Transcript Slide 1
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
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
Classification of high blood pressure in adults
Classification is based on 2 measurments made
at 2 separate office visits
Normal
Prehypertension
Systolic 120-129 OR diastolic 80-89
Increased risk for progression to hypertension
Stage 1 hypertension
Systolic 120 AND diastolic 80
Systolic 140-159 OR diastolic 90-99
Stage 2 hypertension
Systolic 160 OR diastolic 100
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
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
Management of hypetension
Dietary Approaches to Stop Hypertension (DASH diet)
For a 2100 kcal/day eating plan:
Total fat: 27% of calories
Saturated fat: 6% of calories
Protein: 18% of calories
Carbohydrate: 55% of calories
Cholesterol: 150 mg
Sodium: 2,300 mg
Potassium: 4,700 mg
Calcium: 1,250 mg
Magnesium: 500 mg
Fiber: 30 g
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
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
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)
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
Management of hypertension
with ischemic heart disease
Stable angina pectoris
Beta blockers are first-line therapy
Acute coronary syndrome (unstable angina or
myocardial infarction)
Calcium-channel blockers are an alternative to beta blockers
Beta blocker
ACE inhibitors
Post-myocardial infarction
Beta blocker
ACE inhibitor
Aldosterone antagonists
(lipid management and aspirin therapy)
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)
Management of hypertension
In African Americans
Have a reduced response to monotherapy with…
…compared with
Beta blockers
ACE inhibitors
ARBS
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
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 120–139
mmHg or a diastolic blood pressure of 80–89 mmHg
should be considered as prehypertensive and require
health-promoting lifestyle modifications to prevent CVD.
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 (<140/90 mmHg, or <130/80 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).
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 (<140/90 mmHg, or <130/80 mmHg for patients
with diabetes or chronic kidney disease).
If blood pressure is >20/10 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.
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
physician’s judgment remains paramount.
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
physician’s judgment remains paramount.
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 physician’s
judgment remains paramount.
Question
Category
Normal
Prehypertension
Stage 1
hypertension
Stage 2
hypertension
Systolic
pressure
Diastolic
pressure
Question
Indication
(assume
no comorbidity)
Prehypertension
Hypertension
Stage 1 hypertension
Stage 2 hypertension
Recommended initial
therapy
Question
Comorbidity
Diabetes mellitus
Hypertension
Ischemic heart disease
Congestive heart failure
Recommended initial
therapy