[Skip to Content]
[Skip to Content Landing]
Article
January 25, 1993

The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V)

Arch Intern Med. 1993;153(2):154-183. doi:10.1001/archinte.1993.00410020010002
Abstract

THIS FIFTH Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure—published on the 20th anniversary of the National High Blood Pressure Education Program—aims to contribute to progress in the primary prevention and control of high blood pressure. Like its predecessors, this document builds on the available scientific evidence regarding the detection, evaluation, and treatment of hypertension. More information is available today to guide clinicians and community programs in preventing and managing this important public health problem. However, this increase in information makes clinical choices increasingly complex. Thus, the need for consensus becomes even more important.

The purpose of this report is to guide practicing physicians and other health professionals in their care of hypertensive patients and health professionals participating in the many community high blood pressure control programs.

This report has several new features: • Prevalence, awareness, treatment, and control rates for high blood

References
1.
Roberts J.  Blood pressure of persons 18-74 years, United States, 1971-72: data from the National Health Survey .  Vital Health Stat 11. 1975; No. (150) . Department of Health, Education, and Welfare publication 75-1632.
2.
Rowland M, Roberts J.  Blood pressure levels and hypertension in persons ages 6-74 years: United States, 1976-80 .  Vital Health Stat. 1982; No. 84. Department of Health and Human Services publication 82-1250.
3.
Roccella EJ, Lenfant C.  Regional and racial differences among stroke victims in the United States .  Clin Cardiol. 1989;12:IV-18-IV-22.
4.
Trials of Hypertension Prevention Collaborative Research Group.  The effects of nonpharmacologic interventions of blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, Phase I .  JAMA. 1992;267:1213-1220.Crossref
5.
Stamler R, Stamler J, Gosch FC, et al.  Primary prevention of hypertension by nutritionalhygienic means: final report of a randomized, controlled trial .  JAMA. 1989;262:1801-1807.Crossref
6.
Frohlich ED, Grim C, Labarthe DR, et al.  Recommendations for human blood pressure determination by sphygmomanometers: report of a special task force appointed by the Steering Committee, American Heart Association .  Hypertension. 1988;11:209A-222A.Crossref
7.
American Society of Hypertension.  Recommendations for routine blood pressure measurement by indirect cuff sphygmomanometry .  Am J Hypertens. 1992;5:207-209.Crossref
8.
Working Group on Ambulatory Blood Pressure Monitoring,  National High Blood Pressure Education Program Coordinating Committee. National High Blood Pressure Education Program Working Group report on ambulatory blood pressure monitoring .  Arch Intern Med. 1990;150: 2270-2280.Crossref
9.
Parati G, Pomidossi G, Albini F, Malaspina D, Mancia G.  Relationship of 24-hour blood pressure mean and variability to severity of target-organ damage in hypertension .  J Hypertens. 1987;5: 93-98.Crossref
10.
Perloff D, Sokolow M, Cowan RM, Juster RP.  Prognostic value of ambulatory blood pressure measurements: further analyses .  J Hypertens. 1989;7( (suppl 3) ):S3-S10.
11.
Pickering TG, Devereux RB.  Ambulatory monitoring of blood pressure as a predictor of cardiovascular risk .  Am Heart J. 1987;114:925-928.Crossref
12.
Gifford RW Jr, Kirkendall W, O'Connor DT, Weidman W.  Office evaluation of hypertension: a statement for health professionals by a Writing Group of the Council for High Blood Pressure Research, American Heart Association .  Circulation. 1989;79:721-731.Crossref
13.
Anderson KM, Wilson PWF, Odell PM, Kannel WB.  An updated coronary risk profile: a statement for health professionals .  Circulation. 1991; 83:356-362.Crossref
14.
Levine DM, Bone L.  The impact of a planned health education approach on the control of hypertension in a high risk population .  J Hum Hypertens. 1990;4:317-321.
15.
