National High Blood Pressure Education Program

Complete Report

The Seventh Report
of the Joint National
Committee on
Prevention,
Detection,
Evaluation, and
Treatment of
High Blood Pressure

U . S . D E P A R T M E N T O F H E A LT H A N D H U M A N S E R V I C E S
National Institutes of Health
National Heart, Lung, and Blood Institute

Complete Report

The Seventh Report
of the Joint National
Committee on

Prevention,
Detection,
Evaluation, and
Treatment of
High Blood Pressure

This work was supported entirely by the
National Heart, Lung, and Blood Institute.
The Executive Committee, writing teams,
and reviewers served as volunteers without
remuneration.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program

NIH Publication No. 04-5230
August 2004

.

M. GlaxoSmithKline. Boerhinger-Ingelheim.D. Boerhinger-Ingelheim. (Case Dr. research projects from Abbott Laboratories. Reliant. MA) Ingelheim. he Schwarz Pharma. Bristol-Myers Squibb. M. Materson. for research projects from Astra-Zeneca. (University Dr. Astra- Executive Committee Zeneca. Pfizer. Astra-Zeneca.P. tant/advisor for Bristol-Myers Squibb. and Pharmacia. Henry R. Sanofi. Pfizer.D. Novartis. Black. Solvay. Jr. Biovail. Novartis. Sanofi. Suzanne Oparil. Zeneca. Jackson. Wright. Dr. and Solvay. Schering Plough. Forest.B. (Rush University GlaxoSmithKline. Bristol-Myers Squibb. Bakris has received honoraria for serving as a Novartis. Solvay. and Biovail. M. Astra-Zeneca. and Dr. (National research projects from Boehringer-Ingelheim. he has received funding/grant support for research pro. Joseph L. Izzo. Evaluation. GD Searle.D. Abbott. MS). and Blood Institute. GlaxoSmithKline. Merck. and Pharmacia. Green. William C. Merck. Sankyo. M. and Bristol-Myers Squibb. (State University of New York at Pfizer. Abbott. NY). Ann Arbor. (University of Miami. Forest. and Sankyo. Forest. (Rush University Medical Center.A. Medical Center. Sanofi. Bristol-Myers Squibb.D. M. IL). Barry J. he has served as a consul. Merck. Cushman has received funding/grant support of Michigan. TN). Novartis. MD) and Biovail. GlaxoSmithKline. Merck. Aventis Pharma. Wyeth- The Seventh Report of the Joint National Committee on Prevention. and Executive Secretary Sankyo. Intercure. Alteon. Ph. Solvay. Novartis. Dr. Forest.. Dr. he has stock holdings in Dr. Sankyo. as a speaker from Monarch. Kos. Astra. IL). (University Pharmacia. GlaxoSmithKline.. the NHBPEP Coordinating Committee. Buffalo. for Unimed.H. Lee A. (Boston University projects from Bristol-Myers Squibb. Miami.. OH) speaker from Boehringer-Ingelheim. Lung.. Dr. Jones. George L. (Veterans Affairs Medical Center. Monarch.D. Ph. Pharmaceuticals. Noven.D. Takeda. M. Alteon. Carter has served as a consultant/advisor for Chicago. M. Forest. Biovail. Pharmacia. M. Bethesda. he has served as a consul- Medical Center. Merck. Pharmacia. Heart. Oparil has received funding/grant support for Squibb. Izzo has received honoraria for serving as a Western Reserve University.P. Boston. Manger has served as a consultant/advisor for Squibb. Pfizer. Materson has served as a consultant/advisor jects from National Institutes of Health. Jr. Bristol-Myers Dr. Bristol-Myers Squibb. Tanabe. of Alabama at Birmingham. Cushman. Novartis.. Merck. Pfizer. MI). M. Merck. Chobanian. Memphis. Chicago. Novartis [Ciba]. Jackson T. speaker from Astra-Zeneca. he has served as a consultant/advisor for Abbott. Jones has served as a consultant/advisor for Pfizer. Forest. M. (University of Mississippi Boehringer-Ingelheim.D. Boehringer- School of Medicine. and Nexcura. Sanofi/BioClin.D.Chair has received funding/grant support for research Aram V. Novartis. M. and Daniel W. Pfizer. Cleveland. Merck. Solvay. Abbott. Financial Disclosures Sankyo. speaker from Astra-Zeneca. GlaxoSmithKline. AL). Bristol-Myers Squibb. Boerhinger-Ingelheim. Pfizer. Roccella.. Birmingham. King Buffalo School of Medicine. Novartis. GlaxoSmithKline.D. Boehringer-Ingelheim. Detection. Bakris. M.D. Forest. M. Pfizer. he served as a consultant/advisor for Merck. and Solvay. Nexcura. Novartis. and Wyeth-Ayerst. Bristol-Myers Squibb. Astra-Zeneca. Merck. Eli Lilly. and Solvay.D. Boehringer-Ingelheim. GlaxoSmithKline. tant/advisor for Astra-Zeneca. Novartis. and Treatment of High Blood Pressure iii . Wyeth. Sankyo. he has received funding/grant support for Edward J. Astra-Zeneca. Chobanian has received honoraria for serving Intercure.D. Merck. Astra- Zeneca.H. Scios Inc. FL). Black has received honoraria for serving as a GlaxoSmithKline. Alteon. Biovail. Bristol-Myers Dr. Aventis. Merck.

R. M. and Blood Institute.H. M. F. M. William A. Cohen. M.P. MD). B. F.. Medicine. Bethesda.M. Marshall. Ayerst. Manger. NY). Vicki Burt. NY)... D. MD). M.D. Birmingham.E.D.D.N. M.. Bethesda. Jr.A.D.A.M. Merck. (SUNY Health Science Center TN). Miami. O.C. Rita D. St. D. and Treatment of High Blood Pressure . (Stanford Claude Lenfant. Iowa City. F. M. Mark J. OH).O. Snyder. Michael Glick. Denver. Edwin C. M.P. Chesley. (American Blood Institute. M. (Centers for Medicare & National High Blood Pressure Education Program Medicaid Services. Atlanta. (New Jersey Dental Ed. Gifford. Colman.N. Merck. (Philadelphia College of Osteopathic University Medical Center. (State University of New York speaker from Med Com Vascular Biology at Buffalo School of Medicine. he Daniel W.H. (National Stroke Association. Rochester.D.S. (Saint Medicine.. (Health Core. Forest. Louis University School of Medicine.D.H.. M. (University of Miami..S. Phoenix Stuart Linas.D. GlaxoSmithKline. Solvay/Unimed.D. Ph. Joseph L. Bethesda. R. Davis. iv The Seventh Report of the Joint National Committee on Prevention. projects from Novartis and Astra-Zeneca. Aventis. (Health Resources and Services Administration. Sc. (Rush D. New York. Academy of Physician Assistants.C. Memphis. Oakhurst. (University of Alabama at Birmingham..D. Lung.H. GA). Squibb. N. (University of Iowa.A.A. M. Newark. Lung. Ph. at Brooklyn.. Bristol-Myers Squibb. F. Louis. (American Rockville. Pamela J. (Agency for Healthcare Research and Quality. John J. Thomas H. IL). MD). (Yale University School of Bakris.N. PA). Mason.. Ann Arbor. William C. M.C. C. NJ). Health Statistics. Washington.S.. MS).P.D.D. M. Medical Center.D.Ph. Bethesda.D. (National Heart. Chicago.. Jones. M.A. AL).H. Pfizer. LA). Corporation. Kolasa.C. M. MD).P. Detection. M. Hyattsville. Jackson. Lee Shaughnessy Podiatric Medical Association. NC). James W. Brooklyn. New Orleans.N.D. IA). Biovail. M. Keith Copelin Ferdinand. Sheps. Forest. and Texas Biotechnology School. Washington.D. DC). Buffalo..D. she is also on the Board of Directors for Baltimore. (National Heart.A. Medicine. M. Gamble. Jr. F. (University of Mississippi has received funding/grant support for research Medical Center. The Salt Institute. Ray W. Nickey. Cushman. Newark.D.H. (University of Maryland School of Medicine.D.H. (New York Institute of Technology. M. D. MN). (Howard University Hospital.. M. Greenville.C.N. Randall. Aventis... Hostetter. Ayerst. Pfizer.N. Jay Merchant.D.D.D. Bloomington. Pharmaceuticals. M. IL).. NJ). M. M. R. M.P.D. (Brody School of Medicine speaker from Astra.-C. (Eye Group. Novartis. Francis D.B. (Heartbeats Life Center. (Cleveland Ronald Stout. Sankyo.O. FL).C. Materson.D.. M. Green..C. PA).N. she has served as a consultant/advi.P. Jerome D. Malvern.D. Roccella.D. Bristol-Myers at East Carolina University.C. William Solvay/Unimed. Sowers has received honoraria for serving as a Izzo. Carter. Sowers. Suzanne Oparil. James R. NY). Jr.P. Kathryn M. Barry L. (Sanofi-Synthelabo Research.D. Otelio S. Nancy Coordinating Committee Houston Miller. Strickland.. M. M. M. R.E. Black. GlaxoSmithKline. Norvartis. Chicago.. Sanofi. Bayer.A. Medical Center. Fountain Hills.A. Lee A. Solvay. and MO). L. P. Pharm. Memphis. (National Center for M.C.D. Stephen Havas. Pfizer.S. Dr. F.D. (University of Michigan. David B.. (Mayo Clinic. CO). (Morehouse School of Rockville. M.D. MD).P. Working Group and Joslin Clinic Foundation. MD). Barry J. Scarsdale. DE).D. O. R. Leonard M.. R. Reed. Dr. Cziraky. the Texas Biotechnology Corporation. sor for Bristol-Myers Squibb... (University of Colorado Pharmaceuticals. MD).D. George L. M. Wright has received honoraria for serving as a Ph. Steiner.S.A.H.. MI). DC).P.A. and Wyeth. Henry R.. Palo Alto.M.D. Norvartis. he has received funding/grant M.S.A. Phoenix University School of Optometry. and IN). F.D. TN). NY). (Veterans Affairs Sheldon G..D. Inc. and Health Sciences Center. MD). M. (New York University support for research projects from Astra. Lynn Kirby. F. University School of Medicine. Marvin Moser. Evaluation.C. (Indiana Merck.. (Rush University Medical Center. Philadelphia.P. Bayer.. Englewood. AZ).. (National Institutes of Diabetes and Digestive and Kidney Diseases. CO). (Procter and Clinic Foundation. Edward J. M. CA).D. Pharm. M.

