Prehypertension: A literature-documented public health concern
The authors report no competing interests.
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Johnanna Hernandez, PhD, RN, FNP-BC, 5500 Southwestern Medical Avenue, Dallas, TX 75235. Tel: 214-689-6733; Fax: 214-689-6583; E-mail: JHernandez18@TWU.edu
Purpose: To provide nurse practitioners (NPs) with an overview of prehypertension identification and management. Additionally, the article serves to highlight the prevalence and impact of prehypertension in the United States.
Data sources: A comprehensive review of the literature was conducted using multiple databases, including PubMed, Medline, CINAHL, and SAGE Health Sciences databases. The review was not limited by discipline, year of publication, or type of research. Key words used to obtain relevant articles included prehypertension, nurse practitioner, health promotion, disease prevention, hypertension, and chronic disease.
Conclusions: Approximately 70 million individuals have been recognized as prehypertensive in the United States, placing them at increased risk for hypertension and cardiovascular disease. Identifying and managing prehypertension has been recognized in national health policy as a priority to improve public health. Prehypertension is managed primarily by eliminating risk factors and implementing lifestyle modification.
Implications for practice: Health promotion and disease prevention form the cornerstone of the NP role. The designation of prehypertension serves as an opportunity for NPs to assist in decreasing the burden on the health system from chronic disease and improve patient quality of life.
Hypertension remains an uncontrolled and frequently neglected disease that costs the Unites States an estimated $73 billion annually (Institutes of Medicine [IOM], 2010). According to a recent IOM report on hypertension, “millions of Americans continue to develop, live with, and die from hypertension because we are failing to translate our public health and clinical knowledge into effective prevention, treatment, and control programs” (IOM, p. 2). The same report calls for healthcare providers to pay diligence to hypertension prevention and control. The National Heart, Lung, and Blood Institute (NHLBI), in a series of expert consensus panels known collectively as the National High Blood Pressure Education Program (NHBPEP), issued guidelines and advisories through the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) in 2003 to increase awareness, prevention, and treatment of high blood pressure (see Table 1; Chobanion et al., 2003). Prehypertension, defined as blood pressure values of 120–139 systolic or 80–89 diastolic, was introduced not as a disease category but as a designation to identify at-risk individuals. This designation is to signal a need for increased primary prevention and provided a stimulus for healthcare providers to act on prevention of hypertension as a major public health challenge (Chobanion et al., 2003).
Table 1. Changes in blood pressure classification between JNC 6 and JNC 7
|140–159/90–99||Stage 1||Stage 1|
|160–179/100–109||Stage 2||Stage 2|
|≥180/110||Stage 3|| |
A classic 1939 study conducted by Robinson and Brucer established normal ranges for blood pressure. At the same time, the authors introduced the term prehypertension into medical literature and noted a full fifth of the population bore “the stigma of an ominous prognosis” that accompanied hypertension; the estimate grew to 40% when broadened to include prehypertension (Robinson & Brucer, 1939, p. 409). Analysis of 10,383 persons (n= 7478 men and n= 3405 women), incorporating a 5–10 year longitudinal review of 500 men, found a difference in the vascular system in healthy and prehypertensive individuals. Thus, the upper limit of normal systolic pressure was established at 120 mmHg. The authors cautioned, “by no stretch of the imagination can pressures of 130–140 mmHg be considered normal,” adding “diastolic pressures over 80 mmHg are associated with an increase in the death rate that is not compatible with the word ‘norm’” (p. 434). An additional observation was the high frequency of cardiovascular disease (CVD) and high blood pressure. Further noting the difficulty of addressing elevated blood pressures in otherwise healthy patients, Robinson and Brucer (1939) foreshadowed the contemporary challenges facing nurse practitioners (NPs) who seek to promote health in patients who, despite abnormal blood pressures, feel well until advanced stages of the condition.
Hypertension and CVD are leading causes of morbidity and mortality in the United States (Chobanion et al., 2003; Lloyd-Jones et al., 2010). Prehypertensive individuals are at risk for developing hypertension, adverse cardiac events, and CVD (Liszka, Mainous, King, Everett, & Egan, 2005; Quershi, Suri, Kirmani, Divani, & Mohammad, 2005; Svetkey, 2005). Between ages 40 and 69, a difference of 20 mmHg in the usual systolic and 10 mmHg in the usual diastolic blood pressure is associated with a twofold increase in stroke death rate, ischemic heart disease death rate, and death from other vascular causes (Prospective Studies Collaboration, 2002).