Farquhar JW, Fortmann SP, Flora JA, et al.  Effects of communitywide education on cardiovascular disease risk factors: the Stanford Five-City Project .  JAMA. 1990;264:359-365.Crossref
16.
Lefebvre RC, Lasater TM, Carleton RA, Peterson G.  Theory and delivery of health programming in the community: the Pawtucket Heart Health Program .  Prev Med. 1987;16:80-95.Crossref
17.
Mittelmark MB, Luepker RV, Jacobs DR, et al.  Community-wide prevention of cardiovascular disease: education strategies of the Minnesota Heart Health Program .  Prev Med. 1986;15:1-17.Crossref
18.
National High Blood Pressure Education Program.  Measuring Progress in High Blood Pressure Control: An Evaluation Handbook . Bethesda, Md: US Dept of Health and Human Services, National Heart, Lung, and Blood Institute; (April) 1986. National Institutes of Health publication 86-2647.
19.
World Hypertension League.  WHL Workshop: economics of hypertension control .  World Hypertens News. December 1991; No. (20) :4.
20.
 Task Force on the Availability of Cardiovascular Drugs to the Medically Indigent. Report of the Task Force on the Availability of Cardiovascular Drugs to the Medically Indigent .  Circulation. 1992;85:850-860.
21.
Pickering TG.  The potential contribution of ambulatory blood pressure monitoring to decision making in hypertension and its impact on the health-care system . In: Pickering TG, Pieper C, Schechter CB.  Ambulatory Monitoring and Blood Pressure Variability . London, England: Science Press; 1991:15.1-15.8.
22.
Floras JS.  Will knowing the variability of ambulatory blood pressure improve clinical outcome? an additional consideration in the critical evaluation of this technology .  Clin Invest Med. 1991;14:231-240.
23.
Fletcher AE, Bulpitt CJ.  How far should blood pressure be lowered ?  N Engl J Med. 1992;326: 251-254.Crossref
24.
Treatment of Mild Hypertension Research Group.  The Treatment of Mild Hypertension Study: a randomized, placebo-controlled trial of a nutritional-hygienic regimen along with various drug monotherapies .  Arch Intern Med. 1991;151:1413-1423.Crossref
25.
Wassertheil-Smoller S, Blaufox MD, Oberman AS, Langford HG, Davis BR. Wylie-Rosett J.  The Trial of Antihypertensive Interventions and Management (TAIM) Study: adequate weight loss, alone and combined with drug therapy in the treatment of mild hypertension .  Arch Intern Med. 1992;152:131-136.Crossref
26.
Hypertension Prevention Trial Research Group.  The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure .  Arch Intern Med. 1990;150:153-162.Crossref
27.
 Subcommittee on Nonpharmacologic Therapy of the 1984 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Nonpharmacological approaches to the control of high blood pressure .  Hypertension. 1986;8:444-467.Crossref
28.
Stamler R, Stamler J, Grimm R, et al.  Nutritional therapy for high blood pressure: final report of a four-year randomized controlled trial— the Hypertension Control Program .  JAMA. 1987; 257:1484-1491.Crossref
29.
Little P, Girling G, Hasler A, Trafford A.  A controlled trial of a low sodium, low fat, high fibre diet in treated hypertensive patients: effect on antihypertensive drug requirement in clinical practice .  J Hum Hypertens. 1991;5:175-181.
30.
Working Group on Management of Patients With Hypertension and High Blood Cholesterol.  National Education Programs Working Group report on the management of patients with hypertension and high blood cholesterol .  Ann Intern Med. 1991;114:224-237.Crossref
31.
Greenberg G, Thompson SG, Brennan PJ.  The relationship between smoking and the response to antihypertensive treatment in mild hypertensives in the Medical Research Council's Trial of Treatment .  Int J Epidemiol. 1987; 16:25-30.Crossref
32.
Langford HG, Stamler J, Wassertheil-Smoller S, Prineas RJ.  All-cause mortality in the Hypertension Detection and Follow-up Program: findings in the whole cohort and for persons with less severe hypertension, with and without other traits related to risk of mortality .  Prog Cardiovasc Dis. 1986;29( (suppl 1) ):29-54.Crossref
33.