Ph. VA). (Rush Medical College.C.C. IL).. M.. and Blood Institute.D. F.D. F. Cleeman... Washington. M. M.D.. M. M. Laurie F. Walter Reed Army York.. Bethesda. Howard S. M.D. Gorelik. M. James I. Buffalo. M. and Mayo Foundation. Kaplan.. Egan. (Georgetown University Medical Center. Philadelphia.S. (Baylor College of Medicine. (Medical College of Georgia. (Mayo Clinic Pressure and Cholesterol.. (Mayo Clinic and Mayo OH). FL). Ph.D. Elliott. CT) Administration Hospital. PA). American Academy of Family Physicians Chicago. Hand. (American Heart Townsend. Daniel Levy. OH). (Marshfield Clinic.A.A.A.P. M. Dallas.R. Staff Lung. F. (American Darla E.. MD) MD). Augusta..B.C. Philip B. American Dental Association TX). D.A.D. MD).C. R.P. NY). F. Humberto Vidaillet. Donald G.D. R. Cleveland. M. Ray Mary Winston. Houston. American College of Chest Physicians Chicago. Pickering. M. Ph. NY). L. Cleveland.M.D.D. Framingham. Basile. Piña.P. Jack P.H. M.C.D..A.. Clive Rosendorff. F. Ileana L. D.P.C.H. M. Joanne Karimbakas. American Academy of Ophthalmology Flack. Philadelphia.D. PA). Environmental Medicine Bethesda. (Mount Sinai Medical Center. Danford. Ph. Whisnant.C. (Rush University Medical Center..Sc. MN).P. (Thomas American Academy of Neurology Jefferson University. F.P. Detroit...P. Bethesda. (Medical University of South National High Blood Pressure Education Program Carolina. American Hospital Association The Seventh Report of the Joint National Committee on Prevention.. Rochester.P. Medical Center. Cleveland. MD). (Citizens for Public Action on Blood Virend K.. S. M. NY). Springfield Gardens. M. R. M. Somers. School of Medicine..Phil. M. American Dietetic Association James W.S. Falls Church.C. TX).D. OH). MA).. Miami. Falkner.. M. Lung. (University of Pennsylvania Association. Karen A.. Medical School.D. Detection. Wilson. Charleston. (The University of Jan N. (Cleveland Clinic Foundation.. MN). F. Charleston.I. Wright. M. Richard A. M. VA Medical Center. Weiss.N. and Blood Institute. Michael Prisant. M. (Marshfield Clinic.A.D.L. MD). (Louis Stokes Cleveland Silver Spring. Willshire.A. MI). M.A.C. (National Institutes for Research Health Program.D. American College of Physicians-American (VA WNY Healthcare System. (National Heart. David Lee American Association of Occupational Health Gordon. (University of Miami School of Nurses Medicine. WI).A.H. (Veterans Affairs Medical Center. (Case Western Reserve University.D. F. Evaluation.P.D. Jackson T. GA). R.D. M. American College of Cardiology M. F.C. New Washington Hospital Center. Bonita E.A. Inc. (University Hospitals of Cleveland. SC)..D.D.H. DC). Dallas.D.C. NY). M.H.P. Society of Internal Medicine Norman M. Vasilios Papademetriou. Carlos Vallbona..A. John M. Coordinating Committee Member Organizations M. Brent M.P. Ph.D. M. M. Marshfield. Farmington.D. M. R.. We appreciate the assistance by: Carol Creech. Mark E. NY). Ed. Bronx.. Gerald J.P. Dunlap. Lung. (VA WNY Healthcare American Heart Association System and SUNY Buffalo.D. Washington. Heart. M.. OH) Marshfield. IL). MD).D. (American Red Cross.D. Mary M.D.C. Thomas G. (University of Texas American College of Preventive Medicine Southwestern Medical School at Dallas. Bethesda. SC). Institutes for Research Health Program.D.D. TX). and Treatment of High Blood Pressure v .C. Cleveland. (Wayne State University American Academy of Physician Assistants School of Medicine. Jr.C. M. Buffalo. MD). and Blood Institute.D.S. Vidt. (Veterans Affairs Medical Center. Rochester.N American College of Occupational and (National Heart. Lohr. Hershey. WI). M.D. (National Heart. and Gabrielle Gessner (American Lung. and Blood Institute. Lung. M.A.P. Additional Contributors William White. DC). M.D.D. M. Donato.D. William J. M. Linda A.D. (Veterans Connecticut Health Center. American Diabetes Association and Blood Institute. (National Heart. Potomac. F.D. M.. Silver Spring.D.H.H. M. Dart.

Hypertension Education Foundation. and Blood Institute National Institute of Diabetes and Digestive and Kidney Diseases vi The Seventh Report of the Joint National Committee on Prevention. Inc. Evaluation. National Hypertension Association. Detection. 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. National Medical Association National Optometric Association National Stroke Association National Heart. and Blood Institute Ad Hoc Committee on Minority Populations Society for Nutrition Education The Society of Geriatric Cardiology Federal Agencies: Agency for Health Care Research and Quality Centers for Medicare & Medicaid Services Department of Veterans Affairs Health Resources and Services Administration National Center for Health Statistics National Heart. and Treatment of High Blood Pressure . Inc. Inc. Inc. International Society on Hypertension in Blacks National Black Nurses Association. National Kidney Foundation. Lung. Lung.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Lifestyle Modifications . . . . . . . . . 19 Self-Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Community Programs . . . . . . . . . . . . . . . . . 8 Blood Pressure and Cardiovascular Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Prevention of Hypertension: Public Health Challenges . . . . . . . . . . . . . . . . . . . xiv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Heart Failure . . . . . . . . . 11 Classification of Blood Pressure. . . . . . . . . . 38 Other Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation. . . . . . . . . . . . 25 Goals of Therapy . . . . . . . . . . . . . . . . . . . 37 Patients With Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . 29 Achieving Blood Pressure Control in Individual Patients. . xiii Abstract . . 20 Laboratory Tests and Other Diagnostic Procedures . 30 Followup and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Benefits of Lowering Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . 6 Lifetime Risk of Hypertension . . . . . . . . . . . . . . . . 33 Compelling Indications . . . . . . . . . . . 32 Special Situations in Hypertension Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maintenance. 21 Identifiable Causes of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and Use of Blood Pressure Devices. . . . 33 Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 The Seventh Report of the Joint National Committee on Prevention. . . . . . . . . . . . . . . . . . . . . . . 24 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Cardiovascular Disease Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Ambulatory Blood Pressure Monitoring. . . 17 Calibration. . . . . . . 9 Basis for Reclassification of Blood Pressure . . . . . . . . . 26 Rationale for Recommendation of Thiazide-Type Diuretics as Preferred Initial Agent . . . . . . . . . . . . . . . . . and Treatment of High Blood Pressure vii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Methods . . . . . . . . . . . . . . . . . . . . . . 25 Blood Pressure Control Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Pharmacologic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Genetics of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . 18 Accurate Blood Pressure Measurement in the Office. . . . . . . . . . . . 12 Importance of Systolic Blood Pressure . . . . . . . . . 19 Patient Evaluation . . . . . 39 Minorities . . . . . Contents Foreword . . . . . . . . . . . . . 34 Diabetes and Hypertension . . . . . . . 39 Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . .

. 57 Renal Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Goal Setting and Behavioral Change . . . . . . . 61 Clinical Inertia . 63 Characterization of Patients Leading to Tailored Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 57 Hypertension and the Eye . . . . . . . . . . . . . . . . . . . 53 Hypertensive Crises: Emergencies and Urgencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Patients Undergoing Surgery . . . . . . . . . . 58 Drugs and Other Agents Affecting Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Urinary Outflow Obstruction . . . . . . . . . . 41 Clinical Management of the Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 References . 41 Clinical Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Nonaspirin Nonsteroidal Anti-Inflammatory Drugs . . . . . . . . . . . . Prevelance . . . . . 61 Role of Other Health Care Professionals . . . . 41 Left Ventricular Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . 46 Resistant Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Erectile Dysfunction and Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Obstructive Sleep Apnea . . . . . . 44 Orthostatic Hypotension. . . . . . . . . . . 40 Age Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Patients With Renovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Issues Dealing With Adherence to Regimens . . . . . . . . . . . . . . . . . . . . . . . 56 Dental Issues in Hypertensive Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Economic Barriers . . . . . . . . 48 Hypertension in Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 What Can the Clinician Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Improving Hypertension Control . . . . . . . . . . . . . and Treatment of High Blood Pressure . . . . . . . . Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Hypertension in Women . . . 62 Patient Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 66 viii The Seventh Report of the Joint National Committee on Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Additional Sources of Information. . . . 59 Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Cognitive Function and Dementia . . . . . . . . . . . . . . . . . . 43 Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Lipids. . . . . . . . . . . 43 Hypertension in Older People . . . . . . . . . . . . . . . . . . . 41 Overweight and Obesity . . . . . . . . . 64 Scheme Used for Classification of the Evidence. . . . . Evaluation. . . . . . . . . . . . . .

33 Ta b l e 1 3 . . . . . . . . . . . . . . . . . . . . . . . . by the 50th and 75th height percentiles. . . Causes of resistant hypertension . . . . . . . 52 Ta b l e 2 2 . . . . . . . . . . . . . . . Combination drugs for hypertension. Screening tests for identifiable hypertension . . . . . . . . . . . . . . . 40 Ta b l e 1 4 . . . . hypertension. . Clinical trial and guideline basis for compelling indications for individual drug classes . . . . Estimated prevalence of the metabolic syndrome using the Adult Treatment Panel III definition among normal weight. . . . . . . . Parenteral drugs for treatment of hypertensive emergencies . . . . . . . The 95th percentile of blood pressure by selected ages. . . . . . . . . . . . . . . . . . . . . Classification of blood pressure for adults. . . . . . . . . . . . . . . . . . . . . . 40 Ta b l e 1 5 . . . . 19 Ta b l e 6 . . . . . . . . . . Treatment of chronic hypertension in pregnancy . . . Lifestyle changes beneficial in reducing weight . . . . . . . . . . 12 Ta b l e 4 . . Detection. . . . . heart disease. . Common substances associated with hypertension in humans . . Changes in blood pressure classification . . 27 Ta b l e 1 1 . . . 51 Ta b l e 2 1 . . . . . . . . and stroke over the next decade among men initially free of disease stratified by baseline body mass index. . Lifestyle modifications to prevent and manage hypertension . . . . . 50 Ta b l e 2 0 . treatment. . . . . . . . . . . . Treatment of acute severe hypertension in preeclampsia. . . . . . . . . . . . . . . . . . . . . 26 Ta b l e 1 0 . . . . . . . . . . . . . . 21 Ta b l e 8 . . . . . . . . . . . . . . . . 20 Ta b l e 7 . Clinical criteria defining the metabolic syndrome in Adult Treatment Panel III . . . . and control of high blood pressure. . . . Cardiovascular risk factors. 61 The Seventh Report of the Joint National Committee on Prevention. Oral antihypertensive drugs . . 42 Ta b l e 1 7 . . Clinical situations in which ambulatory blood pressure monitoring may be helpful . . Relative 10-year risk for diabetes. . . . . . 53 Ta b l e 2 3 . 44 Ta b l e 1 8 . . . . . . . . 18 Ta b l e 5 . . . . 1976–2000 . . . 47 Ta b l e 1 9 . . . . . . Provide empathetic reinforcement . . . . . 59 Ta b l e 2 5 . . . . 11 Ta b l e 3 . . . . . . . . Trends in awareness. . . . . . 1 Ta b l e 2 . . . . . . . Medical therapies of peripheral arterial disease . . . . . . . . . . . . . . Recommendations for followup based on initial blood pressure measurements for adults without acute end organ damage . . . . . . . . . . . . . and by gender in children and adolescents. . . . . . . L i s t o f Ta b l e s Ta b l e 1 . . . . . . . . . . . and obese men and women in the National Health and Nutrition Examination Survey III . . Evaluation. . . . . . . . . . . . . . . 42 Ta b l e 1 6 . . . . . . . . . . . . . . . . . . 22 Ta b l e 9 . . . . 29 Ta b l e 1 2 . . . . . . . . . . . . . . . . . . . . . . . and Treatment of High Blood Pressure ix . . . . . . . . . Classification of hypertension in pregnancy. . . . . . . . . . . . . . . . Identifiable causes of hypertension . . . . . overweight. 55 Ta b l e 2 4 . . . . . . . . . . . . . . .

. . . Patient education about treatment . . . . . . . . 63 Ta b l e 3 1 . 62 Ta b l e 3 0 . . . . . . and Treatment of High Blood Pressure . . . . . . . . . . . . . 62 Ta b l e 2 8 . . . . . . . . . Evaluation. . Promote social support systems . . . . . . . . . . . . . Collaborate with other health professionals . . . . . . . Detection. . . . . . . . . . . . . . . . . . . . . . . . . . 63 x The Seventh Report of the Joint National Committee on Prevention. . . . . . . Ta b l e 2 6 . 62 Ta b l e 2 9 . . . . 61 Ta b l e 2 7 . . . . . . . . . . . . . Organize care delivery systems . Individualize the regimen . . . . . . . . . . . . . . Clinician awareness and monitoring . . . . . . . . . . . .

. by primary diagnosis (adjusted for age. . 1960–1991. . . . . Prevalence of congestive heart failure by race and gender. . . . . 5 Fi g u r e 8 . . . . . . . . Frequency distribution of untreated hypertensive individuals by age and hypertension subtype . 1970–2000. 1971–2000 . . . . . . . . . . race) . . . . . . Hospital case-fatality rates for congestive heart failure for ages younger than 65 years and 65 years and older: United States. . . . . . . . . . . . . . 14 Fi g u r e 1 4 . . 2 Fi g u r e 2 . . . . 3 Fi g u r e 4 . . . . . . . . ages 25–74 years: United States. Evaluation. . . . . Ischemic heart disease mortality rate in each decade of age versus usual blood pressure at the start of that decade . . . . . 9 Fi g u r e 1 0 . . LIST OF FIGURES Fi g u r e 1 . . . . . . Residual lifetime risk of hypertension in women and men aged 65 years . . . . . . . . . Detection. and 90th percentile of systolic blood pressure for ages 60–74 years: United States. . . . . . . 15 Fi g u r e 1 5 . . . . 31 Fi g u r e 1 7 . . . . 3 Fi g u r e 5 . . . . 1971–74 to 1999–2000 . . . . . . . 2 Fi g u r e 3 . . 16 Fi g u r e 1 6 . . Systolic blood pressure distributions . . . . 10 Fi g u r e 1 2 . . Changes in systolic and diastolic blood pressure with age . . . . . Hospitalization rates for congestive heart failure. gender. . . . . . . . . 10 Fi g u r e 1 1 . . . . . . . Percent decline in age-adjusted mortality rates for coronary heart disease by gender and race: United States. . . . . . 13 Fi g u r e 1 3 . . . . 4 Fi g u r e 6 . . . . . . 44 The Seventh Report of the Joint National Committee on Prevention. . . . . . . . . . . Trends in incident rates of end-stage renal disease. . . . . . . . . . . . . 1970–2000 . . . . . . 1981–2000 . . . . . ages 45–64 years and 65 years and older: United States. . . . . . . . . . . Algorithm for treatment of hypertension . . . . . . . Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade . . . . . . . . . . . . . Difference in coronary heart disease prediction between systolic and diastolic blood pressure as a function of age . . . . . . 8 Fi g u r e 9 . . median. . Ten-year risk for coronary heart disease by systolic blood pressure and presence of other risk factors. . . . . Impact of high normal blood pressure on the risk of cardiovascular disease . Percent decline in age-adjusted mortality rates for stroke by gender and race: United States. . Smoothed weighted frequency distribution. 5 Fi g u r e 7 . . and Treatment of High Blood Pressure xi .

