1. Top of page
  2. Abstract
  3. References

Knowing is not enough; we must apply. Willing is not enough; we must do.

The publication of the report by Cushman et al.1 appears at a most opportune time. Indeed, 2002 is the 30th anniversary of a nationwide effort to control high blood pressure. In 1972, the secretary of the (then) Department of Health, Education, and Welfare, Elliot Richardson, commissioned the (then) National Heart and Lung Institute of the National Institutes of Health to initiate a national program to combat high blood pressure through public and professional education. This was the birth of the National High Blood Pressure Education Program (NHBPEP). The program was to be governed by a Coordinating Committee, the members of which are representatives of professional and voluntary organizations as well as of agencies of the Public Health Service.

Since then, the Coordinating Committee has met frequently—three times a year for about 25 years and, now, twice a year. It has produced nearly 40 reports, including six Joint National Committee Reports on the Prevention, Diagnosis, and Treatment of High Blood Pressure, known worldwide as the JNC I through VI. Number VII will undoubtedly emerge shortly after the publication of the main outcome paper of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). In addition, the NHBPEP recently published a pioneering report on how to prevent the development of high blood pressure.2

Also emanating from the NHBPEP have been many workshops, conferences, and specific educational campaigns and activities such as High Blood Pressure Month. Special attention has been focused on the Stroke Belt, older Americans, persons with diabetes, children, pregnant women, and African Americans. Several organizations (e.g., the American Society of Hypertension, the International Society of Hypertension in Blacks) have been founded to join the hypertension campaign; they have addressed special markets and now are members of the Coordinating Committee.

Finally, millions of dollars have been spent on research, ranging from basic studies to clinical investigations to demonstrations to applications, as well as small and large clinical trials, including studies on how to influence patient behavior to ensure compliance with medical regimens.

During the past 30 years, the official public health effort has been accompanied by a productive development program of the pharmaceutical industry. Many new classes of antihypertensive medications have been developed, and in each class we have seen the production of many new formulations. Moreover, while the efficacy of the drugs has increased we have even seen their price decline.

To sum it up, if we did not know better, we would declare that the huge national effort has been a smashing success. It is time to celebrate!

Not so fast—put the champagne away! The reality is that we have not come close to reaching our potential.

For sure, there is some good news. Between 1974 and 1994 we made progress with the hypertensive population defined as having blood pressures ≥160/95 mm Hg—treatment rates increased from 32% to 78%, and control rates increased from 20% to 63%. The disappointing news, however, is that for the hypertensive population defined as having blood pressures ≥140/90 mm Hg, progress has been mediocre. Between 1976 and 2000, treatment rates increased from 30% to 50%, and control rates increased from 8% to 26%. Furthermore, most of the gains occurred between 1976 and 1990, and little improvement has been observed since that time.

What is going on? Are we tilting at windmills? Surely not! Just look at the stunning results from ALLHAT as reported by Cushman et al.1 Like a well-conditioned athlete, the study soars over the hypertension control rate bar and shows what can be done. And remarkably, this was achieved not by super-select experts but by 623 care centers, big and small, who treat ordinary patients. This is a wake-up call for all of us. Public health officials must reexamine what they do, and evaluate the effectiveness of their programs. We must remember that programs per se mean nothing; what counts is what they achieve. Health care systems, likewise, must assess how they deliver care to their patients. Specialists and practicing physicians must consider how they can better work with their patients to meet hypertension control goals.

Of course, it is well recognized that participants in clinical trials tend to achieve better results than the general population. It is true that some patients in the general population are excluded from trials for a variety of reasons, such as being too ill to participate. But it is also true that clinical trial participants, both physicians and patients alike, are motivated and motivation is the prime reason behind these wonderful control rates. Some will suggest there is not enough time at each visit to properly educate or motivate patients. But this is like asking for more time to be put on the clock in order to win a game. Great coaches motivate their players to rise to the occasion and make the wisest use of the time they have available. There is no reason why the results from this study cannot be replicated by all if they have the will to motivate. When the control rates among the general hypertensive population approach those achieved by ALLHAT, it will be time to celebrate.


  1. Top of page
  2. Abstract
  3. References
  • 1
    Cushman WC, Ford CE, Cutler JA, et al., For The ALLHAT Collaborative Research Group. Success and predictors of blood pressure control in diverse North American settings: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens.2002;4:393404.
  • 2
    Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension. Clinical and public health advisory from the National High Blood Pressure Education Program. JAMA. 2002;288:18821888.