Després J-P, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C.  Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease .  Arteriosclerosis. 1990;10:497-511.Crossref
34.
Langford HG, Davis BR, Blaufox MD, et al.  Effect of drug and diet treatment of mild hypertension on diastolic blood pressure .  Hypertension. 1991;17:210-217.Crossref
35.
Schotte DE, Stunkard AJ.  The effects of weight reduction on blood pressure in 301 obese patients .  Arch Intern Med. 1990;150:1701-1704.Crossref
36.
World Hypertension League.  Alcohol and hypertension—implications for management: a consensus statement by the World Hypertension League .  J Hum Hypertens. 1991;5:1854-1856.
37.
Maheswaran R, Gill JS, Davies P, Beevers DG.  High blood pressure due to alcohol: a rapidly reversible effect .  Hypertension. 1991;17:787-792.Crossref
38.
Blair SN, Kohl HW III, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW.  Physical fitness and all-cause mortality: a prospective study of healthy men and women .  JAMA. 1989;262: 2395-2401.Crossref
39.
Blair SN, Goodyear NN, Gibbons LW, Cooper KH.  Physical fitness and incidence of hypertension in healthy normotensive men and women .  JAMA. 1984;252:487-490.Crossref
40.
World Hypertension League.  Physical exercise in the management of hypertension: a consensus statement by the World Hypertension League .  J Hypertens. 1991;9:283-287.Crossref
41.
Intersalt Cooperative Research Group.  Intersalt: an international study of electrolyte excretion and blood pressure: results for 24 hour urinary sodium and potassium excretion .  BMJ. 1988;297:319-328.Crossref
42.
Law MR, Frost CD, Wald NJ.  By how much does dietary salt reduction lower blood pressure? I: analysis of observational data among populations .  BMJ. 1991;302:811-815.Crossref
43.
Intersalt Cooperative Research Group.  Sodium, potassium, body mass, alcohol and blood pressure: the INTERSALT Study .  J Hypertens. 1988;6( (suppl 4) ):S584-S586.Crossref
44.
Cutler JA, Follmann D, Elliott P, Suh I.  An overview of randomized trials of sodium reduction and blood pressure .  Hypertension. 1991;17 ( (suppl I) ):I-27—I-33.Crossref
45.
Law MR, Frost CD, Wald NJ.  By how much does dietary salt reduction lower blood pressure? III: analysis of data from trials of salt reduction .  BMJ. 1991;302:819-824.Crossref
46.
Sullivan J.  Salt sensitivity: definition, conception, methodology, and long-term issues .  Hypertension. 1991;17( (suppl I) ):I-61—I-68.Crossref
47.
Flack JM, Ensrud KE, Mascioli S, et al.  Racial and ethnic modifiers of the salt-blood pressure response .  Hypertension. 1991;17( (suppl I) ): I-115—I-121.Crossref
48.
Grobbee DE.  Methodology of sodium sensitivity assessment: the example of age and sex .  Hypertension. 1991;17( (suppl I) ):I-109—I-114.Crossref
49.
Linas SL.  The role of potassium in the pathogenesis and treatment of hypertension .  Kidney Int. 1991;39:771-786.Crossref
50.
Hamet P. Mongeau E, Lambert J, et al.  Interactions among calcium, sodium, and alcohol intake as determinants of blood pressure .  Hypertension. 1991;17( (suppl I) ):I-150—I-154.Crossref
51.
Cutler JA, Brittain E.  Calcium and blood pressure: an epidemiologic perspective .  Am J Hypertens. 1990;3:137S-146S.Crossref
52.
Sacks FM.  Dietary fats and blood pressure: a critical review of the evidence .  Nutr Rev. 1989; 47:291-300.Crossref
53.
Knapp HR, Fitzgerald GA.  The antihypertensive effects of fish oil: a controlled study of polyunsaturated fatty acid supplements in essential hypertension .  N Engl J Med. 1989;320:1037-1043.Crossref
54.