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JNC documents other advisories as the scientific evidence becomes are tools to be adopted and implemented in local available. Lung.nih. Evaluation. Your Guide to Lowering High Blood Coordinating Committee. the conclusion is and that best management practice occurs when hyper. Reference Card from the JNC 7 for and the contributors to this document. Therefore. Dr. and individual settings. His brilliant (NHBPEP) recognizes the responsible clinician’s leadership is what made the JNC 7 and related judgment regarding the management of patients materials possible. Chair tension is treated to goal levels and blood pressure National High Blood Pressure Education Program control is sustained over time. Facts About the DASH Eating Committee. and Blood Institute the United States and worldwide. have clinicians. Readers of this contribute to the further prevention of premature report should remember that this document is morbidity and mortality. This is irrefutable Coordinating Committee but. as well as the writers Pressure. tific evidence to bolster other JNC 7 products: Dr. addressed the important public health issue of and Palm application of the JNC 7 recommenda. Alving. M. Detection. These educational materials are available Applying JNC 7 recommendations to clinical on the NHLBI Web site http://www.gov/. Chobanian has our intended as a guide. hypertension treatment and Foreword xiii . improving inadequate blood pressure control.nhlbi. The NHBPEP will release remains paramount. much discussion was generated regarding the interpretation of the available scientific literature. In the production of this report. The National deep gratitude for leading the effort to develop High Blood Pressure Education Program this report in such a timely manner. By developing this stellar landmark report. unfortunately. practice will prevent the devastating consequences of uncontrolled hypertension. not a mandate. and members of the NHBPEP Plan. they could be. tions. I recommend this The purpose of JNC reports is to synthesize the guideline to clinicians and public health workers available scientific evidence and offer guidance with the conviction that its contents will indeed to busy primary care clinicians. the JNC 7 Executive the JNC 7 Express. after all of the discussions within the JNC 7 Executive Committee and the NHBPEP Coordinating Committee.D. Acting Director conferences and scientific meetings conducted in National Heart. Blood Pressure Wallet Card for patients.Foreword The complete version of the Seventh Report of control rates worldwide are simply not as good as the Joint National Committee on Prevention. Aram Chobanian. However. and Treatment of High Blood Pressure (JNC7) provides additional scien. as well as the many discussions at Barbara M.

their treatment plan. prehypertensive individuals (SBP 120–139 be controlled if patients are motivated to stay on mmHg or DBP 80–89 mmHg) require health. Evaluation. and Treatment of High Blood drug classes (angiotensin-converting enzyme Pressure (JNC 7) is to provide an evidence-based inhibitors. two or hypertension. Detection. beta approach to the prevention and management of blockers. Detection. those who are using two agents. calcium channel blockers). classes. hypertension will only sion. Abstract The purpose of the Seventh Report of the Joint high-risk conditions. less of therapy or care. beginning BP is >20 mmHg above the SBP goal or 10 at 115/75 mmHg. angiotensin-receptor blockers. This report serves uncomplicated hypertension. for motivation and satisfaction. which are compelling National Committee on Prevention. one of which usually will be a normotensive at 55 years of age will have a thiazide diuretic. and the committee continues to should be used in drug treatment for most. systolic blood required to achieve goal BP (<140/90 mmHg. thiazide diuretic as a guide. trust promoting lifestyle modifications to prevent the in the clinician. The key messages of this report more antihypertensive medications will be are: in those older than age 50. and empathy improve patient progressive rise in blood pressure and CVD. CVD risk doubles for each mmHg above the DBP goal. recognize that the responsible physician’s either alone or combined with drugs from other judgment remains paramount. for patients whose factor than diastolic BP (DBP). and Treatment of High Blood Pressure . pressure (SBP) of >140 mmHg is a more impor. should be considered. regard- 90 percent lifetime risk of developing hyperten. initiation of therapy increment of 20/10 mmHg. Positive experiences. or <130/80 mmHg for patients with diabetes tant cardiovascular disease (CVD) risk and chronic kidney disease). this report delineates specific xiv The Seventh Report of the Joint National Committee on Prevention. indications for the use of other antihypertensive Evaluation.

age-adjusted death rates from stroke much as 1 billion individuals. voluntary organizations and 7 Federal agencies. 1976–2000* National Health and Nutrition Examination Survey. a improved from a level of 51 percent in the period coalition of 39 major professional. In addition. Introduction 1 . These changes have that 50 million or more Americans have high BP been associated with highly favorable trends in the warranting some form of treatment.1. treatment. treatment. to 59 percent in the same period.2 Worldwide morbidity and mortality attributed to hypertension. 2 Data from The Sixth Report of the Joint National Committee on Prevention.289:2560–71.Introduction For more than three decades. 3 The Seventh Report of the Joint National Committee on Prevention. Prevalance of hypertension in the US adult population. Within the last two disease and 49 percent of ischemic heart disease decades. and on antihypertensive medication. Results from the Third National Health and Nutrition Examination Survey. preven. 1988–1991. Sources: 1 Data from Burt VL. been associated with a considerable reduction in suboptimal BP is the number one attributable risk the hospital case-fatality rate for heart failure factor for death throughout the world. and control of hypertension (high age of persons with high BP controlled to below blood pressure [BP]). race.3 The World Health Organization respectively (figures 2 and 3). and 1976–1980 to 70 percent in 1999–2000 (table 1). better treatment of hypertension has (IHD). Percent 1976–801 1988–911 1991–942 1999–20003 Awareness 51 73 68 70 Treatment 31 55 54 59 Control† 10 29 27 34 * Percentage of adults ages 18 to 74 years with SBP of 140 mmHg or greater. Detection. or responsible for 62 percent of cerebrovascular socioeconomic status. and Treatment of High Blood Pressure. age.1 million deaths per year may be attributable to by approximately 60 percent and 50 percent. Considerable success has been achieved in the Lung. Table 1. or taking antihypertensive medication.26:60–9. 140/90 mmHg has increased from 10 percent to 34 percent. JAMA 2003. The percentage of patients with hypertension One important function is to issue guidelines and receiving treatment has increased from 31 percent advisories designed to increase awareness. Trends in awareness. The tered the National High Blood Pressure Education awareness of hypertension among Americans has Program (NHBPEP) Coordinating Committee. the National Heart. prevalence estimates for hypertension may be as Since 1972. Hypertension 1995. past in meeting the goals of the program.157:2413–46. These benefits have reports that suboptimal BP (>115 mmHg SBP) is occurred independent of gender. Between 1960 and 1991. This information suggests that there have been substantial improvements. Evaluation. and Blood Institute (NHLBI) has adminis. DBP of 90 mmHg or greater. † SBP below 140 mmHg and DBP below 90 mmHg. median SBP Data from the National Health and Nutrition for individuals ages 60–74 declined by approxi- Examination Survey (NHANES) have indicated mately 16 mmHg (figure 1). and approximately and coronary heart disease (CHD) have declined 7. and the percent- tion. Arch Intern Med 1997. hypertension. public. and Treatment of High Blood Pressure. Evaluation. Detection. with little variation by sex.3 (HF) (figure 4). and control of high blood pressure. et al.

S. et al. Data from the health examination surveys. and 90th percentile of systolic blood pressure for ages 60–74 years: United States. Evaluation. National Health and Nutrition Examination Survey. Detection. Death rates are age-adjusted to the 2000 U. 1960–1991 % 14 AGES 60 to 74 12 10 8 Median 6 90th percentile 4 2 0 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 mmHg NHES I (1960–62) NHANES I (1971–74) NHANES II (1976–80) NHANES III (1988–91) NHANES. NHES. 2 The Seventh Report of the Joint National Committee on Prevention. median. census population. treatment. Lung. National Center for Health Statistics. Percent decline in age-adjusted mortality rates for stroke by gender and race: United States. National Health Examination Survey Source: Burt VL. awareness. 1970–2000 10 0 -10 P e r c e n t D ec l i n e -20 -30 -40 -50 -60 -70 1970 1975 1980 1985 1990 1995 2000 Ye a r White men Black men White women Black women Source: Prepared by Thom T. Figure 2. and control of hypertension in the adult US population.7(5):1192. Erratum in: Hypertension 1996. and Treatment of High Blood Pressure . Figure 1. Trends in the prevalance. and Blood Institute from Vital Statistics of the United States. 1960 to 1991. Smoothed weighted frequency distribution. National Heart.

Chart 3-36. Lung. and Blood Institute from Vital Statistics of the United States. Lung. Hospital case-fatality rates for congestive heart failure for ages younger than 65 years and 65 years and older: United States. Accessed November 2003.htm. Introduction 3 .nih. 1981–2000 14 I n H o s pi ta l M o rta l i t y ( P e r c e n t ) 12 10 8 6 4 2 0 1980 1985 1990 1995 2000 Ye a r Ages <65 Ages 65+ Source: National Heart.gov/resources/docs/cht-book. http://www. census population. and Blood Diseases. Percent decline in age-adjusted mortality rates for coronary heart disease by gender and race: United States. Lung. Death rates are age-adjusted to the 2000 U. National Heart. Figure 4. and Blood Institute. National Center for Health Statistics.S. Morbidity and Mortality: 2002 Chart Book on Cardiovascular. Figure 3.nhlbi. 1970–2000 10 0 -10 P e r c e n t D ec l i n e -20 -30 -40 -50 -60 -70 1970 1975 1980 1985 1990 1995 2000 Ye a r White men Black men White women Black women Source: Prepared by Thom T.

and Blood Institute. Furthermore. delivery system. Accessed November 2003. http://www. Undiagnosed. census population. and two-thirds of hypertensive only to diabetes as the most common antecedent patients are not being controlled to BP levels for this condition (figure 7). Lung. Prevalence* of congestive heart failure by race and gender. and Treatment of High Blood Pressure . Current control wherein the majority of patients have hyperten- rates for hypertension in the United States are sion prior to developing HF. the untreated. Lung. increasing trend in end-stage renal disease (ESRD) >40 percent of individuals with hypertension are by primary diagnosis. Note: White and Black in 1999–2000 exclude Hispanics. 4 The Seventh Report of the Joint National Committee on Prevention. Source: National Heart. there is an of adults are still unaware of their hypertension. Lung. <140/90 mmHg (table 1).nhlbi. Hypertension is second not on treatment.htm and 1999–2000 unpublished data computed by Wolz M and Thom T. 1971–74 to 1999–2000 3 P e r c e n t o f P o p u l at i o n 2 1 0 WHITE BLACK MALE FEMALE ■ 1971–74 ■ 1976–80 ■ 1988–91 ■ 1991–94 ■ 1999–2000 * Age-adjusted to 2000 U.S. have continued to clearly unacceptable. Evaluation. June 2003. ages 25–74 years: United States. Approximately 30 percent increase (figures 5 and 6). National Heart. and uncontrolled hypertension clearly decline rates in CHD. these improvements have not been the prevalence and hospitalization rates of HF. Detection.and stroke-associated deaths places a substantial strain on the health care have slowed in the past decade.gov/resources/docs/cht-book.nih. Morbidity and Mortality: 2002 Chart Book on Cardiovascular. However. Moreover. and Blood Diseases. In addition. and Blood Institute. extended to the total population. Figure 5.