Several landmark studies provide valuable foundational knowledge to guide NPs and have served as useful datasets for secondary analysis. Beginning in 1949–1950, a longitudinal, 20-year epidemiological study measured the extent and development of CVD in a cross-section of the 30–59 year old population in Framingham, Massachusetts. This important study, including 2336 men and 2873 women with no history of stroke or myocardial infarction (MI), has become known as the Framingham Heart Study (FHS) and has provided input into development of healthcare guidelines (Dawber, Meadors, & Moore, 1951; Dawber, Moore, & Mann, 1957). Another important study, the National Health and Nutrition Examination Survey (NHANES), conducted in 1971 and 1972, examined health and nutritional status of 20,749 adults ages 25–74 years (Cornoni-Huntley et al., 1983; Kerr et al., 1982). Since the completion of NHANES I, follow-up studies have been conducted (NHANES II and NHANES III) to assess the health and nutritional status of children and adults in the United States. Since 1999, NHANES studies have continuously examined approximately 5000 individuals per year to provide data regarding the prevalence of major diseases and risk factors.
Framingham Heart Study.
A number of studies have used FHS data to examine the long-term risk of CVD associated with prehypertension. Quershi et al. (2005) classified FHS blood pressure readings based upon JNC 7 categories and explored the incidence of atherothrombotic stroke, all strokes, MI, and coronary artery disease (CAD). Results indicated an increased risk for MI and CAD among prehypertensive individuals. Over a 50-year follow-up, participants classified as prehypertensive were more likely to progress to hypertension than those initially classified as normotensive. Vasan et al. (2001) provided additional insight by evaluating 10-year cumulative incidence of CVD in 6859 FHS participants. Findings indicate participants with blood pressures of 130–139 systolic or 85–89 diastolic were more likely to develop CVD. Vasan, Larson, Leip, Kannel, and Levy (2001) used FHS data to examine the rate of progression from prehypertension to hypertension. Blood pressures of 4200 men and 5645 women with a mean age of 53 years were included; normal blood pressure was defined as 120–129 systolic or 80–84 diastolic, while high-normal blood pressure was defined as 130–139 systolic or 85–89 diastolic. Individuals with “normal” and “high-normal” blood pressures, both now recognized as prehypertension, were more likely to progress to hypertension over a 4-year period than individuals with optimal (<120/80) blood pressure.
National Health and Nutrition Examination Survey.
As with FHS studies, NHANES data have been used for numerous secondary analyses to evaluate the impact of prehypertension. Prevalence of prehypertension and associated risk factors in the United States were calculated using data from NHANES I (Chobanion, 2006; Greenlund, Croft, & Mensah, 2004; Mainous, Everett, Liszka, King, & Egan, 2004; Wang & Wang, 2004), finding prehypertension in 43 million men and 28 million women, 30%–37% of the adult population (Chobanion, 2006; Chobanion, 2009; Egan, Nesbitt, & Julius, 2008; Wang & Wang, 2004). Cross-sectional analysis of data from the 1999 to 2000 NHANES indicates approximately 60% of individuals 18 years or older were either prehypertensive or hypertensive, with African Americans ages 20–39 at increased risk for prehypertension. Cardiovascular risk factors such as obesity, diabetes mellitus, overweight, and hypercholesterolemia were more prevalent in prehypertensive adults than normotensive adults (Chobanion, 2006; Greenlund et al., 2004; Mainous et al., 2004; Wang & Wang, 2004).
Data from the 1976 to 1980 NHANES II and 1992 NHANES II Mortality Study, including 9087 individuals ages 30–74 years were used to assess the independent risk of prehypertension for increased mortality (Liszka et al., 2005). Results indicated higher mortality for prehypertensive than for normotensive individuals. However, 90% of prehypertensive individuals had other CVD risk factors, adjusting for which resulted in weakening the relationship between mortality and prehypertension. Further, the percentage of individuals diagnosed of subjects with prehypertension decreased with age as the physiologic changes progressed to hypertension. Such findings indicate eradication of risk factors as the most effective strategy for decreasing incidence of prehypertension and, therefore, subsequent development of hypertension. Study findings were correlated with data from NHANES I, revealing risk for major cardiovascular events significantly increased in prehypertensive individuals. Further, development of CVD was more prevalent in the higher prehypertensive category of 130–139 systolic and 85–89 diastolic (Liszka et al., 2005). Another study of over 5000 patients found prehypertensive individuals were more likely to develop hypertension and/or CVD (Quershi et al., 2005). Other studies revealed up to 88% of individuals with prehypertensive blood pressures had at least one cardiovascular risk factor such as dyslipidemia or obesity (Liszka et al., 2005; Svetkey, 2005).
