National Heart, Lung, and Blood Institute
National
High Blood Pressure Education Program
Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
EXPRESS Slide Set
Title Page--Department of Health and Human
Services
National Institutes of Health
National Heart, Lung, and Blood
Institute
National High Blood Pressure Education Program
Seventh Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7)
I. Introduction
1 | 2 | 3 | 4 | 5 | 6
| 7 | 8
II. Measurement and Evaluation
9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 |
III. Treatment
24 | 25 | 26 | 27 | 28 | 29 | 30 |
IV. Special Considerations
31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 |
V. Improving Hypertension Control
45 | 46 | 47 | 48 | 49 | 50 | 51 | 52 | 53 | 54
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SLIDE 1: National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 7) EXPRESS
SLIDE 2: Seventh Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Executive Committee
Aram Chobanian, M.D., Chair Dean’s Office and Department of
Medicine Boston University School of Medicine
- George L. Bakris, M.D.
Department of Preventive Medicine
Rush-Presbyterian-St. Luke’s Medical Center
- Henry R. Black, M.D.
Department of Preventive
Medicine
Rush-Presbyterian-St. Luke’s Medical Center
- William C. Cushman, M.D.
Preventive Medicine Section
Veterans Affairs Medical Center
- Lee A. Green, M.D.
Department of Family Medicine
University
of Michigan
- Joseph L. Izzo, Jr., M.D.
Department of Medicine and Pharmacology
SUNY at Buffalo School of Medicine
- Daniel W. Jones, M.D.
Department of Medicine and Center for
Excellence in Cardiovascular-Renal Research
University of Mississippi
Medical Center
- Barry J. Materson, M.D.
Department of Medicine U
niversity of
Miami School of Medicine
- Suzanne Oparil, M.D.
Department of Medicine, Physiology &
Biophysics Division of Cardiovascular Disease
University of Alabama
- Jackson T. Wright, Jr., M.D.
University Hospitals of Cleveland
Case Western Reserve University
- Executive Secretary
Edward J. Roccella, Ph.D, M.P.H.
National
Heart, Lung, and Blood Institute
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SLIDE 3: National High Blood Pressure Education
Program Coordinating Committee
American Academy of Family
Physicians
American Academy of Neurology
American Academy of
Ophthalmology
American Academy of Physician Assistants
American
Association of Occupational Health Nurses
American College of
Cardiology
American College of Chest Physicians
American College of
Occupational and Environmental Medicine
American College of Physicians
—American Society of Internal Medicine
American College of Preventive
Medicine
American Dental Association
American Diabetes Association
American Dietetic Association
American Heart Association
American
Hospital Association
American Medical Association
American Nurses
Association
American Optometric Association
American Osteopathic
Association
American Pharmaceutical Association
American Podiatric
Medical Association
American Public Health Association
American Red
Cross
American Society of Health-System Pharmacists
American Society of
Hypertension
American Society of Nephrology
Association of Black
Cardiologists
Citizens for Public Action on High Blood Pressure and
Cholesterol, Inc.
Hypertension Education Foundation, Inc.
International
Society on Hypertension in Blacks
National Black Nurses Association,
Inc.
National Hypertension Association, Inc.
National Kidney
Foundation, Inc.
National Medical Association
National Optometric
Association
National Stroke Association
NHLBI Ad Hoc Committee on
Minority Populations
Society for Nutrition Education
The Society of
Geriatric Cardiology
Federal Agencies:
Agency for Healthcare Research
and Quality
Centers for Medicare & Medicaid Services
Department of
Veterans Affairs
Health Resources and Services Administration
National
Center for Health Statistics
National Heart, Lung, and Blood Institute
National Institute of Diabetes and Digestive and Kidney Diseases
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SLIDE 4: JNC 7
- Express—Succinct evidence-based recommendations. Published in
JAMA May 21, 2003, and as a Government Printing Office publication.
- Full Report—comprehensive justification and rationale (coming
soon).
SLIDE 5: Purpose
Why 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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SLIDE 6: New Features and Key Messages
- 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 health-promoting lifestyle modifications
to prevent CVD.
SLIDE 7: New Features and Key Messages
(Continued)
- 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 >20/10 mmHg above goal, initiate therapy with two agents,
one usually should be a thiazide-type diuretic.
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SLIDE 8: New Features and Key Messages
(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.
