with di- Table 5. Combination Drugs for Hypertension
Combination Type
Fixed-Dose Combination, mg*
Trade Name
Obesity and the Metabolic Syndrome. development of hypertension and CVD.
conditions: abdominal obesity (waist cir- Candesartan cilexetil/hydrochlorothiazide each of its components as indicated.
Left Ventricular Hypertrophy. Left ven- risk factor that increases the risk of sub- Peripheral Arterial Disease. Periph- eral arterial disease is equivalent in risk Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker; HCl, hydrochloride; HCT, hydrochlorothiazide; LA, long-acting.
*Some drug combinations are available in multiple fixed doses. Each drug dose is reported in milligrams.
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greater adjusted for age, height, and sex.73 traception. In contrast, hormone replace- define diastolic BP. Clinicians should be Postural Hypotension. A decrease in fully because of increased risks to mother vasodilators are preferred medications for cologic therapy instituted for higher lev- ics, venodilators (eg, nitrates, ␣-block- ers, and sildenafil-like drugs), and some cause of the potential for fetal defects and similar in children and adults, but effec- tive doses for children are often smaller physical activities, particularly because monitoring, early fetal delivery, and par- Hypertension in Women. Oral contra- modifiable risk factors (eg, smoking).
Children and Adolescents. In chil- Hypertensive Urgencies and Emergen- cies. Patients with marked BP eleva- Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes
Recommended Drugs
High-Risk Conditions
With Compelling
Aldosterone
Indication*
Diuretic
␤-Blocker
Inhibitor
Antagonist
Clinical Trial Basis†
MERIT-HF,41 COPERNICUS,42 CIBIS,43SOLVD,44 AIRE,45 TRACE,46 ValHEFT,47RALES48 NKF-ADA Guideline,21,22 UKPDS,54 ALLHAT33 NKF Guideline,22 Captopril Trial,55 RENAAL,56 Abbreviations: AASK, African American Study of Kidney Disease and Hypertension; ACC/AHA, American College of Cardiology/American Heart Association; ACE, angiotensin- converting enzyme; AIRE, Acute Infarction Ramipril Efficacy; ALLHAT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ANBP2, Second AustralianNational Blood Pressure Study; ARB, angiotensin-receptor blocker; BHAT, ␤-Blocker Heart Attack Trial; CCB, calcium channel blocker; CIBIS, Cardiac Insufficiency BisoprololStudy; CONVINCE, Controlled Onset Verapamil Investigation of Cardiovascular End Points; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival Study;EPHESUS, Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; HOPE, Heart Outcomes Prevention Evaluation Study; IDNT, Inbesartan Dia-betic Nephropathy Trial; LIFE, Losartan Intervention For Endpoint Reduction in Hypertension Study; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in CongestiveHeart Failure; NKF-ADA, National Kidney Foundation–American Diabetes Association; PROGRESS, Perindopril Protection Against Recurrent Stroke Study; RALES, RandomizedAldactone Evaluation Study; REIN, Ramipril Efficacy in Nephropathy Study; RENAAL, Reduction of Endpoints in Non–Insulin-Dependent Diabetes Mellitus with the Angiotensin IIAntagonist Losartan Study; SAVE, Survival and Ventricular Enlargement Study; SOLVD, Studies of Left Ventricular Dysfunction; TRACE, Trandolapril Cardiac Evaluation Study;UKPDS, United Kingdom Prospective Diabetes Study; ValHEFT, Valsartan Heart Failure Trial.
*Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with †Conditions for which clinical trials demonstrate benefit of specific classes of antihypertensive drugs.
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tions and acute target-organ damage(eg, encephalopathy, myocardial in- Box 3. Causes of Resistant Hypertension
life-threatening arterial bleeding, or aor- Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics) able causes of hypertension (Box 2).
Additional Considerations in Anti-
hypertensive Drug Choices. Antihyper-
Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (eg, ephedra, favorable effects on other comorbidities.
Potential Favorable Effects. Thiazide- mineralization in osteoporosis. ␤-Block- Identifiable causes of hypertension (see Box 2) ers can be useful in the treatment ofatrial tachyarrhythmias/fibrillation, mi-graine, thyrotoxicosis (short-term), es-sential tremor, or perioperative hyper- if the patient is motivated to take the pre- ing can also be useful. Patients’ nonad- maintain a health-promoting lifestyle.
