JNC 7 Organizational Structure

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EVALUATION, MANAGEMENT OF HIGH BLOOD
PRESSURE GUIDELINES JNC 7 AMR ELTOUKHY, MD, PhD
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Objectives

• Introduction
• JNC 7
• Clinical Evaluation
• BP Measurements
• Benefits Of Lowering BP
• CVD Risk Factors
• BP Goal
• Choice Of Drug Therapy

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Learning Objectives

• At the end of this presentation, participants
  will be able to-
• 1) appreciate the goals of anti-htn therapy
• 2) understand anti-htn choices

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• Introduction
• The treatment of hypertension is the most common
  reason for office visits of adults to physicians
  in the United States and for use of prescription
  drugs
• In 1999-2000 there was approximately about 58 to
  65 million hypertensives in the United States,
  compared to only 43.2 million in1988-1991
  NHANES-III survey .
• Despite the prevalence of hypertension and its
  associated complications, control of the disease
  is far from adequate . Data from NHANES show that
  only 34 percent of persons with hypertension have
  their blood pressure under control, defined as a
  level below 140/90 mmHg

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HTN management

• 52 yo male with no significant PMH comes for a
  physical check up and his BP was 160/90. What it
  is the target BP? What is the choice of therapy?
  Two months later 180/100?
• 54 yo male with PMH of HTN, DM, CKD(stage III) ,
  goal BP? choice for the drug therapy?
• 70 you male with PMH of HTN, CAD, DM, LVSD(EF
  30)? Goal BP? Drug therapy?

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JNC 7

• Publication of many new studies.
• Need for a new, clear, and concise guideline
  useful for clinicians.
• Need to simplify the classification of BP.

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New Facts

• 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 120139 mmHg or DBP 8089 mmHg
  should be considered prehypertensive who require
  health-promoting lifestyle modifications to
  prevent CVD.

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BP Measurement
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Office BP Measurement

• 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.

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Ambulatory BP Monitoring

• evaluation of white-coat HTN in the absence of
  target organ injury.
• Ambulatory BP values are usually lower than
  clinic readings.
• Awake, individuals with hypertension have an
  average BP of gt135/85 mmHg and during sleep
  gt120/75 mmHg.
• BP drops by 10 to 20 during the night if
  negative, may indicate possible increased risk
  for cardiovascular events.

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Self-Measurement of BP

• Provides information on
• Response to antihypertensive therapy
• Improving adherence with therapy
• Evaluating white-coat HTN
• Home measurement of gt135/85 mmHg is generally
  considered to be hypertensive.
• Home measurement devices should be checked
  regularly.

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Blood Pressure Grades
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Benefits of Lowering BP
Average Percent Reduction Stroke incidence
3540 Myocardial infarction 2025
Heart failure 50
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Benefits of Lowering BP
In stage 1 HTN and additional CVD risk factors,
achieving a sustained 12 mmHg reduction in SBP
over 10 years will prevent 1 death for every 11
patients treated.
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CVD Risk Factors

• Hypertension
• Cigarette smoking
• Obesity (BMI gt30 kg/m2)
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or estimated GFR lt60 ml/min
• 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.
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CVD Risk

• HTN prevalence 50 million people in the United
  States.
• Each increment of 20/10 mmHg doubles the risk of
  CVD across the entire BP range starting from
  115/75 mmHg.

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Target Organ Damage

• Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Heart failure
• Brain
• Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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Identifiable Causes of Hypertension

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushings syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

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TreatmentOverview

• Goals of therapy
• Lifestyle modification
• Pharmacologic treatment
• Algorithm for treatment of hypertension
• Classification and management of BP for adults
• Followup and monitoring

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Goals of Therapy

• Reduce CVD and renal morbidity and mortality.
• Treat to BP lt140/90 mmHg or BP lt130/80 mmHg in
  patients with diabetes or chronic kidney disease
  or lt120/80 if LVD.
• Achieve SBP goal especially in persons gt50 years
  of age.

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Lifestyle Modificationeffect on BP
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Choice of drug therapy

• Thiazide-type diuretics should be initial drug
  therapy for most, either alone or combined with
  other drug classes.
• Certain high-risk conditions are compelling
  indications for other drug classes.
• Most patients will require two or more
  antihypertensive drugs to achieve goal BP.
• If BP is gt20/10 mmHg above goal, initiate therapy
  with two agents, one usually should be a
  thiazide-type diuretic.