SLIDE 9: BP Measurement and Clinical Evaluation
- Classification of BP
- CVD Risk
- Benefits of Lowering BP
- BP Control Rates
- BP Measurement Techniques
- In-office
- Ambulatory BP Monitoring
- Self-measurement
- Patient Evaluation
- Laboratory Tests and Other Diagnostic Procedures
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SLIDE 10: Blood Pressure Classification
| BP Classification |
SBP mmHg |
|
DBP 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 |
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SLIDE 11: CVD Risk
- HTN prevalence ~ 50 million people in the United States.
- The BP relationship to risk of CVD is continuous, consistent, and
independent of other risk factors.
- Each increment of 20/10 mmHg doubles the risk of CVD across the
entire BP range starting from 115/75 mmHg.
- Prehypertension signals the need for increased education to reduce BP
in order to prevent hypertension.
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SLIDE 12: Benefits of Lowering BP
| |
Average Percent Reduction |
| Stroke incidence |
35–40% |
| Myocardial infarction |
35–40% |
| Heart failure |
50% |
SLIDE 13: 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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SLIDE 14: BP Control Rates
Trends in awareness, treatment, and control of high blood pressure in
adults ages 18–74
| Trends in awareness, treatment, and control of high
blood pressure in adults ages 18–74 |
| |
II
1976–80 |
II
(Phase 1)
1988–91 |
II
(Phase 2)
1991–94
|
1999–2000 |
| Awareness |
51 |
73 |
68 |
70 |
| Treatment |
31 |
55 |
54 |
59 |
| Control |
10 |
29 |
27 |
34 |
SLIDE 15: BP Measurement Techniques
| Method |
Brief Description |
| In-office |
Two readings, 5 minutes
apart, sitting in chair. Confirm elevated reading in contralateral arm. |
| Ambulatory BP monitoring
|
Indicated for evaluation of
“white-coat” HTN. Absence of 10–20% BP decrease during sleep may
indicate increased CVD risk. |
| Self-measurement |
Provides information on
response to therapy. May help improve adherence to therapy and evaluate
“white-coat” HTN. |
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SLIDE 16: 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.
SLIDE 17: Ambulatory BP Monitoring
- ABPM is warranted for 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 >135/85
mmHg and during sleep >120/75 mmHg.
- BP drops by 10 to 20% during the night; if not, signals possible
increased risk for cardiovascular events.
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SLIDE 18: Self-Measurement of BP
- Provides information on:
- Response to antihypertensive therapy
- Improving adherence with therapy
- Evaluating white-coat HTN
- Home measurement of >135/85 mmHg is generally considered to be
hypertensive.
- Home measurement devices should be checked regularly.
SLIDE 19: Patient Evaluation
Evaluation of patients with documented HTN has three objectives:
- Assess lifestyle and identify other CV risk factors or concomitant
disorders that affects prognosis and guides treatment.
- Reveal identifiable causes of high BP.
- Assess the presence or absence of target organ damage and CVD.
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SLIDE 20: CVD Risk Factors
- Hypertension*
- Cigarette smoking
- Obesity* (BMI
30 kg/m2)
- Physical inactivity
- Dyslipidemia*
- Diabetes mellitus*
- Microalbuminuria or estimated GFR <60 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.
SLIDE 21: Identifiable Causes of Hypertension
- Sleep apnea
- Drug-induced or related causes
- Chronic kidney disease
- Primary aldosteronism
- Renovascular disease
- Chronic steroid therapy and Cushing’s syndrome
- Pheochromocytoma
- Coarctation of the aorta
- Thyroid or parathyroid disease
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SLIDE 22: Target Organ Damage
- Heart
- Left ventricular hypertrophy
- Angina or prior myocardial infarction
- Prior coronary revascularization
- Heart failure
- Brain
- Stroke or transient ischemic attack
- Chronic kidney disease
- Peripheral arterial disease
- Retinopathy
SLIDE 23: 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
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SLIDE 24: Treatment Overview
- Goals of therapy
- Lifestyle modification
- Pharmacologic treatment
- Algorithm for treatment of hypertension
- Classification and management of BP for adults
- Followup and monitoring
SLIDE 25: 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.