http://www. Figure 6.nhlbi. 2002. Source: United States Renal Data System. by primary diagnosis (adjusted for age. Hospitalization rates for congestive heart failure. http://www.nih.14. 0 0 0 P o p u l at i o n 200 150 100 50 0 1970 1975 1980 1985 1990 1995 2000 Ye a r Ages 45–64 Ages 65+ Source: National Heart. Trends in incident rates of end-stage renal disease. ages 45–64 years and 65 years and older: United States.usrds.gov/resources/docs/cht-book. Introduction 5 . and Blood Institute. Figure 7. Figure 1. 1971–2000 250 H o s pi ta l i z at i o n s / 1 0 . gender. Accessed November 2003. Lung.htm. and Blood Diseases.htm. Morbidity and Mortality: 2002 Chart Book on Cardiovascular. Chart 3-35. Accessed November 2003. Lung.org/slides. race) 350 R at e pe r M i l l i o n P o p u l at i o n 300 250 150 100 50 0 1992 1994 1996 1998 2000 Ye a r All Diabetes* Hypertension* Glomerulonephritis Cystic kidney * These disease categories were treated as being mutually exclusive.

4 the need for a new. professional. in writing. and the classification scheme used in JNC long-range planning. Thereafter. the com. to the writing and review of the document. and 6 and other NHBPEP clinical guidelines was public education. The practical guide. the NHBPEP Coordinating result in maximum benefit to the public. and program organization. more compre. which contributed Medical Association. In the Evidence). chaired by to generate MEDLINE searches that focused on the director of the NHLBI. 1997. epidemiology. duct this task. and the information warrant changes in medical practice (“patient- is also used to develop program plans for future oriented evidence that matters. has regularly reviewed English-language.” or POEMs). outlined critical issues. the Coordinating Committee is Various systems of grading the evidence were con- divided into four subcommittees: science base. and Treatment of High Blood Pressure . To con. sidered. NHBPEP Coordinating Committee were used to mittee recognizes that the responsible physician’s create the report outline. Based on these critical judgment is paramount in managing his or her issues and concepts. Detection. The selected.12. the Executive committee reviews are summarized and posted Committee focused its deliberations on evidence on the NHLBI Web site. ture from January 1997 through April 2003.6 This ongoing review pertaining to outcomes of importance to patients process keeps the committee apprised of the and with effects of sufficient magnitude to current state of the science. hensive report provides a broader discussion and justification for the recommendations made by the The concepts for the new report identified by the committee. the NHBPEP Coordinating was based on four factors: the publication of Committee chair solicited opinions regarding many new hypertension observational studies and the need to update the JNC 6 report. and an Executive Committee derived from the tions. The initial “Express” version. Coordinating Committee members served on one 2003 issue of the Journal of the American of five JNC 7 writing teams. The entire clinical trials since the last report was published in Coordinating Committee provided. These MeSH terms were used NHBPEP Coordinating Committee. This Committee chair appointed the JNC 7 chair JNC report is presented in two separate publica.7–10 This scheme classifies studies subcommittees work together to review the according to a process adapted from Last and hypertension scientific literature from clinical Abramson (see Scheme Used for Classification of trials.13 activities.4.11 many instances. As with prior JNC reports. the Executive Committee patients. peer-reviewed. Methods The decision to appoint a committee for JNC 7 During fall 2002.5 The current. scientific litera- and discussed studies on hypertension. the updating JNC 6. the principal investigator of the larger studies has presented the information In reviewing the exceptionally large body of directly to the Coordinating Committee. and need to simplify the classification of BP. The research literature on hypertension. and behavioral science. patient. Evaluation. a succinct Coordinating Committee membership. the scientific literature. such as continuing education. and concise a detailed rationale explaining the necessity for guideline that would be useful to clinicians. Patient-oriented outcomes include not only 6 The Seventh Report of the Joint National Committee on Prevention. clear. and a provided concepts to be addressed in the new clear recognition that the JNC reports did not report. was published in the May 21. developed relevant medical subject headings (MeSH) terms and keywords to further review the Since the publication of the JNC 6 report.

During this time. Coordinating Committee. and ability to carry out daily At its meetings. and Committee met on six occasions. CHD. 21. and in print on May Committee members for review and comment. To complete the longer JNC 7 version. such as sexual nications to develop the report. 2003. the Executive The JNC 7 chair synthesized the comments. roles. and renal resolve issues. The NHBPEP Coordinating disease. hence. Committee. the Executive The Coordinating Committee began the process Committee members met via teleconferences and of developing the JNC 7 Express report in in person and circulated sections of the larger December 2002. These outcomes are strongly modified nominal group process14 to identify and affected by nonfatal stroke. HF. ability to maintain family and social drafts were created and reviewed repeatedly. ability to work. 2003.” or DOEs) leaders reviewed and commented on the docu- were used to address questions where POEMs ment.mortality but also other outcomes that affect met by teleconference and used electronic commu- patients’ lives and well-being. approved the JNC 7 Express report. Studies of physiological end. these outcomes were considered Committee reviewed the penultimate draft and along with mortality in the committee’s evidence. Twenty-four function. the Executive Committee used a living activities. It was published in an electronic circulated among the NHBPEP Coordinating format on May 14. The NHBPEP Coordinating Committee were not available. 33 national hypertension points (“disease-oriented evidence. two of which the longer version was submitted to the journal included meetings with the entire NHBPEP Hypertension in November 2003. The writing teams also Methods 7 . provided written comments to the Executive based deliberations. The sections were assem- the Journal of the American Medical Association bled and edited by the JNC 7 chair and were in April 2003. and the report was submitted to document via e-mail. In addition.

and Treatment of High Blood Pressure . Lifetime Risk of Hypertension Hypertension is an increasingly important medical Study investigators recently reported the lifetime and public health issue.15 The impressive increase of BP to hypertensive lev- Whereas the short-term absolute risk for hyper. els with age is also illustrated by data indicating tension is conveyed effectively by incidence rates. et al. Detection.16 Even after adjusting for competing years of age and older are affected. hypertension with increasing age. which is the probability of with BP in the 130–139/85–89 mmHg range and developing hypertension during the remaining 26 percent for those with BP between years of life (either adjusted or unadjusted for 120–129/80–84 mmHg range. Source: Vasan RS. Data for 65-year-old men in the 1952–1975 period is truncated at 15 years since there were few participants in this age category who were followed up beyond this time interval. All rights reserved. that the 4-year rates of progression to hyperten- the long-term risk is best summarized by the life. mortality. American Medical Association. sion are 50 percent for those 65 years and older time risk statistic. 8 The Seventh Report of the Joint National Committee on Prevention. Evaluation. Copyright 2002.1 The age. risk of hypertension to be approximately 90 per- tension increases with advancing age to the point cent for men and women who were nonhyperten- where more than half of people 60–69 years of sive at 55 or 65 years and survived to age 80–85 age and approximately three-fourths of those 70 (figure 8).287:1003–10. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. % 60 60 40 40 20 20 0 0 0 4 8 12 16 20 0 4 8 12 16 20 Ye a r s o f Fo l l o w u p Ye a r s o f Fo l l o w u p 1976–1998 1952–1975 Cumulative incidence of hypertension in 65-year-old women and men. the remaining lifetime risks of hyperten- related rise in SBP is primarily responsible for an sion were 86–90 percent in women and 81–83 increase in both incidence and prevalence of percent in men.17 competing causes of death). Framingham Heart Figure 8. The prevalence of hyper. Residual lifetime risk of hypertension in women and men aged 65 years 100 A WOMEN AGED 65 YEARS 100 B MEN AGED 65 YEARS 80 80 R i s k o f H y pe rt e n s i o n . JAMA 2002.

19 every 20 mmHg systolic or 10 mmHg diastolic increase in BP.B lo o d P r e s s u r e a n d C a r d i o v a s c u l a r R i s k Data from observational studies involving more In addition. Figure 9.18 The increased risks are present in indi. et al. ischemic heart disease Source: Reprinted with permission from Elsevier. (The Lancet 2002:360:1903–13). Lewington S. Ischemic heart disease mortality rate in each decade of age versus usual blood pressure at the start of that decade A SYSTOLIC BLOOD PRESSURE B DIASTOLIC BLOOD PRESSURE 256 256 ( Float i n g A b s o lu t e R i s k a n d 9 5 % C I ) ( Float i n g A b s o lu t e R i s k a n d 9 5 % C I ) 128 128 64 64 32 32 I H D M o rta l i t y I H D M o rta l i t y 16 16 8 8 4 4 2 2 1 1 0 0 120 140 160 180 70 80 90 100 110 Usual Systolic Blood Usual Diastolic Blood Pressure (mmHg) Pressure (mmHg) Age at risk: 80–89 years 70–79 years 60–69 years 50–59 years 40–49 years IHD. For mmHg (figure 11). Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. longitudinal data obtained from the than 1 million individuals have indicated that Framingham Heart Study have indicated that BP death from both IHD and stroke increases pro. Blood Pressure and Cardiovascular Risk 9 . values between 130–139/85–89 mmHg are associ- gressively and linearly from levels as low as 115 ated with a more than twofold increase in relative mmHg SBP and 75 mmHg DBP upward (figures 9 risk from cardiovascular disease (CVD) as com- and 10). there is a doubling of mortality from both IHD and stroke. pared with those with BP levels below 120/80 viduals ranging from 40 to 89 years of age.