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Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (lt140/90 mmHg)
(lt130/80 mmHg for those with diabetes or chronic
kidney disease) (lt 120/80 with LVD)
Initial Drug Choices
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Followup and Monitoring

• Patients should return for follow up and
  adjustment of medications until the BP goal is
  reached.
• More frequent visits for stage 2 HTN or with
  complicating comorbid conditions.
• Serum potassium and creatinine monitored 12
  times per year.

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Special Indications for Individual Drug Classes
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Special Indications for Individual Drug Classes
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Special indication Left Ventricular Dysfucntion

• LVD is an independent risk factor that increases
  the risk of CVD.
• GOAL BPlt120/80
• Avoid direct vasodilators hydralazine and
  minoxidil.

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Hypertension in OlderPersons

• More than two-thirds of people over 65 have HTN.
• This population has the lowest rates of BP
  control.
• Treatment, including those who with isolated
  systolic HTN, should follow same principles
  outlined for general care of HTN.
• Lower initial drug doses may be indicated to
  avoid symptoms standard doses and multiple drugs
  will be needed to reach BP targets.

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Considerations in Antihypertensive Drug Choices

• Potential favorable effects
• Thiazide-type diuretics useful in slowing
  demineralization in osteoporosis.
• BBs useful in the treatment of atrial
  tachyarrhythmias/fibrillation, migraine,
  thyrotoxicosis (short-term), essential tremor, or
  perioperative HTN.
• CCBs useful in Raynauds syndrome and certain
  arrhythmias.

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Special consideration in Antihypertensive Drug
Choices

• Potential side effects
• Thiazide diuretics should be used cautiously in
  gout or a history of significant hyponatremia.
• BBs should be generally avoided in patients with
  asthma, reactive airways disease, or second- or
  third-degree heart block.
• ACEIs and ARBs are contraindicated in pregnant
  women or those likely to become pregnant.
• ACEIs should not be used in individuals with a
  history of angioedema.
• Aldosterone antagonists and potassium-sparing
  diuretics can cause hyperkalemia.

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Summary
BP goal no CVD lt140/90 CKD,
DM lt130/80 LVD lt
120/80 If Systolicgt20 0r Diastolicgt10 use 2
agents Choice of therapy 1st
line Thiazide diuretics ,
ACEI, ARB, CCB CKD, DM ACEI,
ARB CAD BB
Post-MI (anterior wall) BB,
spironolactone antagonists
(aldactone) Stroke Thiazide
and ACEI
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• A 58-year-old man is evaluated for a 3-month
  history of intermittent cough and shortness of
  breath with exertion. He has a history of
  hypertension and type 2 diabetes mellitus but no
  history of coronary artery disease. His
  medications include extended-release metoprolol,
  aspirin, metformin, and atorvastatin.
• On examination, blood pressure is 165/92 mm Hg
  and heart rate is 88/min. Jugular venous
  distention is 5 cm above the clavicle at a
  45-degree incline. Faint crackles are present at
  the bases of both lungs, cardiac rhythm is
  regular, an S3 is present as is a small amount of
  peripheral edema. Electrocardiogram shows normal
  sinus rhythm and voltage criteria for left
  ventricular hypertrophy. Laboratory results
  include potassium 4.2 meq/L (4.2 mmol/L), and
  creatinine 1.0 mg/dL (88.42 µmol/L). An
  echocardiogram is ordered and furosemide is
  prescribed, and the patient returns the following
  week with resolution of his symptoms. His blood
  pressure at this visit is 130/78 mm Hg, his heart
  rate is 65/min, jugular venous distention is at
  the level of the clavicle at a 45-degree incline,
  his chest is clear to auscultation, the S3 is
  absent, and there is no peripheral edema. The
  echocardiogram shows left ventricular
  hypertrophy, reduced systolic function (left
  ventricular ejection fraction 40), and inferior
  wall hypokinesis. Which of the following is the
  most appropriate medication change at this time?
• No change
• Change metop to coreg
• Start lisinopril
• Start digoxin
• Start spironolactone