Van Montfrans GA, Karemaker JM, Wieling W, Dunning AJ.  Relaxation therapy and continuous ambulatory blood pressure in mild hypertension: a controlled study .  BMJ. 1990;300: 1368-1372.Crossref
55.
Collins R, Peto R, MacMahon S, et al.  Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context .  Lancet. 1990;335:827-838.Crossref
56.
MacMahon S, Peto R, Cutler J, et al.  Blood pressure, stroke, and coronary heart disease, part 1: prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias .  Lancet. 1990;335:765-774.Crossref
57.
SHEP Cooperative Research Group.  Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension .  JAMA. 1991;265:3255-3264.Crossref
58.
Dahlöf B, Lindholm LH, Hansson L, Scherstén B, Ekbom T, Wester P-O.  Morbidity and mortality in the Swedish Trial in Old Patients With Hypertension (STOP-Hypertension) .  Lancet. 1991; 338:1281-1285.Crossref
59.
MRC Working Party.  Medical Research Council trial of treatment of hypertension in older adults: principal results .  BMJ. 1992;304:405-412.Crossref
60.
Hypertension Detection and Follow-up Program Cooperative Group.  The effect of treatment on mortality in 'mild' hypertension: results of the Hypertension Detection and Follow-up Program .  N Engl J Med. 1982;307:976-980.Crossref
61.
Alderman MH.  Which antihypertensive drugs first—and why !  JAMA. 1992;267:2786-2787.Crossref
62.
Olin BR, ed.  Drug Facts and Comparisons . St Louis, Mo: JB Lippincott Co; 1991:495-806.
63.
Lam YWF, Shepherd MM.  Drug interactions in hypertensive patients: pharmacokinetic, pharmacodynamic and genetic considerations .  Clin Pharmacokinet. 1990;18:295-317.Crossref
64.
Hansten PD, Horn JR.  Drug Interactions and Updates . Malvern, Pa: Lea & Febiger; 1990.
65.
Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR.  The effect of prescribed daily dose frequency on patient medication compliance .  Arch Intern Med. 1990;150:1881-1884.Crossref
66.
Farnett L, Mulrow CD, Linn WD, Lucey CR, Tuley MR.  The J-curve phenomenon and the treatment of hypertension: is there a point beyond which pressure reduction is dangerous ?  JAMA. 1991;265:489-495.Crossref
67.
Gifford RW Jr.  Management of hypertensive crises .  JAMA. 1991;266:829-835.Crossref
68.
Working Group on Health Education and High Blood Pressure Control, National High Blood Pressure Education Program.  The Physician's Guide: Improving Adherence Among Hypertensive Patients. Bethesda, Md: US Dept of Health and Human Services, National Heart, Lung, and Blood Institute; (March) 1987.
69.
Tyroler HA.  Twenty-year mortality in black residents of Evans County, Georgia .  J Clin Hypertens. 1987;3( (suppl) ):9S-15S.
70.
Gillum RF.  Cardiovascular disease in the United States: an epidemiologic overview . In: Saunders E, ed.  Cardiovascular Diseases in Blacks . Philadelphia, Pa: FA Davis Co; 1991:3-16.
71.
Ferguson R, Grim CE, Opgenorth TJ.  The epidemiology of end-stage renal disease: the six-year South-Central Los Angeles experience, 1980-85 .  Am J Public Health. 1987;77:864-865.Crossref
72.
Ooi WL, Budner NS, Cohen H, et al.  Impact of race on treatment response and cardiovascular disease among hypertensives .  Hypertension. 1989;14:227-234.Crossref
73.
 Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987 .  Pediatrics. 1987;79:1-25.
74.
MacMahon SW, Furberg CD, Cutler JA.  Women as participants in trials of the primary and secondary prevention of cardiovascular disease, part I: primary prevention: the hypertension trials . In: Eaker ED, Packard B, Wenger NK, Clarkson TB, Tyroler HA, eds.  Coronary Heart Disease in Women: Proceedings of an N.I.H. Workshop . New York, NY: Haymarket Doyma; 1987:233-240.
