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Hypertension Guidelines

Classication and Management of Blood Pressure


BP Classication Normal Prehypertension Stage 1 hypertension Stage 2 hypertension Treatment Goals Systolic BP, mm Hg* < 120 120-139 140-159 160 and or or or Diastolic BP, mm Hg* < 80 80-89 90-99 100

All hypertensives: < 140/90 mm Hg Patients with diabetes: < 130/80 mm Hg Patients with chronic kidney failure: < 130/80 mm Hg

*Treatment determined by highest BP category. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289:2561.

Hypertension Guidelines
Recommendations for Follow-up Based on Initial Blood Pressure Measurements for Adults Without Acute End-Organ Damage
Initial Blood Pressure, mm Hg* Normal Prehypertension Stage 1 hypertension Stage 2 hypertension Follow-up Recommended Recheck in 2 y Recheck in 1 y within 2 mo Evaluate or refer to source of care within 1 mo. For those with higher pressures (eg, > 180/110 mm Hg), evaluate and treat immediately or within 1 wk depending on clinical situation and complications.

* If systolic and diastolic categories are different, follow recommendations for shorter time follow-up (eg, 160/86 mm Hg should be evaluated or referred to source of care within 1 mo). Modify the scheduling of follow-up according to reliable information about past BP measurements, other cardiovascular risk factors, or target organ disease. Provide advice about lifestyle Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1213.

Classication and Management of Blood Pressure for Adults Aged 18 Years or Older
Management* Initial Drug Therapy Lifestyle Encourage Yes Yes Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, -blocker, CCB, or combination 2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or -blocker or CCB) No antihypertensive drug indicated Drug(s) for the compelling indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed Without Compelling Indication With Compelling Indication

Classication

BP

Systolic BP, mm Hg*

Diastolic BP, mm Hg*

Normal

< 120

and

< 80

Prehypertension

120-139

or

80-89

Hypertension Guidelines

Stage 1 hypertension

140-159

or

90-99

Stage 2 hypertension Yes

160

or

100

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; BP, blood pressure; CCB, calcium channel blocker. * Treatment determined by highest BP category. Treat patients with chronic kidney disease or diabetes to BP goal of less than 130/80 mm Hg.

Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289:2561.

Hypertension Guidelines
Algorithm for Treatment of Hypertension
Lifestyle Modications Not at Goal BP (<140/90 mm Hg or <130/80 mm Hg for Those With Diabetes or Chronic Kidney Disease) Initial Drug Choices

Hypertension Without Compelling Indications

Hypertension With Compelling Indications

Stage 1 Hypertension (Systolic BP 140-159 mm Hg or Diastolic BP 90-99 mm Hg) Thiazide-type Diuretics for most May consider ACE Inhibitor, ARB, -Blocker, CCB, or combination

Stage 2 Hypertension (Systolic BP 160 mm Hg or Diastolic BP 100 mm Hg) Two-drug combination for most (usually Thiazide-type Diuretic and ACE Inhibitor or ARB or -Blocker or CCB)

Drug(s) for the Compelling Indications (see Tables 9 and 10) Other Antihypertensive Drugs (Diuretics, ACE Inhibitor, ARB, -Blocker, CCB) as needed

Not at Goal BP Optimize Dosages or Add Additional Drugs Until Goal Blood Pressure is Achieved Consider Consultation With Hypertension Specialist.
Abbreviations: BP, blood pressure; ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; and CCB, calcium channel blocker. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289:2561.

Hypertension Guidelines
Lifestyle Modications to Manage Hypertension*
Modication Weight reduction Adopt DASH eating plan Recommendation Maintain normal body weight (BMI, 18.5-24.9 kg/m2) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce dietary sodium intake to no more than 100 mmol (2.4-g sodium or 6-g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week) Limit consumption to no more than 2 drinks (eg, 24-oz beer, 10-oz wine, or 3-oz 80-proof whiskey) per day in most men and no more than 1 drink per day in women and lighter-weight persons Approximate Systolic BP Reduction Range 5-20 mm Hg/1O kg/wt loss 8-14 mm Hg

Dietary sodium reduction

2-8 mm Hg

Physical activity

4-9 mm Hg

Moderation of alcohol consumption

2-4 mm Hg

* For overall cardiovascular risk reduction, stop smoking. The effects of implementing these are dose and time dependent and could be higher for some individuals. Abbreviations: BMI, body mass index calculated as weight in kilograms divided by the square of height in meters; BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289:2561.