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SLIDE 26: Lifestyle Modification
| Modification |
Approximate SBP reduction (range) |
| Weight reduction |
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 |
SLIDE 27: Algorithm for Treatment of
Hypertension
| |
|
|
|
Initial drug
therapy |
| BP classification |
SBP* mmHg |
DBP* mHg |
Lifestyle modification
|
Without compelling
indication |
With compelling
indications |
| Normal |
<120 |
and <80 |
Encourage |
|
|
| Prehypertension |
120–139 |
or 80–89 |
Yes |
No antihypertensive drug
indicated. |
Drug(s) for compelling
indications.*** |
| Stage 1 Hypertension |
140–159 |
or 90–99 |
Yes |
Thiazide-type diuretics for
most. May consider ACEI, ARB, BB, CCB, or combination. |
Drug(s) for the compelling
indications.***
Other antihypertensive
drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
| Stage 2 Hypertension |
160 |
or
100 |
Yes |
Two-drug combination for
most** (usually thiazide-type diuretic and
ACEI or ARB or BB or CCB). |
Drug(s) for the compelling
indications.***
Other antihypertensive
drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
*Treatment determined by highest BP category.
**Initial combined therapy should be used cautiously
in those at risk for orthostatic hypotension.
***Treat patients with chronic kidney disease or diabetes to BP goal of
<130/80 mmHg.
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SLIDE 28: Classification and Management of BP for
adults
| |
|
|
|
Initial drug
therapy |
| BP classification |
SBP* mmHg |
DBP* mHg |
Lifestyle modification
|
Without compelling
indication |
With compelling
indications |
| Normal |
<120 |
and <80 |
Encourage |
|
|
| Prehypertension |
120–139 |
or 80–89 |
Yes |
No antihypertensive drug
indicated. |
Drug(s) for compelling
indications.*** |
| Stage 1 Hypertension |
140–159 |
or 90–99 |
Yes |
Thiazide-type diuretics for
most. May consider ACEI, ARB, BB, CCB, or combination. |
Drug(s) for the compelling
indications.***
Other antihypertensive
drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
| Stage 2 Hypertension |
160 |
or
100 |
Yes |
Two-drug combination for
most** (usually thiazide-type diuretic and
ACEI or ARB or BB or CCB). |
Drug(s) for the compelling
indications.***
Other antihypertensive
drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
*Treatment determined by highest BP category.
**Initial combined therapy should be used cautiously
in those at risk for orthostatic hypotension.
***Treat patients with chronic kidney disease or diabetes to BP goal of
<130/80 mmHg.
SLIDE 29: Followup and Monitoring
- Patients should return for followup 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 1–2 times per year.
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SLIDE 30: Followup and Monitoring (continued)
- After BP at goal and stable, followup visits at 3- to 6-month
intervals.
- Comorbidities, such as heart failure, associated diseases, such as
diabetes, and the need for laboratory tests influence the frequency of visits.
SLIDE 31: Special Considerations
- Compelling Indications
- Other Special Situations
- Minority populations
- Obesity and the metabolic syndrome
- Left ventricular hypertrophy
- Peripheral arterial disease
- Hypertension in older persons
- Postural hypotension
- Dementia
- Hypertension in women
- Hypertension in children and adolescents
- Hypertension urgencies and emergencies
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SLIDE 32: Compelling Indications for Individual
Drug Classes
| Compelling Indication |
Initial Therapy Options |
Clinical Trial Basis |
| Heart failure |
THIAZ, BB, ACEI, ARB, ALDO ANT |
ACC/AHA Heart Failure Guideline,
MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES |
| Postmyocardial infarction |
BB, ACEI, ALDO ANT |
ACC/AHA Post-MI Guideline, BHAT, SAVE,
Capricorn, EPHESUS |
| High CAD risk |
THIAZ, BB, ACE, CCB |
ALLHAT, HOPE, ANBP2, LIFE, CONVINCE |
SLIDE 33: Compelling Indications for Individual
Drug Classes
| Compelling Indication |
Initial Therapy Options |
Clinical Trial Basis |
| Diabetes |
THIAZ, BB, ACE, ARB, CCB |
NKF-ADA Guideline, UKPDS, ALLHAT |
| Chronic kidney disease |
ACEI, ARB |
NKF Guideline, Captopril Trial, RENAAL,
IDNT, REIN, AASK |
| Recurrent stroke prevention |
THIAZ, ACEI |
PROGRESS |
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SLIDE 34: Minority Populations
- In general, treatment similar for all demographic groups.
- Socioeconomic factors and lifestyle important barriers to BP control.
- Prevalence, severity of HTN increased in African Americans.
- African Americans demonstrate somewhat reduced BP responses to
monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs.
- These differences usually eliminated by adding adequate doses of a
diuretic.
SLIDE 35: Left Ventricular Hypertrophy
- LVH is an independent risk factor that increases the risk of CVD.
- Regression of LVH occurs with aggressive BP management: weight loss,
sodium restriction, and treatment with all classes of drugs except the direct
vasodilators hydralazine and minoxidil.
