The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Internal Medicine/Pediatrics Noon conference series July 31, 2006

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The Seventh Reportof the Joint National
Committee on the Prevention, Detection,
Evaluation, and Treatment of High Blood
PressureInternal Medicine/PediatricsNoon
conference seriesJuly 31, 2006
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Accurate blood pressure measurement in the office

• Patient position
• Patient should be seated in a chair (not on an
  examination table) for 5 minutes
• Feet on floor
• Arm supported at heart level
• Appropriate size cuff
• Cuff bladder encircling at least 80 of the arm

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Classification of high blood pressure in adults

• Classification is based on 2 measurments made at
  2 separate office visits
• Normal
• Systolic ? 120 AND diastolic ? 80
• Prehypertension
• Systolic 120-129 OR diastolic 80-89
• Increased risk for progression to hypertension
• Stage 1 hypertension
• Systolic 140-159 OR diastolic 90-99
• Stage 2 hypertension
• Systolic ? 160 OR diastolic ? 100

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Management of hypetension

• Goals of pharmacotherapy

• Reduction of cardiovascular and renal morbidity
  and mortality
• In patients with diabetes mellitus or renal
  disease, the target blood pressure is ? 130/80
• In patients without diabetes mellitus or renal
  disease, the target blood pressure is ? 140/90
• Primary focus should be directed toward achieving
  the systolic blood pressure goal
• Most patients will achieve the diastolic
  pressure goal once the systolic pressure is at
  goal

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Management of hypetension

• Lifestyle modifications

• Dietary Approaches to Stop Hypertension (DASH)
  diet
• Dietary sodium reduction
• Independent of DASH diet
• Physical activity
• Moderation of alcohol consumption

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Management of hypetension

• Dietary Approaches to Stop Hypertension (DASH
  diet)

• For a 2100 kcal/day eating plan
• Total fat 27 of caloriesSaturated fat 6 of
  caloriesProtein 18 of caloriesCarbohydrate
  55 of caloriesCholesterol 150 mgSodium 2,300
  mg
• Potassium 4,700 mgCalcium 1,250 mgMagnesium
  500 mgFiber 30 g

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Management of hypertension

• Pharmacotherapy

• Thiazide-type diuretics should be used as initial
  therapy for most patients
• Certain comorbidities are compelling
  indciations for the use of other drugs as
  initial monotherapy (see below)
• Most patients will require ? drugs to achieve
  target blood pressure
• If blood pressure is ? 20/10 mmHg above target,
  consider initiating therapy with 2 drugs
  (separately or in combination)
• Consider the risk of orthostatic hypotension in
  such patients who also have diabetes mellitus,
  autonomic neuropathy, etc

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Management of hypertension

• Monitoring

• Patients should return at approximately monthy
  intervals until target blood pressure is reached
• After blood pressure is stable at target,
  monitoring can usually be done at 3-6 month
  intervals
• Serum potassium and creatinine should be
  monitored at least 1-2 times per year
• Cormorbidities (diabetes mellitus, congestive
  heart failure, etc) may influence the monitoring
  schedule

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Management of hypertension

• with diabetes mellitus

• Target blood pressure ? 130/80 mmHg
• Combinations of ? 2 medications are usually
  necessary
• ACE and ARBS slow the progression of non-diabetic
  (as well as diabetic) kidney disease
• Limited creatine elevation (? 35 above baseline)
  is acceptable (unless hyperkalemia develops)

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Management of hypertension

• with chronic kidney disease

• Target blood pressure ? 130/80 mmHg
• Combinations of ? 3 medications are usually
  necessary
• ACE and ARBS slow the progression of diabetic
  nephropathy

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Management of hypertension

• with ischemic heart disease

• Stable angina pectoris
• Beta blockers are first-line therapy
• Calcium-channel blockers are an alternative to
  beta blockers
• Acute coronary syndrome (unstable angina or
  myocardial infarction)
• Beta blocker
• ACE inhibitors
• Post-myocardial infarction
• Beta blocker
• ACE inhibitor
• Aldosterone antagonists
• (lipid management and aspirin therapy)