Hypertension Guidelines
Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes
Recommended Drugs Diuretic -Blocker ACE Inhibitor ARB CCB Aldosterone Antagonist

Compelling Indication* Heart failure

Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK PROGRESS

Postmyocardial infarction High coronary disease risk Diabetes Chronic kidney disease Recurrent stroke prevention

* Compelling indications for antihypertensive drugs are based on from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the blood pressure. Drug abbreviations: BB, -blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; Aldo ANT, aldosterone antagonist Conditions for which clinical trials demonstrate of classes of antihypertensive drugs. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289:2561.
Abbreviations: AASK, African American Study of Kidney Disease and Hypertension; ACC/AHA, American College of Cardiology/American Heart Association; AIRE, Acute Infarction Ramipril ALLHAT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ANBP2, Second Australian National Blood Pressure Study; BHAT, -Blocker Heart Attack Trial; CIBIS, Cardiac Bisoprolol Study; CONVINCE, Controlled Onset Verapamil Investigation of Cardiovascular End Points; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival Study; EPHESUS, Eplerenone Post-Acute Myocardial Infarction Heart Failure Efcacy and Survival Study; HOPE, Heart Outcomes Prevention Evaluation Study; IDNT, Inbesartan Diabetic Nephropathy Trial; LIFE, Losartan Intervention For Endpoint Reduction in Hypertension Study; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure; NKF-ADA, National Kidney FoundationAmerican Diabetes Association; PROGRESS, Perindopril Protection Against Recurrent Stroke Study; RALES, Randomized Aldactone Evaluation Study; REIN, Ramipril in Nephropathy Study; RENAAL, Reduction of Endpoints in NonInsulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan Study; SAVE, Survival and Ventricular Enlargement Study; SOLVD, Studies of Left Ventricular Dysfunction; TRACE, Trandolapril Cardiac Evaluation Study; UKPDS, United Kingdom Prospective Diabetes Study; ValHEFT, Valsartan Heart Failure Trial.

Hypertension Guidelines
Oral Antihypertensive Drugs
Class Thiazide diuretics Drug (Trade Name) Chlorothiazide (Diuril) Chlorthalidone (generic) Hydrochlorothiazide (Microzide, HydroDIURIL) Polythiazide (Renese) Indapamide (Lozol) Metolazone (Mykrox) Metolazone (Zaroxolyn) Loop diuretics Bumetanide (Bumex) Furosemide (Lasix) Torsemide (Demadex) Potassiumsparing diuretics Aldosterone receptor blockers -blockers Amiloride (Midamor) Triamterene (Dyrenium) Eplerenone (Inspra) Spironolactone (Aldactone) Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (Zebeta) Metoprolol (Lopressor) Metoprolol extended release (Toprol XL) Nadolol (Corgard) Nebivolol (Bystolic) Propranolol (Inderal) Propranolol LA (Inderal LA) Timolol (Blocadren) -blockers with intrinsic sympathomimetic activity Acebutolol (Sectral) Penbutolol (Levatol) Pindolol (generic) Usual Dose Range, mg/d 125-500 12.5-25 12.5-50 2-4 1.25-2.5 0.5-1.0 2.5-5 0.5-2 20-80 2.5-10 5-10 50-100 50-100 25-50 25-100 5-20 2.5-10 50-100 50-100 40-120 2.5-40 40-160 60-180 20-40 200-800 10-40 10-40 Usual Daily Frequency* 1-2 1 1 1 1 1 1 2 2 1 1-2 1-2 1 1 1 1 1 1-2 1 1 1 2 1 2 2 1 2 Table continues

Hypertension Guidelines
Oral Antihypertensive Drugs (cont)
Class Combined -blockers and -blockers ACEIs Drug (Trade Name) Carvedilol (Coreg) Labetalol (Normodyne, Trandate) Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Angiotensin II antagonists Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan) CCBs Nondihydropyridines 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) Usual Dose Range, mg/d 12.5-50 200-800 10-40 25-100 5-40 10-40 10-40 7.5-30 4-8 10-80 2.5-20 1-4 8-32 400-800 150-300 25-100 20-40 20-80 80-320 180-420 120-540 80-320 120-480 120-360 Usual Daily Frequency* 2 2 1 2 1-2 1 1 1 1 1 1 1 1 1-2 1 1-2 1 1 1-2 1 1 2 1-2 1 Table continues