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SLIDE 36: Peripheral Arterial Disease (PAD)
- PAD is equivalent in risk to ischemic heart disease.
- Any class of drugs can be used in most PAD patients.
- Other risk factors should be managed aggressively.
- Aspirin should be used.
SLIDE 37: Hypertension in Older Persons
- 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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SLIDE 38: Postural Hypotension
- Decrease in standing SBP >10 mmHg, when associated with
dizziness/fainting, more frequent in older SBP patients with diabetes, taking
diuretics, venodilators, and some psychotropic drugs.
- BP in these individuals should be monitored in the upright position.
- Avoid volume depletion and excessively rapid dose titration of drugs.
SLIDE 39: Dementia
- Dementia and cognitive impairment occur more commonly in people with
HTN.
- Reduced progression of cognitive impairment occurs with effective
antihypertensive therapy.
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SLIDE 40: Hypertension in Women
- Oral contraceptives may increase BP, and BP should be checked
regularly. In contrast, HRT does not raise BP.
- Development of HTN—consider other forms of contraception.
- Pregnant women with HTN should be followed carefully. Methyldopa,
BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs
contraindicated in pregnancy.
SLIDE 41: Children and Adolescents
- HTN defined as BP—95th percentile or greater, adjusted for age,
height, and gender.
- Use lifestyle interventions first, then drug therapy for higher
levels of BP or if insufficient response to lifestyle modifications.
- Drug choices similar in children and adults, but effective doses are
often smaller.
- Uncomplicated HTN not a reason to restrict physical activity.
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SLIDE 42: Hypertensive Urgencies and
Emergencies
- Patients with marked BP elevations and acute TOD (e.g.,
encephalopathy, myocardial infarction, unstable angina, pulmonary edema,
eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic
dissection) require hospitalization and parenteral drug therapy.
- Patients with markedly elevated BP but without acute TOD usually do
not require hospitalization, but should receive immediate combination oral
antihypertensive therapy.
SLIDE 43: Additional 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 Raynaud’s syndrome and certain arrhythmias.
- Alpha-blockers useful in prostatism.
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SLIDE 44: Additional Considerations in
Antihypertensive Drug Choices
Potential unfavorable 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.
SLIDE 45: Improving Hypertension Control
- Adherence to regimens
- Resistant hypertension
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SLIDE 46: Strategies for Improving Adherence to
Regimens
- Clinician empathy increases patient trust, motivation, and adherence
to therapy.
- Physicians should consider their patients’ cultural beliefs and
individual attitudes in formulating therapy.
SLIDE 47: Causes of Resistant Hypertension
- Improper BP measurement
- Excess sodium intake
- Inadequate diuretic therapy
- Medication
- Inadequate doses
- Drug actions and interactions (e.g., nonsteroidal
anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral
contraceptives)
- Over-the-counter (OTC) drugs and herbal supplements
- Excess alcohol intake
- Identifiable causes of HTN
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SLIDE 48: Public Health Challenges and Community
Programs
- Public health approaches (e.g. reducing calories, saturated fat, and
salt in processed foods and increasing community/school opportunities for
physical activity) can achieve a downward shift in the distribution of a
population’s BP, thus potentially reducing morbidity, mortality, and the
lifetime risk of an individual’s becoming hypertensive.
- These public health approaches can provide an attractive opportunity
to interrupt and prevent the continuing costly cycle of managing HTN and its
complications.
SLIDE 49: Population-Based Strategy
SBP
Distributions
| |
% Reduction in Mortality
|
| Reduction in SBP mmHg |
Stroke |
CHD |
Total |
| 2 |
–6 |
–4 |
–3 |
| 3 |
–8 |
–5 |
–4 |
| 5 |
–14 |
–9 |
–7 |
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SLIDE 50: Supporting Materials
- Web site www.nhlbi.nih.gov/
- For patients and the general public
- “Facts About the DASH Eating Plan” (Revised May 2003)
- “Your Guide to Lowering Blood Pressure”
- For health professionals
- Reference Card
- Slide Show
SLIDE 51: Web site www.nhlbi.nih.gov/
- Photo of the JNC 7 Website.
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SLIDE 52: DASH Fact Sheet
- Photo of the DASH Fact Sheet.
SLIDE 53: Your Guide to Lowering Blood Pressure
- Photo of the Your Guide to Lowering Blood Pressure publication.
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SLIDE 54: Reference Card
- Photo of the Reference Card.
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