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The 7th Report of JNC on Hypertension Dr. Mohammed Othman Al-Rukban, ABFM,SBFM. Assistant Professor Department of Family And Community Medicine Contents Methodology Classification CVD risk Benefits of lowering BP BP control rates Measurements of BP Patients evaluation Treatments Special considerations Improving Hypertension control Public health challenges & Community programs Methodology I. II. III. IV. Publication of many hypertension observational studies and clinical trials. Need for a new, clear, and concise guideline that would be useful for clinicians. Need to simplify the classification of blood pressure. Clear recognition that the JNC reports were not being used to their maximum benefit. Dr. Mohammed Al Rukban Methodology NHLBI NHBPEP CC –46 Professional, Voluntary, and Federal Organizations –Biannual meetings –Dr. Aram Chobanian –5 months work Medline searches English Language Jan1997—April 2003 >80 Papers Revised by 33 Hypertension leaders Dr. Mohammed Al Rukban Classification Bp classification Normal Prehypertention Stage1 Hypertension Stage 2 Hypertension Dr. Mohammed Al Rukban SBP mmHg DBP mmHg <120 And <80 120-139 Or 80-89 140-159 Or 90-99 >160 Or >100 Classification Bp classification SBP mmHg DBP mmHg Lifestyle Modifi -cation Normal <120 And <80 Encourage Prehypertention 120139 Or 80-89 Yes Stage1 Hypertension 140159 Or 90-99 Yes Stage 2 Hypertension >160 Or >100 Dr. Mohammed Al Rukban Yes Initial Drug Therapy Without Compelling Indication With compelling Indications No antihypertensive drug indicated Drugs for compelling indications Thiazide-type diuretics for most. may consider ACEI, ARB, CCB, or combination Drug(s) for the compelling indications. other antihyperte nsive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) CVD risk @ 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 Dr. Mohammed Al Rukban BENEFITS OF LOWERING BP # In clinical trials, antihypertensive therapy has been associated with reductions in incidence of: – Stroke (35-40%) – Myocardial infarction (20-25%) – Heart failure (>50%) # In patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated. # In the presence of CVD or target organ damage, only 9 patients would require such BP reduction to prevent a death. Dr. Mohammed Al Rukban BLOOD PRESSURE CONTROL RATES National Health and Nutrition Examination Survey, percent II (1976-80) III III PHASE 1 phase 2 (1988-91) (1991-94) 1999-2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34 Dr. Mohammed Al Rukban Measurements of BP ACCURATE BLOOD PRESSURE MEASUREMENT IN THE OFFICE (Clinicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals) AMBULATORY BLOOD PRESSURE MONITORING SELF-MEASUREMENT OF BLOOD PRESSURE Dr. Mohammed Al Rukban PATIENT EVALUATION OBJECTIVES: 1. To access lifestyle 2. Identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment 3. To reveal identifiable causes of high BP 4. To assess the presence or absence of target organ damage and CVD. Dr. Mohammed Al Rukban PATIENT EVALUATION 1. 2. Medical history Physical examination - Appropriate measurement of BP - Auscultation for carotid, abdominal, and femoral bruits - Palpation of the thyroid gland - Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation - Palpation of the lower extremities for edema and pulses - Neurological assessment Dr. Mohammed Al Rukban PATIENT EVALUATION 3- LABORATORY TESTS AND OTHER DIAGNOSTIC PROCEDURES Electrocardiogram Urinalysis Blood glucose and hematocrit Serum potassium, creatinine & calcium Lipid profile Optional tests include; measurement of urinary albumin excretion or albumin/creatinine ratio. Dr. Mohammed Al Rukban TREATMENT Goals of therapy @ Reduction of cardiovascular and renal morbidity and mortality. @ Treating SBP and DBP to targets that are <140/90 mmHg @ In patients with Hypertension and diabetes or renal disease, the BP goal is < 130/80 mmHg. Dr. Mohammed Al Rukban Lifestyle Modification Modification Recommendation Approximate SBP Reduction (RANGE) Weight Reduction Maintain normal body weight (body mass index 18.5-24.9 ). 5-20 mmHg/10 kg weight loss Adopt DASH eating plan Consume a diet rich in fruits,vegetables, and low fat diary products with a reduced content of saturated and total fat. 8-14 mmHg Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2-8 mmHg Dr. Mohammed Al Rukban Lifestyle Modification Physical Activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week 4-9 mmHg Moderation of Alcohol consumption Limit consumption to no more than 2 drinks (1 oz or 30 mL ethanol; e.g 24 oz beer, 10 oz wine or 3 oz 80- proof whisky) per day in women and lighter 2-4 mmHg weight persons. Dr. Mohammed Al Rukban Pharmacological Treatment Class Drug (Trade Name) Thiazide diuretics Chlorothiazed (Diuril) Chlorthalidone (generic) Hydroclorothiazide (Microzide, Hydro DIURIL) Polythiazide (Renese) Indapamide (Lozol) Metalozol (Mykrox) Metalazone (zaroxolyn) 125-500 12.5-25 12.5-50 Bumetanide (bumex) Furosemide (Lasix) Torsemide (Demadex) 0.5-2 20-80 2.5-10 Loop diuretics PotassiumAmiloride (Midamor) sparing diuretics Triamtrene (Dyrenium) Aldosterone receptor blockers Usual Dose Range in MG/ DAY 2-4 1.25-2.5 0.5-1.0 2.5-5 5-10 50-100 Eplernone ( Inspra) 50-100 Spironolactone (Aldactone) 25-50 Dr. Mohammed Al Rukban Pharmacological Treatment Beta-Blockers Beta-Blockers with intrinsic sypathomimetic activity Combined Alpha– and