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Prehypertension—prevalence, health risks, and management strategies

Key Points

  • Prehypertension, defined as a blood pressure of 120–139/80–89 mmHg, is common and affects 25–50% of adults worldwide

  • Prehypertension increases the risk of incident hypertension, with annual rates ranging from 8% to 20% in studies lasting 2–4 years, and 4% to 9% in longer-term studies

  • Assuming a 50% 5-year risk, 10 adults with prehypertension would require intensive lifestyle change, and four to six would require antihypertensive medication, to prevent one case of incident hypertension

  • Prehypertension increases the risk of cardiovascular events, with stage 2 prehypertension (130–139/85–89 mmHg) having approximately twice the adverse effect of stage 1 prehypertension (120–129/80–84 mmHg)

  • Annual incidence of cardiovascular events is 1% in middle-aged adults with prehypertension but no diabetes mellitus or cardiovascular disease, and 2% to 4% in those with either or both comorbidities

  • Antihypertensive medications reduce cardiovascular events in adults with prehypertension and diabetes or cardiovascular disease, whereas data are lacking and guidelines do not recommend pharmacotherapy for primary prevention without these comorbidities

Abstract

Prehypertension (blood pressure 120–139/80–89 mmHg) affects 25–50% of adults worldwide, and increases the risk of incident hypertension. The relative risk of incident hypertension declines by 20% with intensive lifestyle intervention, and by 34–66% with single antihypertensive medications. To prevent one case of incident hypertension in adults with prehypertension and a 50% 5-year risk of hypertension, 10 individuals would need to receive intensive lifestyle intervention, and four to six patients would need to be treated with antihypertensive medication. The relative risk of incident cardiovascular disease (CVD) is greater with 'stage 2' (130–139/85–89 mmHg) than 'stage 1' (120–129/80–84 mmHg) prehypertension; only stage 2 prehypertension increases cardiovascular mortality. Among individuals with prehypertension, the 10-year absolute CVD risk for middle-aged adults without diabetes mellitus or CVD is 10%, and 40% for middle-aged and older individuals with either or both comorbidities. Antihypertensive medications reduce the relative risk of CVD and death by 15% in secondary-prevention studies of prehypertension. Data on primary prevention of CVD with pharmacotherapy in prehypertension are lacking. Risk-stratified, patient-centred, comparative-effectiveness research is needed in prehypertension to inform an acceptable, safe, and effective balance of lifestyle and medication interventions to prevent incident hypertension and CVD.

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Figure 1: Cardiovascular mortality in the USA from 1900 to 1997.58

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Egan, B., Stevens-Fabry, S. Prehypertension—prevalence, health risks, and management strategies. Nat Rev Cardiol 12, 289–300 (2015). https://doi.org/10.1038/nrcardio.2015.17

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