Potential Unfavorable Effects. Thia- as symbols of ill health, lack of patient pected adverse effects of medications.
asthma, reactive airways disease, or sec- fortable in telling the clinician all con- stood if the clinician is to build trust and tions, despite knowing the patient is not at goal BP, represents clinical inertia and Improving Hypertension Control
Adherence to Regimens. Behavioral
tion of the time needed to reach the goal force instructions to improve patients’ 2003 American Medical Association. All rights reserved.
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Resistant Hypertension. Resistant
ter, Memphis (Dr Cushman); Department of Family (Mayo Clinic and Mayo Medical School, Rochester, Medicine, University of Michigan, Ann Arbor (Dr Minn); Gerald J. Wilson, MA, MBA (Citizens for Public hypertension is the failure to reach goal Green); Department of Medicine and Pharmacology, Action on High Blood Pressure and Cholesterol, Inc, State University of New York at Buffalo School of Medi- Potomac, Md); Mary Winston, EdD, RD (American Heart cine, Buffalo (Dr Izzo); Department of Medicine and Association, Dallas, Tex); Jackson T. Wright, Jr, MD, Center for Excellence in Cardiovascular-Renal Re- PhD (Case Western Reserve University, Cleveland, Ohio); search, University of Mississippi Medical Center, Jack- Staff: Joanne Karimbakas, MS, RD (American Insti- son (Dr Jones); Department of Medicine, University tutes for Research Health Program, Silver Spring, Md).
of Miami School of Medicine, Miami, Fla (Dr Mater- Financial Disclosures: The following authors have re-
son); Department of Medicine, Physiology, and Bio- ceived honoraria for serving as a speaker: Dr Choba- physics, Division of Cardiovascular Disease, Univer- nian (Monarch, Wyeth, Astra-Zeneca, Solvay, Bristol- tient is not at goal BP (B
sity of Alabama at Birmingham (Dr Oparil); Myers Squibb); Dr Bakris (Astra-Zeneca, Abbott, OX 3). Particu-
Departments of Medicine, University Hospitals of Alteon, Biovail, Boerhinger-Ingelheim, Bristol-Myers Cleveland and the Louis Stokes Cleveland Veterans Squibb, Forest, GlaxoSmithKline, Merck, Novartis, Sa- uretic type and dose in relation to renal Affairs Medical Center, Cleveland, Ohio (Dr Wright); nofi, Sankyo, Solvay); Dr Black (Astra-Zeneca, Bristol- and National High Blood Pressure Education Pro- Myers Squibb, Novartis, Pfizer, Pharmacia, Wyeth- gram, National Heart, Lung, and Blood Institute, Na- Ayerst); Dr Izzo (Boehringer-Ingelheim, Merck, Pfizer, ease” section). Consultation with a hy- tional Institutes of Health, Bethesda, Md (Dr Roccella).
Astra-Zeneca, Solvay, Novartis, Forest, Sankyo); Dr Additional Authors/National High Blood Pressure Edu-
Sowers (Med Com Vascular Biology Working Group, cation Program Coordinating Committee Partici-
Joslin Clinic Foundation); Dr Wright (Astra, Aventis, pants: Claude Lenfant, MD, chair (National Heart, Lung,
Bayer, Bristol-Myers Squibb, Forest, Merck, Norvar- and Blood Institute, Bethesda, Md); George L. Bakris, tis, Pfizer, Phoenix Pharmaceuticals, GlaxoSmith- MD, Henry R. Black, MD (Rush Presbyterian-St Luke’s Public Health Challenges
Medical Center, Chicago, Ill); Barry L. Carter, PharmD The following authors have received funding/grant and Community Programs
(University of Iowa, Iowa City); Jerome D. Cohen, MD support for research projects: Dr Bakris (National Insti- (St Louis University School of Medicine, St Louis, Mo); tutes of Health, Astra-Zeneca, Abbott, Alteon, Boer- Pamela J. Colman, DPM (American Podiatric Medical hinger-Ingelheim, Forest, GlaxoSmithKline, Merck, ducing calories, saturated fat, and salt in Association, Bethesda, Md); William C. Cushman, MD Novartis, Sankyo, Solvay); Dr Black (Bristol-Myers (Veterans Affairs Medical Center, Memphis, Tenn); Mark Squibb, Boehringer-Ingelheim, Merck, Pfizer, Pharma- J. Cziraky, PharmD (Health Core, Inc, Newark, Del); John cia); Dr Cushman (Astra-Zeneca, Merck, Pfizer, Kos, J. Davis, PA-C (American Academy of Physician Assis- Aventis Pharma, King Pharmaceuticals, GlaxoSmith- tants, Memphis, Tenn); Keith Copelin Ferdinand, MD Kline, Boehringer-Ingelheim); Dr Izzo (Boehringer- (Heartbeats Life Center, New Orleans, La); Ray W. Gif- Ingelheim, Merck, Astra-Zeneca, Novartis, GlaxoSmith- ward shift in the distribution of a popu- ford, Jr, MD (Cleveland Clinic Foundation, Fountain Hills, Kline, Biovail); Dr Oparil (Abbott Laboratories, Astra- Ariz); Michael Glick, DMD (UMDNJ, New Jersey Den- Zeneca, Aventis, Boehringer-Ingelheim, Bristol-Myers tal School, Newark); Lee A. Green, MD, MPH (Univer- Squibb, Eli Lilly, Forest, GlaxoSmithKline, Monarch, sity of Michigan, Ann Arbor); Stephen Havas, MD, MPH, Novartis [Ciba], Merck, Pfizer, Sanofi/BioClin, Scher- MS (University of Maryland School of Medicine, Bal- ing Plough, Schwarz Pharma, Scios Inc, GD Searle, Wy- timore); Thomas H. Hostetter, MD (National Institute eth-Ayerst, Sankyo, Solvay, Texas Biotechnology Cor- of Diabetes and Digestive and Kidney Diseases, Bethesda, poration); Dr Sowers (Novartis, Astra-Zeneca); Dr Wright Md); Joseph L. Izzo, Jr, MD (State University of New (Astra, Aventis, Bayer, Biovail, Bristol-Myers Squibb, For- als in the United States has increased to York at Buffalo School of Medicine, Buffalo); Daniel W.
est, Merck, Norvartis, Pfizer, Phoenix Pharmaceuti- Jones, MD (University of Mississippi Medical Center, cals, GlaxoSmithKline, Solvay/Unimed).
Jackson); Lynn Kirby, RN, NP, COHNS (Sanofi- The following authors have served as a consultant/ Synthelabo Research, Malvern, Pa); Kathryn M. Kolasa, advisor: Dr Bakris (Astra-Zeneca, Abbott, Alteon, PhD, RD, LDN (Brody School of Medicine at East Caro- Biovail, Boerhinger-Ingelheim, Bristol-Myers Squibb, lina University, Greenville, NC); Stuart Linas, MD (Uni- Forest, GlaxoSmithKline, Merck, Novartis, Sanofi, San- versity of Colorado Health Sciences Center, Denver); kyo, Solvay); Dr Black (Abbott, Astra-Zeneca, Biovail, William M. Manger, MD, PhD (New York University Bristol-Myers Squibb, GlaxoSmithKline, Merck, Pfizer, Medical Center, New York); Edwin C. Marshall, OD, Pharmacia); Dr Carter (Bristol-Myers Squibb); Dr Cush- MS, MPH (Indiana University School of Optometry, man (Bristol-Myers Squibb, Sanofi, GlaxoSmithKline, Bloomington); Barry J. Materson, MD, MBA (Univer- Novartis, Pfizer, Solvay, Pharmacia, Takeda, Sankyo, sity of Miami, Miami, Fla); Jay Merchant, MHA (Cen- Forest, Biovail); Dr Izzo (Merck, Astra-Zeneca, Novar- ters for Medicare and Medicaid Services, Washington, tis, Intercure, Sankyo, Nexcura); Dr Jones (Pfizer, Bristol- DC); Nancy Houston Miller, RN, BSN (Stanford Uni- Myers Squibb, Merck, Forest, Novartis); Dr Manger versity School of Medicine, Palo Alto, Calif ); Marvin (NHBPEP Coordinating Committee); Dr Materson Moser, MD (Yale University School of Medicine, (Unimed, Merck, GlaxoSmithKline, Novartis, Reliant, of racial, ethnic, cultural, linguistic, re- Scarsdale, NY); William A. Nickey, DO (Philadelphia Col- Tanabe, Bristol-Myers Squibb, Pfizer, Pharmacia, No- ligious, and social factors in the deliv- lege of Osteopathic Medicine, Philadelphia, Pa); Suzanne ven, Boehringer-Ingelheim, Solvay); Dr Oparil (Bristol- Oparil, MD (University of Alabama at Birmingham); Ote- Myers Squibb, Merck, Pfizer, Sanofi, Novartis, The Salt lio S. Randall, MD (Howard University Hospital, Wash- ington, DC); James W. Reed, MD (Morehouse School The following author has stock holdings: Dr Izzo (In- of Medicine, Atlanta, Ga); Edward J. Roccella, PhD, MPH (National Heart, Lung, and Blood Institute, Bethesda, Dr Oparil is also on the Board of Directors for the Md); Lee Shaughnessy (National Stroke Association, Englewood, Colo); Sheldon G. Sheps, MD (Mayo Clinic, The NHBPEP Coordinating Committee Thanks the Fol-