Figure 11. and Treatment of High Blood Pressure . (The Lancet 2002. 360:1903–13). Vertical bars indicate 95 percent confidence intervals.734 887 Optimal 1. Impact of high normal blood pressure on the risk of cardiovascular disease Women Men 10 14 12 Cum u l at i ve I n c i d e n c e ( % ) 8 Cum u l at i ve I n c i d e n c e ( % ) 10 6 8 6 4 4 2 2 0 0 0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 14 Time (year) Time (year) Number at Risk Number at Risk Optimal 1. High-normal BP is a systolic pressure of 130–139 mmHg or a diastolic pressure of 85–89 mmHg. Copyright 2001. the higher of the two categories was used.126 1.821 1.039 1.839 1. All rights reserved. Lewington S. 10 The Seventh Report of the Joint National Committee on Prevention. Figure 10.084 1.097 1. Optimal BP is defined here as a systolic pressure of <120 mmHg and a diastolic pressure of <80 mmHg.005 995 973 962 934 892 454 Normal 1. et al.345:1291–7. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. If the systolic and diastolic pressure readings for a subject were in different categories. Evaluation.059 1.115 1. Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade A SYSTOLIC BLOOD PRESSURE B DIASTOLIC BLOOD PRESSURE 256 256 ( Float i n g A b s o lu t e R i s k a n d 9 5 % C I ) ( Float i n g A b s o lu t e R i s k a n d 9 5 % C I ) 128 128 64 64 St r o k e M o rta l i t y St r o k e M o rta l i t y 32 32 16 16 8 8 4 4 2 2 1 1 0 0 120 140 160 180 70 80 90 100 110 Usual Systolic Blood Usual Diastolic Blood Pressure (mmHg) Pressure (mmHg) Age at risk: 80–89 years 70–79 years 60–69 years 50–59 years Source: Reprinted with permission from Elsevier.867 1. Source: Vasan RS. Normal BP is a systolic pressure of 120–129 mmHg or a diastolic pressure of 80–84 mmHg.875 1. Detection.012 982 952 892 520 High normal 891 874 859 840 812 722 520 High normal 903 879 857 819 795 726 441 HIGH NORMAL NORMAL OPTIMAL Cumulative incidence of cardiovascular events in women (panel A) and men (panel B) without hypertension. et al. Impact of high-normal blood pressure on risk of cardiovascular disease.851 1.061 974 649 Normal 1. N Engl J Med 2001. according to blood pressure category at the base-line examination. Massachusetts Medical Society.

289:2560–71. and Treatment of High Blood Pressure.B a s i s f o r R e c l a s s i f i c at i o n o f B lo o d P r e s s u r e Because of the new data on lifetime risk of hyper- tension and the impressive increase in the risk of cardiovascular complications associated with levels of BP previously considered to be normal. JNC. Evaluation. This revision reflects the fact that the approach to the manage- ment of the former two groups is similar (table 2). SBP. Evaluation. Detection. and Treatment of High Blood Pressure. decrease the rate of progression of BP to hypertensive levels with age. Detection. and Treatment of High Blood Pressure. diastolic blood pressure. Arch Intern Med 1997. the JNC 7 report has introduced a new classifica- tion that includes the term “prehypertension” for those with BPs ranging from 120–139 mmHg systolic and/or 80–89 mmHg diastolic. systolic blood pressure Sources: The Sixth Report of the Joint National Committee on Prevention. Detection. Joint National Committee on Prevention.157:2413–46. Evaluation. Another change in classification from JNC 6 is the combining of stage 2 and stage 3 hypertension into a single stage 2 category. The Seventh Report of the Joint National Committee on Prevention. JAMA 2003. or prevent hypertension entirely. Table 2. This new designation is intended to identify those individu- als in whom early intervention by adoption of healthy lifestyles could reduce BP. Changes in blood pressure classification JNC 6 Category JNC 7 Category SBP/DBP Optimal <120/80 Normal Normal 120–129/80–84 Prehypertension Borderline 130–139/85–89 Hypertension >140/90 Hypertension STAGE 1 140–159/90–99 STAGE 1 STAGE 2 160–179/100–109 STAGE 2 STAGE 3 >180/110 DBP. Basis for Reclassification of Blood Pressure 11 .

should either office visits. DBP. Evaluation. diastolic blood pressure 12 The Seventh Report of the Joint National Committee on Prevention.20 The easy and rapid calculation of a Framingham CHD risk score Table 3. who also have diabetes or events is continuous. or both be present. and unambiguously advised to practice lifestyle modification in order to reduce their risk of Cardiovascular Disease Risk developing hypertension in the future (see Lifestyle Modifications). BP readings on each of two or more different treatment recommendations. individuals The relationship between BP and risk of CVD with prehypertension. and modification fails to reduce their BP to 130/80 kidney diseases. JNC 7 suggests that all people with hypertension (stages 1 and 2) be treated. Classification of blood pressure for adults using published tables21 may assist the clinician Blood Pressure SBP DBP and patient in demonstrating the benefits of treat- Classification mmHg mmHg ment. consistent. The goal patients and clinicians are alerted to this risk and for individuals with prehypertension and no encouraged to intervene and prevent or delay the compelling indications is to lower BP to normal disease from developing. The higher the BP. HF. gressive rise in BP using the recommended lifestyle py based on their level of BP and should be firmly modifications (see Lifestyle Modifications). systolic blood pressure. treatment goal for individuals with hypertension it is a designation chosen to identify individuals at and no other compelling conditions is <140/90 high risk of developing hypertension. and independent kidney disease. Detection. Rather. should be considered candidates of other risk factors. Moreover. and prevent the pro- prehypertensive are not candidates for drug thera. The presence of each additional mmHg or less. The classification is based on individuals by the presence or absence of risk the average of two or more properly measured. Stage 1 140–159 or 90–99 Hypertension Stage 2 >160 or >100 Hypertension SBP. stroke. so that both mmHg (see Compelling Indications). Individuals who are levels with lifestyle changes. The Prehypertension is not a disease category. Management of these other risk factors is essential and should follow the established guide- Normal <120 and <80 lines for controlling these coexisting problems Prehypertension 120–139 or 80–89 that contribute to overall cardiovascular risk. and Treatment of High Blood Pressure . factors or target organ damage in order to make seated. the for appropriate drug therapy if a trial of lifestyle greater the chance of heart attack. risk factor compounds the risk from hypertension as illustrated in figure 12. C l a s s i f i c at i o n o f B lo o d P r e s s u r e Table 3 provides a classification of BP for adults This classification does not stratify hypertensive 18 years and older.

left ventricular hypertrophy. SBP. Ten-year risk for coronary heart disease by systolic blood pressure and presence of other risk factors 60 50 1 0 – Ye a r R i s k o f C H D ( % ) 40 30 20 10 0 Cholesterol 180 240 240 240 240 240 HDL 50 50 35 35 35 35 Smoking No No No Yes Yes Yes Diabetes No No No No Yes Yes LVH No No No No No Yes SBP 120 SBP 180 CHD. systolic blood pressure Source: Derived from Anderson KM. high-density lipoprotein. Circulation 1991. Odell PM. coronary heart disease. Figure 12. Wilson PWF. A statement for health professionals. Kannel WB.83:356–62. LVH. An updated coronary risk profile. HDL. Classification of Blood Pressure 13 .

SBP is more important (figure 14). stroke. but SBP control rates were tolic hypertension represents the most common considerably less (60–70 percent).28. Evaluation. tends to largely responsible for the unacceptably low rates level off over the next decade.1. sys. and Treatment of High Blood Pressure .22 cated that three-fourths of them failed to initiate Figure 13. Prevelance of hypertension in the U.25(3):305–13. 1988–1991. The rise in SBP events.26. 1988–1991.27 In the Antihypertensive the same or fall later in life (figure 13).S. and HF BP occur with increasing age.29 Poor SBP form of hypertension. Results from the Third National Health and Nutrition Examination Survey. control is at least in part related to physician atti- diovascular risk factor than SBP until age 50. Hypertension 1995. cal trial data suggest that poor SBP control is which rises until approximately age 50. A survey of primary care physicians indi- thereafter. Data from NHANES III. DBP is a more potent car. Detection. population. Source: Burt VL. adult population. The prevalence of systolic hypertension Points (CONVINCE) Trial. I m p o r ta n c e o f S ys t o l i c B lo o d P r e s s u r e Impressive evidence has accumulated to warrant Clinical trials have demonstrated that control of greater attention to the importance of SBP as a isolated systolic hypertension reduces total mor- major risk factor for CVDs. et al.23–25 Both observational studies and clini- continues throughout life in contrast to DBP. and may remain of overall BP control.15 and Lipid Lowering Treatment to Prevent Heart Diastolic hypertension predominates before age Attack Trial (ALLHAT) and the Controlled Onset 50. cardiovascular mortality. either alone or in combination with SBP eleva. 14 The Seventh Report of the Joint National Committee on Prevention. Verapamil Investigation of Cardiovascular End tion. tudes. Changing patterns of tality. exceeded 90 percent.S. Changes in systolic and diastolic blood pressure with age Men Women 150 150 Systolic Blood Pressure Systolic Blood Pressure 130 130 110 110 mmHg mmHg 80 80 70 70 Diastolic Blood Pressure Diastolic Blood Pressure 0 0 18–29 30–39 40–49 50–59 60–69 70–79 ≥80 18–29 30–39 40–49 50–59 60–69 70–79 ≥80 Age (years) Age (years) NON-HISPANIC BLACK NON-HISPANIC WHITE MEXICAN AMERICAN SBP and DBP by age and race or ethnicity for men and women over 18 years of age in the U. and above 50 years of age. DBP control rates increases with age.