Russell, Valiyeva, and Carson (2004) explored long-term consequences of prehypertension using data extrapolated from NHANES III. The study investigated the effects of prehypertension and residual hypertension (receiving treatment but blood pressure not yet ≤140/90) on hospital and nursing home admissions, and premature death. Study outcomes revealed the potential benefits from eliminating prehypertension accounted for a decline of 4.8% in hospitalizations per 10,000 persons compared to 1.4% for residual hypertension alone. Further, eliminating prehypertension resulted in a 6.2% reduction in nursing home admissions and 8.5% reduction in premature deaths. The findings indicate eradication of prehypertension could significantly impact quality of life and support the need for NPs to be diligent in implementing their primary care role of identifying and managing prehypertension effectively.
Women's Health Initiative.
The Women's Health Initiative (WHI) found prehypertension in 39% of the 161,808 postmenopausal women included in the study. Risk assessment analysis revealed an increased risk for MI, stroke, heart failure, and cardiovascular death in the prehypertensive post-menopausal women. Weight, age, diabetes, and hypercholesterolemia risk factors further increased in both the prehypertensive and hypertensive participants (p < .0001). Adjusting for the risk factors resulted in limited significant correlation between prehypertension and cardiovascular events. The 10-year incidence of cardiovascular events for prehypertensive women was 7.11%. Approximately seven women for every 1000 women with prehypertension had a first cardiovascular event each year, compared to only four per year for normotensive women and 14 per year in women who had progressed to hypertension. The authors suggest that clustering of risk factors with prehypertension requires further research to determine whether the significance of the correlation is related to risk factor characteristics other than blood pressure (Hsia et al., 2007).
Coronary Artery Risk Development in Young Adults.
In a secondary analysis, Pletcher and colleagues (2008) explored the potential benefits of health promotion using data collected for the Coronary Artery Risk Development in Young Adults (CARDIA) study between 1985 and 1986, finding a correlation between prehypertension in young adulthood and coronary calcium later in life. CARDIA subjects (n= 3560) included Black and White, male and female, individuals who had no history of hypertension; 18% (635) of the sample, most often Black, overweight males of lower socioeconomic status, developed prehypertension before age 35. Prehypertension in young adulthood can be harmful later in life. The authors concluded concentrated efforts to address prehypertension in early adulthood could lead to decreased rates of CVD and increased health benefits in middle age.
Additional studies have examined adverse cardiovascular physiologic occurrences related to prehypertension. Altered cardiac autonomic function has been associated with prehypertension (Wu et al., 2008). Erdogan and colleagues (2007) found, while impaired coronary microvascular function along with decreased coronary flow reserve (CFR) were present in prehypertensive adults, hypertensive adults had lower CFR (2.23 ± 0.47) than prehypertensive (2.54 ± 0.48) or normotensive (2.91 ± 0.53) adults. Such findings elucidate the impact of elevated blood pressure on coronary vasculature beginning in prehypertension. Other associated physiologic effects include aortic elasticity impairment in prehypertensive young patients (Celik et al., 2006) and higher levels of serum uric acid (Syamala, Li, & Shankar, 2007).
Research to date indicates a relationship between prehypertension and increased morbidity and mortality. The findings highlight the importance of early detection and management of prehypertension by NPs.
In order to effectively reduce the rate of morbidity and mortality associated with prehypertension, NPs must be aware of proper management of the condition. Prehypertension management is comprised of nonpharmacological methods as well as pharmacological methods in selected patients.
Nonpharmacological treatment of prehypertension
Diet and exercise.
The goal of nonpharmacological treatment is to optimize blood pressure to an acceptable range, prevent age-related increases in blood pressure, and prevent cardiovascular-related events. Nonpharmacological interventions include maintaining or achieving appropriate body weight through increased physical activity, alcohol moderation, and dietary modifications (Chobanion et al., 2003) as shown in Table 2. JNC 7 suggests that prehypertensive individuals be “firmly and unambiguously advised to practice lifestyle modifications in order to reduce their risk of developing hypertension in the future” (Chobanion et al., 2003, p. 1211).