Rochester, Minn); David B. Snyder, RPh, DDS (Health lowing Reviewers: William B. Applegate, MD, MPH
Resources and Services Administration, Rockville, Md); (Wake Forest University School of Medicine, Wins- James R. Sowers, MD (SUNY Health Science Center at ton Salem, NC); Jan N. Basile, MD (Veterans Admin- Brooklyn, Brooklyn, NY); Leonard M. Steiner, MS, OD istration Hospital, Charleston, SC); Robert Carey, MD (Eye Group, Oakhurst, NJ); Ronald Stout, MD, MPH (University of Virginia Health System, Charlottes- Author Affiliations: Department of Medicine, Bos-
(Procter and Gamble, Mason, Ohio); Rita D. Strick- ville, Va); Victor Dzau, MD (Brigham and Women’s ton University School of Medicine, Boston, Mass (Dr land, EdD, RN (New York Institute of Technology, Hospital, Boston, Mass); Brent M. Egan, MD (Medi- Chobanian); Department of Preventive Medicine, Springfield Gardens, NY); Carlos Vallbona, MD (Bay- cal University of South Carolina, Charleston, SC); Bo- Rush-Presbyterian-St Luke’s Medical Center, Chi- lor College of Medicine, Houston, Tex); Howard S. Weiss, nita Falkner, MD ( Jefferson Medical College, Phila- cago, Ill (Drs Bakris and Black); Veterans Affairs Medi- MD, MPH (Georgetown University Medical Center, delphia, Pa); John M. Flack, MD, MPH (Wayne State cal Center, Departments of Preventive Medicine and Washington Hospital Center, Walter Reed Army Medi- University School of Medicine, Detroit, Mich); Ed- Medicine, University of Tennessee Health Science Cen- cal Center, Washington, DC); Jack P. Whisnant, MD ward D. Frohlich, MD (Ochsner Clinic Foundation, New 2570 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted)
2003 American Medical Association. All rights reserved.
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Orleans, La); Haralambos Gavras, MD (Boston Uni-versity School of Medicine, Boston, Mass); Martin Grais,MD (Feinberg School of Medicine, Northwestern Uni- Scheme Used for Classification of the Evidence
versity, Chicago, Ill); Willa A. Hsueh, MD (David Gef- Meta-analysis; use of statistical methods to combine the results from clinical fen School of Medicine, University of California at Los Angeles); Kenneth A. Jamerson, MD (University ofMichigan Medical Center, Ann Arbor); Norman M.
Ra Randomized controlled trials; also known as experimental studies
Kaplan, MD (University of Texas Southwestern Medi- Re Retrospective analyses; also known as case-control studies
cal Center, Dallas); Theodore A. Kotchen, MD (Medi- Prospective study; also known as cohort studies, including historical or pro- cal College of Wisconsin, Milwaukee); Daniel Levy,MD (National Heart, Lung, and Blood Institute, Framingham, Mass); Michael A. Moore, MD (Wake Cross-sectional survey; also known as prevalence studies Forest University School of Medicine and Dan River Pr Previous review or position statements
Region Cardiovascular Health Initiative Program, Dan- ville, Va); Thomas J. Moore, MD (Boston UniversityMedical Center, Boston, Mass); Vasilios Papademe-triou, MD (Veterans Administration Medical Center, These symbols are appended to the citations in the reference list. The studies that Washington, DC); Carl J. Pepine, MD (University of provided evidence supporting the recommendations of this report were classified Florida, College of Medicine, Gainesville, Fla); Rob- and reviewed by the staff and the executive committee. The classification scheme ert A. Phillips, MD, PhD (New York University, Lenox Hill Hospital, New York); Thomas G. Pickering, MD,DPhil (Mount Sinai Medical Center, New York, NY);L. Michael Prisant, MD (Medical College of Georgia,Augusta); C. Venkata S. Ram, MD (University of TexasSouthwestern Medical Center and Texas Blood Pres- 14. Cushman WC, Ford CE, Cutler JA, et al. Success
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