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• A 57-year-old woman is evaluated for intermittent
  claudication of the
• left calf that she has had for 5 years. The
  symptoms reproducibly occur after she walks 100
  yards and resolve after 5 minutes of rest. The
  patient has an 80 pack-year smoking history but
  no longer smokes she also has hypertension, type
  2 diabetes mellitus, hypercholesterolemia, and
  chronic stable angina. Her medications are
  include atenolol, atorvastatin, aspirin,
  lisinopril, and insulin.
• On physical examination, the blood pressure is
  142/94 mm Hg bilaterally and heart rate is
  66/min. Carotid arteries are brisk, with a right
  carotid artery bruit. The lungs are clear to
  auscultation and percussion. There is an S4 and
  nonradiating 2/6 early systolic murmur at the
  left lower sternal border. Examination of the
  abdomen is normal. There is a left femoral artery
  bruit, with absent pulses in the left foot and
  trace pulses in the right foot.
• What is the target blood pressure in this
  patient?
• lt140/85
• lt 140/90
• lt130/90
• lt130/80

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• 55-year-old man with hypertension and diabetic
  nephropathy comes for a follow-up visit. He was
  diagnosed with type 2 diabetes mellitus 10 years
  ago. He has no shortness of breath or edema.
  Medications are glipizide, 5 mg twice daily
  pioglitazone, 30 mg/d metoprolol, 100 mg/d
  fosinopril, 80 mg/d hydrochlorothiazide, 25
  mg/d atorvastatin, 40 mg/d and aspirin, 81
  mg/d.
• On physical examination, pulse rate is 55/min and
  blood pressure is 145/85 mm Hg. He is obese.
  Retinal microaneurysms are present. On cardiac
  examination, there is a regular sinus rhythm with
  no murmurs. The lungs are clear to auscultation.
  There is trace pedal edema.
• Laboratory Studies Creatinine
• 1.0 mg/dL (88.42 µmol/L)
• Sodium 140 meq/L (140 mmol/L)
• Potassium 4.0 meq/L (4.0 mmol/L)
• Chloride 106 meq/L (106 mmol/L)
• Bicarbonate 24 meq/L (24 mmol/L)
• 24-Hour urine protein excretion 6 g/24 h
• Urinalysis 4 protein, 12 erythrocytes and 8
  leukocytes/hpf
• On abdominal ultrasound, the right kidney is 12
  cm and the left kidney is 12.2 cm. There is
  normal echogenicity and no hydronephrosis,
  masses, or stones.
• Which of the following is the most appropriate
  next step in this patient's management?
• Increase hydrochlorothiazide dose to 50 mg/d
• Add amlodipine
• Add losartan
• Add prazosin
• Increase metoprolol dose to 150 mg/d

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• A 45-year-old woman is referred for evaluation
  for a blood pressure measurement of 150/94 mm Hg.
  Her husband is a nurse and regularly measures her
  blood pressure at home. Her usual home blood
  pressure measurement is between 110/76 mm Hg and
  120/80 mm Hg. She does not smoke cigarettes. Her
  mother has hypertension.
• On physical examination, her average blood
  pressure is 148/98 mm Hg. Results of laboratory
  studies, including the creatinine level, are
  normal.
• In addition to counseling regarding lifestyle
  modifications, which of the following is the most
  appropriate management for this patient?
• Begin hydrochlorothiazide
• Begin enalapril
• Perform ambulatory blood pressure monitoring
• Continue home blood pressure measurement

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• 65-year-old woman is evaluated for resistant
  hypertension. Despite use of antihypertensive
  therapy for over 20 years, her blood pressure
  usually is approximately 160/90 mm Hg. For
  several years she has been taking amlodipine, 10
  mg/d, and metoprolol, 100 mg/d. However, her
  regimen recently was changed to lisinopril, 20
  mg/d, and sustained-release verapamil, 180 mg/d.
• On physical examination, pulse rate is 68/min and
  blood pressure is 178/100 mm Hg. On cardiac
  examination, the point of maximal impulse is
  prominent and displaced laterally. The lungs are
  clear to auscultation. The remainder of the
  examination is normal.
• Laboratory Studies
• Blood urea nitrogen 18 mg/dL (6.43 mmol/L)
• Creatinine 0.9 mg/dL (79.58 µmol/L)
• Sodium 147 meq/L (147 mmol/L)
• Potassium 3.3 meq/L (3.3 mmol/L)
• Chloride100 meq/L (100 mmol/L)
• Bicarbonate 28 meq/L (28 mmol/L)
• An echocardiogram reveals increased left
  ventricular mass.
• Which of the following is the most appropriate
  next step in this patient's management?
• Magnetic resonance angiography
• Hydrochlorothiazide, 25 mg/d
• Aldosteronerenin ratio
• CT scanning

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THANK YOU Questions?