Table 2. Recommended lifestyle modifications for blood pressure reduction
|Weight reduction||Maintain BMI 18.5–24.9 kg/m2||5–20 mmHg reduction in SBP per 10 kg weight loss|
|Adopt DASH eating plan||Diet rich in fruits, vegetables, low-fat dairy, and reduced saturated and total fat.||8–14 mmHg reduction in SBP|
|Dietary sodium restriction||Reduce dietary sodium to ≤100 mmol or 2.4 g sodium or 6 g sodium chloride per day.||2–8 mmHg reduction in SBP|
|Physical activity||Regular aerobic physical activity at least 30 min per day most days of the week.||4–9 mmHg reduction in SBP|
|Moderate alcohol consumption||No more than 2 drinks/day for men, 1 drink/day for women and lighter weight persons.||2–4 mmHg reduction in SBP|
The American College of Cardiology Foundation/American Heart Association 2009 Performance Measures for Primary Prevention of Cardiovascular Disease in Adults indicates “diet and physical activity counseling is the foundation of primary prevention” in lowering an individual's risk for CVD (Redberg et al., 2009, p. 1373). Trials of Hypertension Prevention, phase 1 (TOHP-1) examined the relationship among weight loss, sodium reduction, and stress management (Trials of Hypertension Prevention, 1992) and incidence of hypertension. Findings suggest weight loss as a crucial lifestyle modification in blood pressure reduction: weight loss of as little as 2.4 kg resulted in a 6.9 mmHg reduction in systolic blood pressure and 8.6 mmHg reduction in diastolic blood pressure. After 7 years of follow-up, hypertension decreased 77% in the weight loss group (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.25–1.69; p= .37) and 35% in the sodium-restricted group (OR 0.65; 95% CI 0.25–1.69; p= .37). Applying the study findings to prehypertensive patients could lead to similar results (He, Whelton, Appel, Charlestson, & Klag, 2000).
Assessing the efficacy of the Dietary Approaches to Stop Hypertension (DASH) diet, Appel and colleagues (1997) found with body weight and sodium-held constant, the DASH diet resulted in a 5.5 mmHg reduction in systolic pressure and 3.0 mmHg reduction in diastolic pressure in adults with mean baseline systolic and diastolic blood pressures of 131.3 ± 10.8 and 84.7 ± 4.7. In the PREMIER trial, participants were randomized to three different groups: behavioral interventions (weight loss, reduced sodium, increased physical activity, and limited alcohol) (n= 268), behavioral interventions combined with the DASH diet (n= 269), and an advice-only group (n= 273). A combination of both dietary and behavioral interventions over 6 months decreased hypertension from 38% to 12% (Funk et al, 2008; PREMIER Collaborative Research Group, 2003). In a separate study, the DASH diet and low sodium intake resulted in more dramatically improved blood pressures than either modification alone (Sacks et al., 2001).
Accumulated physical activity where participants completed four 10-min walks, one per hour over 4 h, has been associated with greater reduction in blood pressure in prehypertensive adults than a single 40-min walk. Results show systolic blood pressure was reduced for 11 h (5.4 ± 1.7 mmHg, p= .005) and diastolic blood pressure for 10 h (3.4 ± 1.3 mmHg, p= .022) after accumulated physical activity, with both systolic (5.6 ± 1.6 mmHg, p= .002) and diastolic (3.1 ± 0.2 mmHg, p= .022) blood pressure reduction for 7 h following continuous activity. Such findings suggest regular physical activity over time as one effective strategy to reduce prehypertension in adults (Park, Rink, & Wallace, 2006).
Alcohol consumption has also been linked to elevated blood pressure. The International Study of Salt and Blood Pressure (INTERSALT) results found alcohol intake equivalent to three or four drinks per day (300 mL) led to higher blood pressure. Consumption of 300–499 mL of alcohol per week was associated with a systolic blood pressure 2.7 mmHg higher and diastolic blood pressure 1.6 mmHg higher than in nondrinkers. The correlation between heavy alcohol use and elevated blood pressure is evident; however, findings warrant further examination of the effects of moderate alcohol use and blood pressure (Marmot et al., 1994).
Impact of stress and anger.