beta-blockers Dr. Mohammed Al Rukban Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (zebeta) Metoprolol (lopressor) Metoprolol extended release (Toprol XL) Nadolol (Corgard) Propranolol (Inderal) Propranolol longacting (Inderal LA) Timolol (Blocadren) 25-100 5-20 2.5-10 50-100 Acebutolol (Sectral) Penbutolol (Levatol) Pindolol (generic) 200-800 10-40 10-40 50-100 40-120 40-160 60-180 20-40 Carvedilol (Coreg) 12.5-50 Labetalol (Normodyne) 200-800 Pharmacological Treatment ACE Inhibitors Benazepril (Lotensin) captopril (capoten) Enalapril (vasotec) Fosinopril (monopril) Lisinopril (prinivil, zestril) Moexipril (Univasc) Perindopril (Accupril) Quinapril (Accupril) Ramipril (Altace) Trandolapril(Mavik) 10-40 25-100 2.5-40 10-40 10-40 7.5-30 4-8 10-40 2.5-20 1-4 Angiotensin II Antagonists Candesartan (Atacand) Eprosartan (Teveltan) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan) 8-32 400-800 150-300 25-100 20-40 20-80 80-320 Dr. Mohammed Al Rukban Pharmacological Treatment Calcium channel blockers- non Dihydropyridines Calcium Channel Blockers Dihydropyridines Diltiazem extended release (cardizem CD, Dilacor XR, Tiazac) Diltiazem extended release (Cardizem LA) Verapamil immediate release (calan, isoptin) Verapamil long acting (calan SR, Isoptin SR) Verapamil – Coer (Covera HS, Verelan PM) Amlodipine ( Norvasc ) Felodipine (plendil) Isradipine (Dynaciric CR) Nicardipine sustained release (Cardene SR) Nifedipine long-acting (Adalat CC, procardia XL) Nisoldipine (Sular) Dr. Mohammed Al Rukban 180-420 120-540 80-320 120-360 120-360 2.5-10 2.5-20 2.5-10 60-120 30-60 10-40 Pharmacological Treatment Alpha- Blockers Doxazosin ( Cardura) Prazosin (minipress) Terazosin (Hytrin) 1-16 2-20 1-20 Central alphaagonists and other centrally acting drugs Clonidine (Catapres) Clonidine patch (catapres-TTS) Methyldopa (Aldomet) Resrpine (generic) Guanfacine (generic) 0.1-0.8 Hydralazine (Apresoline) Minoxidil (Loniten) 25-100 2.5-80 Direct Vasodilators Dr. Mohammed Al Rukban 0.1-0.3 250-1000 0.05-0.25 0.5-2 Algorithm for treatment of hypertension LIFESTYLE MODIFICATION Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for patients with diabetes or chronic kidney disease) INITIAL DRUG CHOICES Without Compelling Indications Stage1 Hypertension Thiazide –type diuretics for most. May consider ACEI,ARB,BB,CCB, Or combination Dr. Mohammed Al Rukban With Compelling Indications Stage2 Hypertension 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. NOT AT GOAL BLOOD PRESSURE Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Dr. Mohammed Al Rukban SPECIAL CONSIDERATION Compelling Indication Heart failure RECOMMENDED DRUGS Diuretic BB ACEI - - - - - Post myocardial infarction ARB CCB - High coronary disease risk - - - Diabetes - - - - - - Chronic Kidney Disease Recurrent stroke Prevention - - ALDO ANT CLINICAL TRIAL BASIS - ACC/AHA heart failure guideline MERIT HF, COPERNICUS, CIBIS,SOLVD, AIRE, TRACE, VALHEFT,RALES - ACC/AHA POST MI GUIDELINE,BHAT,SAVE Capricom, EPHISUS - ALLHAT,HOPE,ANBP2, LIFE,CONVINCE - NKF-ADA guideline, UKPDS,ALLHAT NKF Guild line Captoprill Trial RENAAL IDNT,REIN,AASK PROGRESS OTHER SPECIAL SITUATION • Minorities • 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 • Hypertensive urgencies and emergencies Dr. Mohammed Al Rukban Antihypertensive Drugs Potential Favorable effects • Thiazide-Type diuretics are useful in slowing demineralization in Osteoporosis. •BBs useful in the treatment of arterial tachyarrhythmias/fibrillation, Migraine, thyrotoxicosis, essential tremor, or preoperative hypertension. •CCBs may be useful in Raynaud’s syndrome and certain arrhythmias • alpha-blockers may be useful in prostatism. Dr. Mohammed Al Rukban Antihypertensive Drugs POTENTIAL UNFAVOURABLE EFFECTS •Thiazide diuretics should be used cautiously in patients who have gout or who have a history of significant hyponatremia. • BBs should generally be avoided in individuals who have asthma, reactive airways diseases, or heart block. • ACEIs and ARBs Should not be given to women likely to become pregnant and contraindicated in those who are. •ACEIs should not be used in individuals with a history of angioedema. •Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia and should generally be avoided In patients who have serum potassium values more than 5.0 mEq/L while not taking medications. Dr. Mohammed Al Rukban Improving Hypertension control Public health challenges & Community programs 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 Dr. Mohammed Al Rukban The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg. Dr. Mohammed Al Rukban Individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension Dr. Mohammed Al Rukban 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. Dr. Mohammed Al Rukban Thiazide -type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drug from other classes. Dr. Mohammed Al Rukban Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotension converting enzyme inhibitors, angiotension receptor blockers, beta-blockers, calcium channel blockers). Dr. Mohammed Al Rukban Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure pressure (<140/90 mmHg,or <130/80 mmHg for patients with diabetes or chronic kidney disease). Dr. Mohammed Al Rukban 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. Dr. Mohammed Al Rukban 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 Dr. Mohammed Al Rukban