75.
Anastos K, Charney P, Charon RA, et al.  Hypertension in women: what is really known ?  Ann Intern Med. 1991;115:287-293.Crossref
76.
Woods JW.  Oral contraceptives and hypertension .  Hypertension. 1988:11( (suppl II) )II-11—II-15.Crossref
77.
Layde PM, Beral V, Kay CR.  Further analyses of mortality in oral contraceptive users: Royal College of General Practitioners' Oral Contraception Study .  Lancet. 1981;1:541-546.
78.
Lim KG, Isles CG, Hodsman GP, Lever AF, Robertson JWK.  Malignant hypertension in women of childbearing age and its relation to the contraceptive pill .  BMJ. 1987;294:1057-1059.Crossref
79.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy.  Working Group report on high blood pressure in pregnancy .  Am J Obstet Gynecol. 1990;163:1689-1712.Crossref
80.
Hanssens M, Keirse MJNC, Vankelecom F, Van Assche FA.  Fetal and neonatal effects of treatment with angiotensin-converting-enzyme inhibitors in pregnancy .  Obstet Gynecol. 1991; 78:128-135.
81.
Barron WM.  Hypertension . In: Barron WM, Lindheimer MD, eds.  Medical Disorders in Pregnancy . Chicago, III: Mosby—Year Book; 1991: 1-42.
82.
Butters L, Kennedy S, Rubin PC.  Atenolol in essential hypertension during pregnancy .  BMJ. 1990;301:587-589.Crossref
83.
Pritchard JA, Cunningham FG, Pritchard FA.  The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases .  Am J Obstet Gynecol. 1984;148:951-963.Crossref
84.
Collins R, Wallenburg HCS.  Pharmacologic prevention and treatment of hypertensive disorders in pregnancy . In: Chalmers I, Enkin M, Keirse MJNC, eds.  Effective Care in Pregnancy and Childbirth, Volume 1: Pregnancy . Oxford, England: Oxford University Press; 1989:512-533.
85.
Wren BG, Routledge DA.  Blood pressure changes: oestrogens in climacteric women .  Med J Aust. 1981;2:528-531.
86.
Messerli FH.  Osler's maneuver, pseudohypertension, and true hypertension in the elderly .  Am J Med. 1986;80:906-910.Crossref
87.
Management Committee.  Treatment of mild hypertension in the elderly .  Med J Aust. 1981;2: 398-402.
88.
Amery A, Birkenhäger W, Brixko P, et al.  Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial .  Lancet. 1985;1:1349-1354.Crossref
89.
Coope J, Warrender TS.  Randomised trial of treatment of hypertension in elderly patients in primary care .  BMJ. 1986;293:1145-1151.Crossref
90.
Stamler J.  Risk factor modification trials: implications for the elderly .  Eur Heart J. 1988;9 ( (suppl D) ):9-53.Crossref
91.
Brott T, Reed RL.  Intensive care for acute stroke in the community hospital setting: the first 24 hours .  Stroke. 1989;20:577-582.Crossref
92.
Phillips SJ, Whisnant JP, on behalf of the National High Blood Pressure Education Program.  Hypertension and the brain .  Arch Intern Med. 1992;152:938-945.Crossref
93.
Multiple Risk Factor Intervention Trial Research Group.  Exercise electrocardiogram and coronary heart disease mortality in the Multiple Risk Factor Intervention Trial .  Am J Cardiol. 1985;55:16-24.Crossref
94.
Multiple Risk Factor Intervention Trial Research Group.  Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial .  JAMA. 1990;263:1795-1801.Crossref
95.
Rautaharju PM, Neaton JD.  Electrocardiographic abnormalities and coronary heart disease mortality among hypertensive men in the Multiple Risk Factor Intervention Trial .  Clin Invest Med. 1987;10:606-615.
96.