Hypertension Guidelines
Oral Antihypertensive Drugs (cont)
Class CCBsDihydropyridines Drug (Trade Name) Amlodipine (Norvasc) Felodipine (Plendil) Isradipine (Dynacirc CR) Nicardipine sustained release (Cardene SR) Nifedipine long-acting (Adalat CC, Procardia XL) Nisoldipine (Sular) 1-blockers Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin) Central 2-agonists and other centrally acting drugs Clonidine (Catapres) Clonidine patch (Catapres-TTS) Methyldopa (Aldomet) Reserpine (generic) Guanfacine (Tenex) Direct vasodilators Hydralazine Minoxidil (Loniten) Usual Dose Range, mg/d 2.5-10 2.5-20 2.5-10 60-120 30-60 10-40 1-16 2-20 1-20 0.1-0.8 0.1-0.3 250-1000 0.1-0.25 0.5-2 25-100 2.5-80 Usual Daily Frequency* 1 1 2 2 1 1 1 2-3 1-2 2 1/wk 2 1 1 2 1-2

*In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval (trough effect). BP should be measured just prior to dosing to determine if satisfactory BP control is obtained. Accordingly, an increase in dosage or frequency may need to be considered. These dosages may vary from those listed in the Physicians Desk Reference, 57th ed. Source: Physicians Desk Reference. 57th ed. Montvale, NJ: Thomson PDR; 2003. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Complete Version. Hypertension. 2003;42:1218-1220. Full prescribing information for Tekturna is available at www.tekturna.com Accessed August 27, 2007.

Hypertension Guidelines
Combination Drugs for Hypertension
Combination Type ACEIs and CCBs Fixed-Dose Combination, mg* Amlodipine-benazepril hydrochloride (2.5/10, 5/10, 5/20, 10/20) Enalapril-felodipine (5/5) Trandolapril-verapamil (2/180, 1/240, 2/240, 4/240) Benazepril-hydrochlorothiazide (5/6.25, 10/12.5, 20/12.5, 20/25) Captopril-hydrochlorothiazide (25/15, 25/25, 50/15, 50/25) Enalapril-hydrochlorothiazide (5/12.5, 10/25) Fosinopril-hydrochlorothiazide (10/12.5, 20/12.5) Lisinopril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25) Moexipril-hydrochlorothiazide (7.5/12.5, 15/25) Quinapril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25) Candesartan-hydrochlorothiazide (16/12.5, 32/12.5) Eprosartan-hydrochlorothiazide (600/12.5, 600/25) Irbesartan-hydrochlorothiazide (150/12.5, 300/12.5) Losartan-hydrochlorothiazide (50/12.5, 100/25) Olmesartan medoxomil-hydrochlorothiazide (20/12.5, 40/12.5, 40/25) Telmisartan-hydrochlorothiazide (40/12.5, 80/12.5) Valsartan-hydrochlorothiazide (80/12.5, 160/12.5, 160/25) Trade Name Lotrel Lexxel Tarka Lotensin HCT Capozide Vaseretic Monopril/HCT Prinzide, Zestoretic Uniretic Accuretic Atacand HCT Teveten-HCT Avalide Hyzaar Benicar HCT Micardis-HCT Diovan-HCT Table continues

ACEIs and diuretics

ARBs and diuretics

Hypertension Guidelines
Combination Drugs for Hypertension (cont)
Combination Type -blockers and diuretics Fixed-Dose Combination, mg Atenolol-chlorthalidone (50/25, 100/25) Bisoprolol-hydrochlorothiazide (2.5/6.25, 5/6.25, 10/6.25) Metoprolol-hydrochlorothiazide (50/25, 100/25) (40/5, 80/5) Propranolol LA-hydrochlorothiazide (40/25, 80/25) Timolol-hydrochlorothiazide (10/25) Centrally acting drug and diuretic Methyldopa-hydrochlorothiazide (250/15, 250/25, 500/30, 500/50) Reserpine-chlorthalidone (0.125/25, 0.25/50) Reserpine-chlorothiazide (0.125/250, 0.25/500) Reserpine-hydrochlorothiazide (0.125/25, 0.125/50) Diuretic and diuretic Amiloride-hydrochlorothiazide (5/50) Spironolactone-hydrochlorothiazide (25/25, 50/50) Triamterene-hydrochlorothiazide (37.5/25, 75/50) Trade Name Tenoretic Ziac Lopressor HCT Corzide Inderide LA Timolide Aldoril Demi-Regroton, Regroton Diupres Hydropres Moduretic Aldactazide Dyazide, Maxzide

Abbreviations: BB, -blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker. Source: Physicians Desk Reference. 57th ed. Montvale, NJ: Thomson PDR; 2003. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Complete Version. Hypertension. 2003;42:1218-1220.

