High blood pressure has now been reclassified, no longer do we talk about mild and moderate and severe, we call it stage I, stage II, and stage III, the reason for that is that the vast majority of people with high blood pressure are in this area and on a population level, the vast majority of strokes and myocardial and kidney disease from hypertension is in people who have this stage of disease so the JNC was loathed to call this mild because it causes a lot of disease simply because the incidence of this kind of problem is very high, so although the risk for an individual patient may not be in stage I as high as it is in stage III on a population basis, you should not think of this as mind and therefore not important. It is a very important problem.

Stage I is 140/90 or above, and that’s really all you need to remember on the slide, that is what hypertension is, 140/90 above, but measured on multiple occasions. Many patient’s who see a physician for the first time have high sympathetic nervous system and have tachycardia, they are sweating and their blood pressure is up a little bit and it is inappropriate for you to label them as having chronic hypertension simply because they are nervous, so the JNC cautions us to confirm elevated blood pressures on at least two visits over a few weeks. I would agree with you that if somebody has a blood pressure of 250/130, and they are having chest pain and are short of breath, and they are in pulmonary edema, that person probably has severe cardiovascular disease, but none of us are going to see that kind of a patient so we really don’t need to worry about that clinical circumstance. The vast majority of the issues we are going to deal with in primary care, are people who have a blood pressure of 148/93 in the office for the first visit, again, nonpregnant patient’s we are talking about here, confirm over the next few weeks to ensure that they do have sustained hypertension and these are just guides and for the most of these patient’s, stage I hypertension, just see the patient again within a couple of months. What I often do is have the patient come back and see the nurse a couple of times and then I will see them a second or third time in one or two months and by that time you will have multiple measurements over several months and then at that point you can make the decision whether or not the patient has sustained elevations in their blood pressure.

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