In a secondary analysis, Player, King, Mainous, and Geesey (2007) assessed the association of trait anger and long-term psychosocial stress with progression from prehypertension to hypertension and resulting coronary heart disease or death. High levels of trait anger were associated with greater risk for progression to hypertension than low/moderate levels of anger (OR 1.53; 95% CI, 1.05–2.24). Adjusting for covariates, trait anger was predictive of progression to hypertension (OR 1.71; 95% CI, 1.04–2.83) and coronary heart disease in men (hazards ratio [HR] 1.92; 95% CI, 1.07–3.54); long-term psychosocial stress was associated with prehypertension and coronary heart disease in both sexes (HR 1.68; 95% CI, 1.18–2.40).
The goal of pharmacological treatment is to control blood pressure and reduce morbidity and mortality in patients with renal disease and diabetes. JNC 7 recommends consideration of pharmacologic treatment for prehypertension with coexisting diabetes or kidney disease (Chobanion et al., 2003).
Diabetes and prehypertension.
An observational study using data from the Strong Heart Study estimated the prevalence of prehypertension and hazard ratios for CVD with prehypertension in diabetic and nondiabetic individuals (Zhang et al., 2006). In a total sample of 2629 participants with no history of hypertension or CVD, prehypertension was noted in 59.4% of diabetic participants at baseline and increased continuously with age. Among nondiabetic participants, prehypertension was noted in 48.2% of participants at baseline and remained steady after 60 years of age. Cumulative incidence of CVD over a 12-year period was highest in diabetic prehypertensive individuals. Hazard ratios for CVD in prehypertensive participants with diabetes were 3.70 (95% CI: 2.66, 5.15), 1.80 (1.28, 2.54) in participants with only prehypertension, and 2.90 (2.03, 4.16) in participants with only diabetes. Results suggest prehypertension is a risk factor for CVD in diabetics (Zhang et al., 2006).
The Trial of Preventing Hypertension (TROPHY) was a 4-year, randomized, double-blind, 71-center study that included 809 participants ages 30–65 years with baseline blood pressures of 130–139 systolic or 85–89 diastolic. TROPHY explored whether treating prehypertension with pharmacotherapy would prevent or delay the development of hypertension. Randomized participants received either candesaratan 16 mg or a placebo once daily for 2 years. After 2 years, all of the study participants began taking the placebo. Two years into the study, 53 individuals in the candesartan group and 154 individuals in the placebo group developed hypertension. At the 4-year conclusion of the study, 208 individuals assigned to the candesartan group versus 240 in the placebo group had developed hypertension. Although incidence of hypertension decreased, authors suggested further research was warranted before treating all prehypertensive individuals with an angiotensin-receptor blocker (Julius et al., 2004, 2006).
Health-related quality of life (HRQL) was also assessed using data from the TROPHY study. Study participants with prehypertension had a high baseline HRQL maintained over the 2-year treatment period with candesartan and the 2-year follow-up period while taking the placebo. Hypertension and prehypertension are conditions with no or few symptoms that greatly impact functioning in the early stages, highlighting the importance of vigilance of the silent disease by NPs. Participants reported a high HRQL but had higher than average BMIs of 30 kg/m2, reinforcing the need for lifestyle modifications (Williams et al., 2008).
Lifestyle modifications are the primary treatment for patients who are prehypertensive. If comorbid conditions of diabetes or renal disease exist, JNC 7 guidelines should be implemented as well. The literature suggests that lifestyle modifications often lead to improved overall health and blood pressure control. Weight loss, reduced sodium intake, limited alcohol use, increased physical activity, and following the DASH diet may prevent prehypertension from progressing to hypertension and decrease the need for pharmacologic intervention.
Implications for practice
The designation of prehypertension serves as a warning and call to action for NPs to emphasize early intervention and prevention. Because of the prevalence of prehypertension in the family practice population, close surveillance of blood pressure readings is warranted (Godwin, Pike, Kirby, Jewer, & Murhpy, 2008). International and national agencies have highlighted the importance of health promotion and prehypertension. A comprehensive report by the IOM, released in February 2010, identified the control and prevention of hypertension as a public health priority, further highlighting the need to address prehypertension in primary care. Despite more than 70 years of research-based knowledge about the consequences of prehypertension and the potential effects on cardiovascular morbidity and mortality, there has been little real change to medical practice (IOM, 2010).
