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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