Yusuf S, Wittes J, Probstfield J.  Evaluating effects of treatment in subgroups of patients within a clinical trial: the case of non-Q-wave myocardial infarction and beta blockers .  Am J Cardiol. 1990;66:220-222.Crossref
97.
SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure .  N Engl J Med. 1991;325:293-302.Crossref
98.
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure .  N Engl J Med. 1991; 325:303-310.Crossref
99.
Levy D, Garison RJ, Savage DD, Kannel WB, Castelli WP.  Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study .  N Engl J Med. 1990;322:1561-1566.Crossref
100.
Devereux RB, Casale PN, Wallerson DC, et al.  Cost-effectiveness of echocardiography and electrocardiography for detection of left ventricular hypertrophy in patients with systemic hypertension .  Hypertension. 1987;9( (suppl 2) ):69-76.Crossref
101.
Frohlich ED, Apstein C, Chobanian AV, et al.  The heart in hypertension .  N Engl J Med. 1992; 14:998-1008.Crossref
102.
MacMahon SW, Wilcken DEL, MacDonald GJ.  The effect of weight reduction on left ventricular mass .  N Engl J Med. 1986;314:334-339.Crossref
103.
Ferrara LA, de Simone G, Pasanisi F, Mancini M, Mancini M.  Left ventricular mass reduction during salt depletion in arterial hypertension .  Hypertension. 1984;6:755-759.Crossref
104.
Mogensen CE.  Angiotensin converting enzyme inhibitors and diabetic nephropathy: their effects on proteinuria may be independent of their effects on blood pressure .  BMJ 1992:304:327-328.Crossref
105.
National High Blood Pressure Education Program.  National High Blood Pressure Education Program Working Group report on hypertension and chronic renal failure .  Arch Intern Med. 1991;151:1280-1287.Crossref
106.
Working Group on Hypertension in Diabetes— National High Blood Pressure Education Program.  Statement on hypertension in diabetes mellitus: final report .  Arch Intern Med. 1987; 147:830-842.Crossref
107.
Epstein M, Sowers JR.  Diabetes mellitus and hypertension .  Hypertension. 1992;19:403418.Crossref
108.
Yusuf S, Peto R, Lewis J, Collins R, Sleight P.  Beta blockade during and after myocardial infarction: an overview of the randomized trials .  Prog Cardiovasc Dis. 1985;27:335-371.Crossref
109.
Estafanous FG.  Hypertension in the surgical patient: management of blood pressure and anesthesia .  Cleve Clin J Med. 1989;56:385-393.Crossref
110.
Gawin FH, Ellinwood EH Jr.  Cocaine and other stimulants: actions, abuse, and treatment .  NEngl JMed. 1988;318:1173-1182.Crossref
111.
Lowenstein DH, Massa SM, Rowbotham MC, Collins SD, McKinney HE, Simon RP.  Acute neurologic and psychiatric complications associated with cocaine abuse .  Am J Med. 1987:83: 841-846.Crossref
112.
Levine SR, Brust JCM, Futrell N, et al.  Cerebrovascular complications of the use of the 'crack' form of alkaloidal cocaine .  N Engl J Med. 1990; 323:699-704.Crossref
113.
Daras M, Tuchman AJ, Marks S.  Central nervous system infarction related to cocaine abuse .  Stroke. 1991;22:1320-1325.Crossref
114.
Smith LH, Drach G, Hall P, et al.  National High Blood Pressure Education Program (NHBPEP): review paper on complications of shock wave lithotripsy for urinary calculi .  Am J Med. 1991; 91:635-641.Crossref
115.
Porter GA, Bennett WM, Sheps SG, et al.  Cyclosporine-associated hypertension .  Arch Intern Med. 1990:150:280-283.Crossref
116.
Luke RG.  Mechanism of cyclosporine-induced hypertension .  Am J Hypertens. 1991:4:468471.Crossref
117.
Raine AEG, Roger SD.  Effects of erythropoietin on blood pressure .  Am J Kidney Dis. 1991 ( (suppl 1) );18:76-83.
×