Hypertension JNC 7 Guidelines The Seventh Report of the Joint National Committee on Prevention www'n

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Hypertension JNC 7 GuidelinesThe Seventh Report
of the Joint National Committee on
Preventionwww.nhlbi.nih.gov/guidelines/hypertensi
on

• Jeffrey Beal, M.D.
• Clinical Director, Florida/Caribbean AIDS
  Education and Training Center
• AAHIVMS

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Disclosure of Financial Relationships

• Speakers Bureau Bristol-Myers Squibb, Glaxo

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
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All of the following are key messages from JNC 7
except

• Systolic BP gt 140 mmHG is a much more important
  CVD risk factor than diastolic BP in persons gt50
  y/o
• The risk of CVD beginning at 115/75 mmHg doubles
  with each increment of 20/10 mmHg
• Thiazide-type diuretics are rarely indicated in
  the treatment of hypertension
• Goal blood pressure for hypertensive patients is
  lt140/90 mmHg, or lt130/80 mmHg for pts with
  Diabetes or CKD

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Which of the following is incorrect for the
proper measurement of BP in the office setting?

• Persons should be seated for at least 5 minutes
  resting before taking the BP
• BP should be taken with the patient sitting on
  exam table with the arm relaxed in their lap
• At least 2 measurements should be made
• SBP is the point at which the first of two or
  more sounds is heard
• DBP is the point before the disappearance of
  sound (phase 5)

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Normal blood pressure is defined in JNC 7 as

• lt120/lt70
• lt120/lt80
• 120-139/80-89
• 140-159/90-99
• 160/ 100

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JNC 7 Classification of BP

• Normal BP lt 120/80
• Prehypertension 120-139/80-89
• Stage 1 HTN 140-159/90-99
• Stage 2 HTN 160/100

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Of the following lifestyle modifications, which
has the greatest potential reduction in SBP?

• Weight loss to normal body weight (BMI 18.5-24.9
  kg/m2)
• Adopting the DASH eating plan
• Dietary sodium restriction
• Physical activity
• Moderation of alcohol intake

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Management of Hypertension

• 60 y/o HIV positive Black female has initial and
  3 subsequent office visits with elevated BP by
  nurse
• Blood pressure 140/96, repeated 5 minutes later
  142/92
• Patient assessed as Stage 1 HTN

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CV Risk Factors

• HTN
• Cigarette Smoking
• Obesity Weight 220lbs, height 56 BMI 35.5
• Physically Inactive
• Dyslipidemia ?Chol, ? HDL, Nl LDL/Trig.
• Diabetes mellitus

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CV Risk Factors

• Microalb. or Estimated GFRlt60 mL/min
• Age gt 55 for ?, gt 65 ?
• FH premature CV disease (lt55 ?, lt 65 ?)

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Physical Exam

• BP equivalent in both arms
• Grade II KW changes on funduscopic
• Waist circumference gt40 ?, gt35 ? (pt.42)
• No carotid, abdominal, femoral bruit
• Nl thyroid palpation, heart, lung and abdomen
  exam, lower ext. pulses, and neurologic exam

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Lab/other diagnostic

• ECG mild LVH
• UA, Glucose, Hct., serum K, Creatinine, Ca,
  Triglycerides normal
• Chol. 230 mg/dL, HDL 30 mg/dL, LDL 88 mg/dL

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Identifiable Causes of HTN

• Sleep apnea
• CKD
• Primary aldosteronism (?K, fails HTN tx.)
• Renovascular ds.
• Chronic steroids/Cushings syndrome
• Pheochromocytoma
• Coarctation of aorta
• Thyroid/Parathyroid disease

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Medications Causing HTN

• NSAID, especially Cox-2 inhibitors
• Cocaine, amphetamine, other illicit drugs
• Sympathomimetics (decongestants, anorectics)
• Oral contraceptives
• Adrenal steroids
• Cyclosporine and tacrolimus
• Erythropoietin
• Licorice (including some chewing tobacco)
• OTC (ephedra, ma haung, bitter orange)

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Lifestyle Modification

• Lifestyle modification education done
• Weight loss and exercise
• Low Na, DASH diet
• Low fat diet
• Patient never drinks more than 4 oz. wine, 2-3
  meals per week

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Patient Concomitant Medication

• Atazanavir 300 mg Ritonavir 100 mg
• Truvada

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What medication(s) would you start?

• Diuretic therapy
• ACE Inhibitor
• Angiotensin receptor blocker
• Beta-blocker
• Calcium channel blocker
• Diuretic plus one of the above

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Generalizations for HTN/HIV

• No clinical studies to date with ARV therapy and
  pharmacologic effect on antihypertensive
  medications
• Best to start with one drug and add using lowest
  starting dose and increasing on at least monthly
  visits if patient clinically stable

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Antihypertensive Drugs

• Diuretics no drug interactions
• Beta Blockers
• Monitor prolonged PR interval ATV
• Ritonavir can increase BB levels
• NNRTI can ?? BB levels
• ACE inhibitors and ARB
• Varied effect
• Calcium Channel Blockers
• In general levels increased