The World Health Organization (WHO, 2009) recognized the pressing need of health promotion and the unparalleled threat to health facing health providers today. Globally, the financial burden of health care is staggering, threatening the sustainability of healthcare systems and national economies. Health promotion is recognized as an “integrative, cost-effective strategy, and as an essential component of health systems primed to respond adequately to emerging concerns” (WHO, 2009, p. 1). Identifying and managing prehypertension falls into the realm of health promotion, and disease prevention, as primary treatment measures are nonpharmacological. NPs have come to epitomize the champions of health promotion and disease prevention. Certifying bodies such as the American Academy of Nurse Practitioners (AANP) indicate promoting health promotion and disease prevention is a core component of practice along with managing acute and chronic illnesses (AANP, 2007).
The importance of health promotion and disease prevention as an important component of current national healthcare policy is highlighted in Healthy People 2010 and Healthy People 2020. Healthy People guidelines and goals represent a national disease prevention agenda of the U.S. Department of Health and Human Services (HHS) that provides a framework for identifying the most significant preventable threats to national health and establishing goals to prevent the threats. An overarching goal is to increase life span and quality of life by focusing on areas such as health communication, educational and community based programs, physical fitness, nutrition, obesity and overweight (Healthy People 2010, 2009; Healthy People 2020, 2010). One of the proposed objectives of Healthy People 2020 is to “increase the proportion of adults with prehypertension who meet the guidelines for body mass index, saturated fat consumption, sodium intake, physical activity, and moderate alcohol consumption” (Healthy People 2020, 2010, hp2020–14).
The American Recovery and Reinvestment Act of 2009 provided an additional $650 million to support evidence-based clinical and community-based prevention and wellness strategies to prevent or delay chronic disease and promote wellness in children and adults (U.S. Department of Health and Human Services, 2009b). In response, the HHS Communities Putting Prevention to Work allotted nearly $450 million for intensive approaches to chronic disease prevention at both the community and state levels to promote wellness and prevent disease (American Recovery and Reinvestment Act, 2009).
The Health Care and Education Reconciliation Act of 2010 (HR 4872) speaks to a national investment in health promotion. One of the purposes of healthcare reform is to reduce the growth in healthcare spending. Disease prevention and wellness are supported through workplace wellness grants for small business owners to promote the health of employees. Additionally, coverage for preventive services under Medicare and Medicaid has been included. The focus of healthcare reform in 2010 is moving from a healthcare system primarily treating people when sick, to one that focuses on keeping people well throughout their life (Health Reform Details, 2010).
A major opportunity for impact is in the area of prehypertension, recognized by the JNC 7 as a focus for the prevention of hypertension. More than 42 million men and 28 million women have prehypertension, placing them at increased risk for other conditions beyond hypertension, including MI, stroke, and heart failure. NPs are uniquely suited to promote lifestyle modification as evidenced by the profession's foundational history, purpose, and emphasis on health promotion and disease prevention (Burman et al., 2009). Moreover, primary care providers such as NPs are often among the first healthcare providers with the opportunity to identify prehypertension. In today's managed care environment, NPs serve as primary care providers for many individuals. Therefore, NPs must focus on the foundation of NP practice in health promotion and disease prevention, roles inherent to the profession because its embryonic stages, to alter the progression of risks inherent in prehypertension.
Taken together, the literature reviewed paints a picture of prehypertension as a warning sign for hypertension, associated predisposing factors, and ultimately for the serious and progressive conditions resulting from the physiologic consequences of prehypertension. If hypertension is thought of as an insidious condition that creeps up without warning, it is because warning signs have either been ignored or defined as normal. Over 70 years ago, Robinson and Brucer (1939) identified blood pressures over 120/80 as problematic, yet normal ranges for blood pressure have only recently been revisited. In this light, prehypertension represents both a cause for concern and an opportunity to take action as primary care providers, as nurses, and as a nation. The JNC 7 designation provides the impetus to identify and promote the health of prehypertensive patients that, coupled with a recent interest in health promotion at the national policy level, makes the early 21st century a propitious time for greater realization of the NP role in health promotion of prehypertensive patients.
The authors would like to acknowledge and thank Dr. Patricia Holden-Huchton, Dr. Rita Dello Stritto, and Dr. Yondell Masten for their support and guidance during this project. The authors would also like to thank Dr. Rod Hicks for his guidance and mentorship throughout the writing of this manuscript.