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Management of hypertension

• with congestive heart failure

• Asymptomatic ventricular dysfunction
• ACE inhibitors
• Beta blockes
• Symptomatic ventricular dysfunction
• ACE inhibitors and ARBs
• Beta blockers
• Aldosterone blockers
• (loop diurectics)

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Management of hypertension

• In African Americans

• Have a reduced response to monotherapy with
• Beta blockers
• ACE inhibitors
• ARBS
• compared with
• Diuretics
• Calcium channel blockers
• Combinations that include a diuretic largely
  eliminate these differences
• Incidence of angioedema 2-4 times greater than in
  other ethnic groups

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Key messages

• In persons older than 50 years, systolic blood
  pressure greater than 140 mmHg is a much more
  important cardiovascular disease (CVD) risk
  factor than diastolic blood pressure.
• The risk of CVD beginning at 115/75 mmHg doubles
  with each increment of 20/10 mmHg individuals
  who are normotensive at age 55 have a 90 percent
  lifetime risk for developing hypertension.
• Individuals with a systolic blood pressure of
  120139 mmHg or a diastolic blood pressure of
  8089 mmHg should be considered as
  prehypertensive and require health-promoting
  lifestyle modifications to prevent CVD.

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Key messages (continued)

• Thiazide-type diuretics should be used in drug
  treatment for most patients with uncomplicated
  hypertension, either alone or combined with drugs
  from other classes. Certain high-risk conditions
  are compelling indications for the initial use of
  other antihypertensive drug classes (angiotensin
  converting enzyme inhibitors, angiotensin
  receptor blockers, beta-blockers, calcium channel
  blockers).
• Most patients with hypertension will require two
  or more antihypertensive medications to achieve
  goal blood pressure (lt140/90 mmHg, or lt130/80
  mmHg for patients with diabetes or chronic kidney
  disease).
• Certain high-risk conditions are compelling
  indications for the initial use of other
  antihypertensive drug classes (angiotensin
  converting enzyme inhibitors, angiotensin
  receptor blockers, beta-blockers, calcium channel
  blockers).

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Key messages (continued)

• Thiazide-type diuretics should be used in drug
  treatment for most patients with uncomplicated
  hypertension, either alone or combined with drugs
  from other classes. Certain high-risk conditions
  are compelling indications for the initial use of
  other antihypertensive drug classes (angiotensin
  converting enzyme inhibitors, angiotensin
  receptor blockers, beta-blockers, calcium channel
  blockers).
• Most patients with hypertension will require two
  or more antihypertensive medications to achieve
  goal blood pressure (lt140/90 mmHg, or lt130/80
  mmHg for patients with diabetes or chronic kidney
  disease).
• If blood pressure is gt20/10 mmHg above goal blood
  pressure, consideration should be given to
  initiating therapy with two agents, one of which
  usually should be a thiazide-type diuretic.

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Key messages

• The most effective therapy prescribed by the
  most careful clinician will
• control hypertension only if patients are
  motivated. Motivation improves
• when patients have positive experiences with, and
  trust in, the clinician.
• Empathy builds trust and is a potent motivator.
• In presenting these guidelines, the committee
  recognizes that the responsible
• physicians judgment remains paramount.

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Key messages

• The most effective therapy prescribed by the
  most careful clinician will
• control hypertension only if patients are
  motivated. Motivation improves
• when patients have positive experiences with, and
  trust in, the clinician.
• Empathy builds trust and is a potent motivator.
• In presenting these guidelines, the committee
  recognizes that the responsible
• physicians judgment remains paramount.

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Key messages

• The most effective therapy prescribed by the most
  careful clinician will control hypertension only
  if patients are motivated. Motivation improves
  when patients have positive experiences with, and
  trust in, the clinician. Empathy builds trust and
  is a potent motivator.
• In presenting these guidelines, the committee
  recognizes that the responsible physicians
  judgment remains paramount.

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Question
Category Systolic pressure Diastolic pressure
Normal
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
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Question
Indication (assume no comorbidity) Recommended initial therapy
Prehypertension
Hypertension
Stage 1 hypertension
Stage 2 hypertension
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Question
Comorbidity Recommended initial therapy
Diabetes mellitus
Hypertension
Ischemic heart disease
Congestive heart failure