Hypertension Guidelines
Patient Education About Treatment
Assess patients understanding and acceptance of the diagnosis of hypertension. Discuss patients concerns and clarify misunderstandings. Tell patient the BP reading and provide a written copy. Come to agreement with the patient on goal BP. Ask patient to rate (1 to 10) his or her chance of staying on treatment. Inform patient about recommended treatment and provide written information about the role of lifestyle including diet, physical activity, dietary supplements, and alcohol intake. Use standard brochures when available. Elicit concerns and questions and provide opportunities for the patient to state behaviors to carry out treatment recommendations. Emphasize: Need to continue treatment Control does not mean cure Uncertainty if BP is elevated by feeling or symptoms; BP must be measured.
Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1240.

Hypertension Guidelines
Clinician Awareness and Monitoring
Anticipate adherence problems for young men. Consider nonadherence as a cause of: Failure to reach goal BP Resistant hypertension Sudden loss of control.

Encourage patients to bring in all medications from all physicians and other sources (prescription, complementary, or over-the-counter) to each visit for review and to rule out iatrogenic causes of elevated blood pressure. Ask what the patient takes for pain. Recognize depression and other psychiatric illnesses, including panic attacks, and manage appropriately. Be willing to change unsuccessful regimens and search for those more likely to succeed.
Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1240.

Hypertension Guidelines
Use of Ambulatory Blood Pressure Monitoring (ABPM) and Clinical Situations in Which Monitoring May Be Helpful
Useful way to assess BP over 24 hours, in early morning and extent of fall in BP during sleep. May be helpful in the following patient groups: suspected white-coat hypertension in patients with hypertension and no target organ damage apparent drug resistance (ofce resistance) hypotensive symptoms with antihypertensive medication episodic hypertension autonomic dysfunction. Those with 24-h ABPM measures exceeding 135/85 mm Hg are nearly twice as likely to have a CVD event. Medicare reimbursement for ABPM is available to assess suspected white-coat hypertension. The CPT code for ambulatory monitoring is 93784-93790.
Adapted from: Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

Hypertension Guidelines
Cardiovascular Risk Factors
Major Risk Factors and Concomitant Disorders Hypertension* Age (older than 55 for men, 65 for women) Diabetes mellitus* Elevated LDL (or total) cholesterol or low HDL cholesterol* Estimated GFR < 60 mL/min Family history of premature cardiovascular disease (men aged < 55 or women aged < 65) Microalbuminuria Obesity* (body mass index 30 kg/m2) Physical inactivity Tobacco usage, particularly cigarettes Target Organ Damage Heart Left ventricular hypertrophy Angina/prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Dementia Chronic kidney disease Peripheral arterial disease Retinopathy
Abbreviations: GFR, glomerular rate. * Components of the metabolic syndrome. Reduced HDL and elevated triglycerides are components of the metabolic syndrome. Abdominal obesity is also a component of metabolic syndrome. lncreased risk begins at approximately 55 and 65 for men and women, respectively. Adult Treatment Panel III used earlier age cutpoints to suggest the need for earlier action. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1214.

Hypertension Guidelines
Identiable Causes of Hypertension
Chronic kidney disease Coarctation of the aorta Cushings syndrome and other glucocorticoid excess states, including chronic steroid therapy Drug-induced or drug-related Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnea Thyroid / parathyroid disease
Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1214.

Hypertension Guidelines
Screening Tests for Identiable Hypertension
Diagnosis Chronic kidney disease Coarctation of the aorta Cushings syndrome and other glucocorticoid excess states, including chronic steroid therapy Drug-induced/related Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnea Thyroid/parathyroid disease Diagnostic Test Estimated GFR CT angiography History/dexamethasone suppression test

History; drug screening 24-h urinary metanephrine and normetanephrine 24-h urinary aldosterone level or measurements of other mineralocorticoids Doppler study; magnetic resonance angiography Sleep study with O2 saturation TSH; serum PTH

Abbreviations: GFR, glomerular rate; CT, computed tomography; TSH, thyroid stimulating hormone; PTH, parathyroid hormone. Adapted from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. Hypertension. 2003;42:1215.