5 25 35 45 55 65 75 Age (years) DBP.008). Circulation 2001.4948 + 0.0 0. as the United States population becomes older. Difference in coronary heart disease prediction between systolic and diastolic blood pressure as a function of age 1. Difference in ß coefficients (from Cox proportional-hazards regression) between SBP and DBP is plotted as a function of age. SBP. Otherwise. and most primary care physicians did not pursue control to <140 mmHg.0 –1.5 ß(SBP)–ß(DBP) 0.0 suggest a greater importance of systolic pressure.0 indicates a stronger effect of DBP on CHD risk. Importance of Systolic Blood Pressure 15 . antihypertensive therapy in older individuals with SBP of 140–159 mmHg. et al.0 –0. systolic blood pressure The strength of the relationship as a function of age is indicated by an increase in the ß coefficient.30.0290 x age (P=0.5 P=0. obtaining this regression line: ß(SBP) – ß(DBP) = 1. Figure 14. diastolic blood pressure. Source: Franklin SS. while levels >0. the toll of uncontrolled SBP will cause increased rates of CVDs and renal diseases. A ß coefficient level <0. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study.31 Most physicians have been taught that the diastolic pressure is more important than SBP and thus treat accordingly.008 –1. Greater emphasis must clearly be placed on managing systolic hypertension.103:1245–9.

75 percent of would result in a 14 percent overall reduction in which comes from processed foods.10. and potassium. Primary prevention of hypertension: Clinical and public health advisory from The National High Blood Pressure Education Program. Systolic blood pressure distributions After Before Intervention Intervention Reduction in BP Reduction in SBP % Reduction in Mortality mmHg Stroke CHD Total 2 -6 -4 -3 3 -8 -5 -4 5 -14 -9 -7 BP. blood pressure.288:1882–8. potential to substantially reduce morbidity and istics is high. is warranted. strategy.34. primary prevention measures prevented.10. A number of important causal factors should be introduced to reduce or minimize these for hypertension have been identified.100 mg per day for men and 5 mmHg reduction of SBP in the population 2.750 mg per day for women. including causal factors in the population. particularly in excess body weight. CHD. and stroke might be levels from rising. treatment strategy. which complements the hypertension ed or diminished. Prevention of Hypertension: P u b l i c H e a lt h C h a l l e n g e s The prevention and management of hypertension Because the lifetime risk of developing hyperten- are major public health challenges for the United sion is very high (figure 8). and excess alco.32 The prevalence of these character. To prevent BP vascular and renal disease. population by even modest amounts has the hol intake. a public health States. systolic blood pressure Source: Whelton PK. coronary heart disease.35 Fewer mortality due to stroke. much of hypertension. JAMA 2002. A population reduced physical activity. and a 7 percent decrease physical activity. For example. At least 122 million Americans are mortality or at least delay the onset of hyperten- overweight or obese. Detection. and Treatment of High Blood Pressure . inadequate intake of approach that decreases the BP level in the general fruits. SBP. cardio. et al. a 9 percent reduction in than 20 percent of Americans engage in regular mortality due to CHD.36 and fewer than 25 percent in all-cause mortality (figure 15). vegetables. If the rise in BP with age could be prevent. excess dietary sodium intake. Evaluation. individuals with prehypertension.37 Figure 15. it has been estimated that a approximately 4.33 Mean sodium intake is sion. 16 The Seventh Report of the Joint National Committee on Prevention.38 consume five or more servings of fruits and veg- etables daily.

but also to commu.48 Healthy People 2010 has identified the communi. lack of exercise programs in tions can promote the prevention of hypertension schools. philanthropic.10 Overcoming the barriers referral programs. lack of availability of religious. lack of reimbursement tions. lack of access to interventional strategies more aptly address the places to engage in physical activity. religious. schools. if Disparities in Cardiovascular Health: The implemented. would reduce BP in the popula.46 NHLBI Healthy People 2010 Gateway. reduce Women About Heart Disease. large amounts of sodium added to foods by providing culturally sensitive educational mes- by the food industry and restaurants. diversity of racial. NHLBI publications and other documents (Facts nities.43 National High Public Health Association and the NHBPEP Blood Pressure Education Month. Hearts N’ Parks.44 The Heart Coordinating Committee that the food industry.42 Your Guide to The recent recommendations by the American Lowering High Blood Pressure. cultural. worksites. ings of food in restaurants. worksites. citizen organizations provide locally focused insufficient attention to health education by orientation to the health needs of diverse popula- health care practitioners.47 Community Programs Cardiovascular Disease Enhanced Dissemination and Utilization Centers [EDUCs] Awardees. Truth: A National Awareness Campaign for including manufacturers and restaurants. and the sages and lifestyle support services and by estab- higher cost of food products that are lower in lishing cardiovascular risk factor screening and sodium and calories. linguistic.49 Healthbeat Radio Network. and social factors in the delivery of healthy food choices in many schools.40 Development Workshop Summary Report. ethnic. and senior Prevention of Hypertension: Public Health Challenges 17 .50 ty as a significant partner and vital point of Salud para su Corazón [For the Health of Your intervention for attaining healthy goals and Heart]51).Barriers to prevention include cultural norms. larger serv. Baltimore City Health Partnership Strategy tion.39. and the food industry.41 Partnerships with community groups such as civic. The probability of success increases as for health education services.45 Mobilizing sodium in the food supply by 50 percent over the African American Communities to Address next decade is the type of approach which. outcomes. Community service organiza- and restaurants. Community-based strategies will require a multipronged approach directed not and programs have been addressed in prior only to high-risk populations. About the DASH Eating Plan. medical services.

For manual determina- tions. and Treatment of High Blood Pressure . concerns those at risk for postural hypotension. or electronic—should two or more Korotkoff sounds is heard (onset of be regularly inspected and validated. necessary drug dose or adding a drug. Detection. those who report symptoms consistent with rate BP determination. Evaluation. For those with higher pressures (e.. and in manometers have created new challenges for accu. 160/86 mmHg should be evaluated or referred to source of care within 1 month). The opera. reduced BP upon standing. evaluate and treat immediately or within 1 week depending on clinical situation and complications. follow recommendations for shorter time followup (e.52 However. C a l i b r at i o n . must cent of the arm) should be used to ensure accura- be appropriately validated and checked regularly cy. the new equipment. exercise.56. the cuff deflation The accurate measurement of BP is the sine qua rate for auscultatory readings should be 2 mmHg non for successful management.53.55 and the average recorded. prior to regarding the accuracy of nonmercury sphygmo. and the disappearance of Korotkoff tor should be trained and regularly retrained in sound (onset of phase 5) is used to define DBP. and arm supported tension is recommended as shown in table 4.4. and smoking Table 4. The equipment— per second. † Modify the scheduling of followup according to reliable information about past BP measurements. with feet on the floor. at heart level. their specific BP numbers and the BP auscultatory method of BP measurement should goal of their treatment.57 The in writing. * If systolic and diastolic categories are different. other cardiovascular risk factors. verbally and be properly prepared and positioned. a n d U s e o f B lo o d P r e s s u r e D e v i c e s The potential of mercury spillage contaminating should be avoided for at least 30 minutes prior to the environment has led to the decreased use or measurement. and the patient must Clinicians should provide to patients. sized cuff (cuff bladder encircling at least 80 per- including all home BP measurement devices. Measurement of BP in the standing elimination of mercury in sphygmomanometers as position is indicated periodically..58 Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam Followup of patients with various stages of hyper- table). M a i n t e n a n c e . the standardized technique. palpated radial pulse obliteration pressure Accurate Blood Pressure Measurement in should be used to estimate SBP—the cuff should the Office then be inflated 20–30 mmHg above this level for the auscultatory determinations. ‡ Provide advice about lifestyle modifications (see Lifestyle Modifications). Caffeine.54 When mercury sphyg. SBP is the point at which the first of whether aneroid.g. At least two measurements should be made for accuracy. phase 1). Recommendations for followup based on initial blood pressure measurements for adults without acute end organ damage Initial Blood Pressure (mmHg)* Followup Recommended† Normal Recheck in 2 years Prehypertension Recheck in 1 year‡ Stage 1 Hypertension Confirm within 2 months‡ Stage 2 Hypertension Evaluate or refer to source of care within 1 month. mercury. >180/110 mmHg). 18 The Seventh Report of the Joint National Committee on Prevention. be used. An appropriately momanometers are replaced.g. especially in well as in thermometers. or target organ disease.

