Transcript JNC 7 Organizational Structure

Hypertension: Measurement,
Diagnosis and Treatment
George L. Bakris, MD
Professor of Medicine
Director, Hypertensive Diseases Unit
University of Chicago Pritzker School of Medicine
Chicago, IL
Office BP Measurement
 Use auscultatory method with a properly calibrated and validated
instrument.
 Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
 Appropriate-sized cuff should be used to ensure accuracy.
 At least two measurements should be made.
 Clinicians should provide to patients, verbally and in writing, specific BP
numbers and BP goals.
Chobanian A, et.al. Hypertension 2003;42:1206
Blood Pressure Classification
BP Classification
SBP mmHg
Normal
<120
and
<80
Prehypertension
120–139
or
80–89
Stage 1 Hypertension
140–159
or
90–99
Stage 2 Hypertension
>160
or
>100
Chobanian A, et.al. Hypertension 2003;42:1206
DBP mmHg
CHD Mortality Rate in Each Decade of Age
Versus Usual SBP at the Start of That Decade
34 000 deaths at ages 40 - 89
Hazard ratio
(floating absolute risks & 95% CI)
Age at risk 20 mmHg  SBP
256
128
64
32
16
80-89
33%  risk
70-79
40%  risk
60-69
46%  risk
50-59
50%  risk
40-49
51%  risk
8
4
2
1
120
140
160
180
Usual systolic blood pressure (mmHg)
Lewington S et.al. Lancet 2002; 360:1903
CVD Risk Factors
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Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria
Estimated GFR <60 ml/min (http://www.nkdep.nih.gov/GFR-cal.htm; www.nephron.com and other sites)
 Age (older than 55 for men, 65 for women)
 Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
Chobanian A, et.al. Hypertension 2003;42:1206
Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
Chobanian A, et.al. Hypertension 2003;42:1206
Comparison of Hypertension Awareness, Treatment,
and Control in the U.S.
N = 14,653 Patients from NHANES Database
*
*
* p <0.05 between 1999-2000 and 2003-2004
For Internal Use Only
Sarafidis P, Bakris GL. J Clin Hypertens. Feb.2008
7
Prevalence of CKD in US in 2007
%
13% US Population
Coresh J et.al. JAMA 2007;298::2038-2049
• CHF admission rates are 5 times higher
in patients with a diagnosis of CKD vs.
non-CKD
• Ischemic heart disease admissions at 22.5 times higher in the CKD population
• Cardiac arrhythmia admission rates are
twice as common in CKD populations
Prevalence, Awareness, Treatment, and Control of
Hypertension in Total KEEP Cohort by CKD stage
with140/90 mm Hg as threshold. (N=10,819)
%
Sarafidis P et.al. Am J Med 2008;121:332-340
Prevalence, Awareness, Treatment, and Control of
Hypertension in Total KEEP Cohort by CKD stage
with140/90 mm Hg as threshold. (N=10,819)
%
Sarafidis P et.al. Am J Med 2008;121:332-340
Goals of Therapy
 Reduce CVD and renal morbidity and mortality.
 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of age.
Chobanian A, et.al. Hypertension 2003;42:1206
JNC 7 Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Chobanian A et.al. JAMA. 2003;289:2560-2572.
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Lifestyle Modification
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
Chobanian A, et.al. Hypertension 2003;42:1206
JNC 7 Compelling Indications
Heart Failure
Diuretic
BB


Post MI
CAD risk
Diabetes Mellitus


Renal disease
Recurrent stroke
prevention




ACEI ARB




CCB


AA
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


BB, beta blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker;
CCB, calcium channel blocker; AA, aldosterone antagonist; HF, Heart Failure;
MI, myocardial infarction; CAD, coronary artery disease; DM, diabetes mellitus
Chobanian A et.al., JAMA. 2003;289:2560-2572.
Trial/ SBP Achieved
INVEST
(136 mm Hg)
CONVINCE
(137 mm Hg)
ALLHAT
(138 mm Hg)
IDNT
(138 mm Hg)
RENAAL
(141 mm Hg)
UKPDS
(144 mm Hg)
ABCD
(132 mm Hg)
MDRD
(132 mm Hg)
HOT
(138 mm Hg)
AASK
(128 mm Hg)
Number of BP Meds
Updated from Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.
If Blood Pressure >130/80 mm Hg in Diabetes (eGFR > 50 ml/min^)
(if systolic BP< 20 mmHg above goal)
Start ARB or ACE Inhibitor titrate upwards
(if systolic BP >20 mmHg above goal)
START with ACEI or ARB + thiazide diuretic* or CCB
Recheck within 2-3 weeks
If BP Still Not at Goal (130/80 mm Hg)
Add Long Acting Thiazide Diuretic* or CCB
Add CCB or b blocker**
Recheck within 2-3 weeks
If BP Still Not at Goal (130/80 mm Hg)
Consider and Aldosterone Receptor Blocker
If CCB used, Add Other Subgroup of CCB
(ie, amlodipine-like agent if verapamil or diltiazem already being used and the converse)
OR could add alpha blocker is not using vasodilating b blocker with alpha effects
Recheck within 4 weeks
If BP Still Not at Goal (130/80 mm Hg)
Refer to a Clinical Hypertension Specialist#
Bakris GL and Sowers JR, J Clin Hypertens, Oct.. 2008
Summary
 All Guidelines-NKF, ADA, JNC 7 state that combination
therapy is required as initial therapy in patients with
systolic BP >160 mmHg or anyone who is 15-20 mmHg
above goal systolic BP
 Using agents with complementary modes of actions
such as ACE inhibitors with calcium antagonists or ACE
inhibitors with diuretics in one pill will help increase
medication adherence in high risk patients who already
ingest an average of 8 to 12 pills daily.
Summary Continued
 For persons over age 50, SBP is a more important than
DBP as CVD risk factor.
 Starting at 115/75 mmHg, CVD risk doubles with each
increment of
20/10 mmHg throughout the BP range.
 Persons who are normotensive at age 55 have a 90%
lifetime risk for developing HTN.
 Those with SBP 120–139 mmHg or DBP 80–89 mmHg
should be considered prehypertensive who require healthpromoting lifestyle modifications to prevent CVD.
 Certain high-risk conditions are compelling indications for
other drug classes.
Summary Continued
 The most effective therapy prescribed by the careful clinician
will control HTN 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.
 The responsible physician’s judgment remains paramount.