>120/75 mmHg. and the extent of BP fall during sleep.15 office BP. and office and out-of-office BP prior to consideration during sleep. a white-coat ■ Episodic hypertension effect (increase in BP primarily in the medical care ■ Autonomic dysfunction environment) is noted in as many as 20–35 per- cent of patients diagnosed with hypertension.62. and the level returns to baseline vascular events. Calibration. Clinical situations in which ambulatory blood techniques. BP drops by 10–20 percent during Self-measurement or ABPM may be particularly the night. Awake hypertensive individuals practical approach to assess differences between have an average BP of >135/85 mmHg. it was reported about 15 minutes after stopping. the overall BP be avoided. with 24-hour mean BPs <135/85 mmHg. irrespec- ties and sleep. In most people. 24-hour monitoring or drug therapy can of BP readings that are elevated. pressure monitoring may be helpful vides multiple readings during all of a patient’s activities. those in whom such reductions are not helpful in assessing BP in smokers. microphone to measure Korotkoff sounds or a cuff that senses arterial waves using oscillometric Table 5. and who lack evidence of target organ ABPM also provides a measure of the percentage disease. While office BP values have been used ■ Suspected white-coat hypertension in patients with hypertension in the numerous studies that have established the and no target organ damage risks associated with an elevated BP and the bene. The level of BP of ABPM. Twenty-four hour BP monitoring pro. office measurements have ■ Hypotensive symptoms with antihypertensive medication some shortcomings. load. Medicare reimbursement for ABPM is for 3 or more hours during the transition of sleep now provided to assess patients with suspected to wakefulness. es BP acutely. and early morning increases table 5.60 These devices use either a white-coat hypertension. much lower values Indications for the use of ABPM are listed in during rest and sleep. In addition.Ambulatory Blood Pressure Monitoring recently that ABPM patients whose 24-hour BP exceeded 135/85 mmHg were nearly twice as Ambulatory blood pressure monitoring (ABPM) likely to have a cardiovascular event as those provides information about BP during daily activi.63 profile.61 Self-Measurement Ambulatory BP values are usually lower than Self-monitoring of BP at home and work is a clinic readings. Smoking rais- present appear to be at increased risk for cardio.59 BP has a reproducible “circadian” tive of the level of the office BP. and Use of Blood Pressure Devices 19 . ■ Apparent drug resistance (office resistance) fits of lowering BP. Maintenance. For those whose out-of-office BPs are measurement using ABPM correlates better than consistently <130/80 mmHg despite an elevated office measurements with target organ injury. For example. with higher values while awake and men- tally and physically active.

Obesity* (BMI >30 kg/m2) Physical inactivity and other diagnostic procedures. LVH. Estimated GFR <60 mL/min ence or absence of target organ damage and CVD. (2) to reveal identifiable caus- Elevated LDL (or total) cholesterol. points to suggest the need for earlier action. chronic kidney disease. an average resting heart † Increased risk begins at approximately 55 and 65 years of age for men rate of 83 beats per minute was associated with a and women. masses. Angina/prior MI an auscultation for carotid. Pat i e n t E v a l u at i o n Table 6. Framingham Heart Study. HDL.64 Moreover. myocardial infarction als have demonstrated that elevations in resting * Components heart rate and reduced heart-rate variability are of the metabolic syndrome. Adult Treatment Panel III used earlier age cut substantially higher risk of death from a cardio. physical examination. left ventricular hypertrophy. CVD. Data from epidemiological studies and clinical tri. a Heart calculation of body mass index (BMI) (measure. abdominal. low-density lipoprotein. an examination of the optic fundi. or low HDL cholesterol* es of high BP (table 7). high-density lipoprotein. Evaluation. Family history of premature CVD (men <55 years of age or women <65 years of age) Patient evaluation is made through medical histo. GFR. In the obesity also is a component of metabolic syndrome. and Prior coronary revascularization femoral bruits. an Stroke or transient ischemic attack examination of the abdomen for enlarged Dementia kidneys. cardiovascular disease. body mass index. Abdominal associated with higher cardiovascular risk. Detection. a Heart failure Brain thorough examination of the heart and lungs. LDL. distended urinary bladder. Reduced HDL and elevated triglycerides are components of the metabolic syndrome. a palpation of the thyroid gland. Target Organ Damage eral arm. and Retinopathy neurological assessment. 65 years for women)† Diabetes mellitus* treatment (table 6). BMI. a palpation of the Peripheral arterial disease lower extremities for edema and pulses. Microalbuminuria ry. LVH ment of waist circumference is also very useful).65 No clinical trials have prospectively evaluated the impact of reduced heart rate on cardiovascular outcomes. with verification in the contralat. MI. reduced heart-rate variability was also associated with an increase in cardiovascular mortality. and (3) to assess the pres. and CKD abnormal aortic pulsation. respectively. CKD. and Treatment of High Blood Pressure . The physical Tobacco usage. vascular event than the risk associated with lower heart rate levels. 20 The Seventh Report of the Joint National Committee on Prevention. glomerular filtration rate. particularly cigarettes examination should include: an appropriate mea- surement of BP. routine laboratory tests. Cardiovascular risk factors Evaluation of hypertensive patients has three objectives: (1) to assess lifestyle and identify Major Risk Factors other cardiovascular risk factors or concomitant Hypertension* disorders that may affect prognosis and guide Age (older than 55 years for men.

even in the setting of normal GFR. the results hypokalemia). or unprovoked higher cardiovascular risk. including microal- Thyroid or parathyroid disease buminuria. urinalysis. initiating therapy include a 12-lead electrocardio- gram. The Obstructive uropathy optimal tests to determine GFR are debated.. creatinine (or the corresponding high-sensitivity C-reactive protein (HS-CRP). estimated glomerular filtration rate [eGFR]). Results lipoprotein cholesterol (LDL-C). Studies reveal Chronic kidney disease a strong relationship between decreases in GFR Coarctation of the aorta and increases in cardiovascular morbidity and Cushing’s syndrome and other glucocorticoid excess states mortality. that elevated CRP is associated with a higher tory evaluation strongly suggests an identifiable cardiovascular event rate. is also associated with an increase in cardiovascular risk. however. particularly those with CVD but lipoprotein cholesterol (HDL-C). especially in women. a marker of inflammation.67.Table 7.67 Serum creatinine Drug induced or drug related (see table 18) may overestimate glomerular filtration.68 Even small decreases in GFR including chronic steroid therapy increase cardiovascular risk.to 12-hour fast) that includes high-density individuals. (See Identifiable Causes of with this marker are not as robust as those with Hypertension for a more thorough discussion.) high HS-CRP.66 and a lipoprotein profile (after (3) elevated heart rate may be considered in some a 9.74 secondary cause (i.e. but Pheochromocytoma calculating GFR from the recent modifications of Primary aldosteronism and other mineralocorticoid excess states the Cockcroft and Gault equations is useful.69 Renovascular hypertension Sleep apnea The presence of albuminuria. such as those with diabetes or Routine laboratory tests recommended before renal disease. had a higher cardiovascular event made.73 Other studies also have shown is not achieved or the clinical and routine labora. blood glucose and hematocrit. three emerging risk factors (1) serum potassium.70-72 Urinary albumin excretion should be Laboratory Tests and Other Diagnostic Procedures quantitated and monitored on an annual basis in high-risk groups. vascular bruits. who also had an elevated disease where annual measurements should be HS-CRP value. Identifiable causes of hypertension has prognostic implications as well. of an analysis of the Framingham Heart Study Optional tests include measurement of urinary cohort demonstrated that those with a LDL albumin excretion or albumin/creatinine ratio value within the range associated with low (ACR) except for those with diabetes or kidney cardiovascular risk. symptoms Elevations in homocysteine have also been linked of catecholamine excess.75. (2) homocysteine. and and calcium. More extensive testing for identifiable rate as compared to those with low CRP and high causes is not generally indicated unless BP control LDL cholesterol. and triglycerides.76 The presence of decreased GFR or albuminuria Patient Evaluation 21 . Additionally. low-density without other risk-factor abnormalities.

77 Decreased circumstances including: (1) onset of hyperten- pressure in the lower extremities or delayed or sion before age 30. history. or initial labora. and Treatment of High Blood Pressure . or onset of significant hypertension coarctation. computed tomography. ed to identify causes of hypertension. diastolic component is present. identifiable cause. and perspiration. Renal patients with labile hypertension or with parox. Evaluation. lonephritis. (2) BP responds poorly to drug therapy. These can generally be hypertension are shown in table 8. hypertension should be suspected in a number of palpitations. serum PTH CT. and purple striae suggest Cushing’s syn. Examples of clues from the laboratory hypertension. pulmonary edema. urinalysis (renal parenchymal disease). associated with hypertension are chronic glomeru- and (4) onset of hypertension is sudden. when there is a high index of suspicion of an nation. artery stenosis and subsequent renovascular ysms of hypertension accompanied by headache. magnetic resonance angiography Sleep apnea Sleep study with O2 saturation Thyroid/parathyroid disease TSH. (4) hypertension that had been easy tests include unprovoked hypokalemia (primary to control but is now resistant. hypercalcemia (hyperparathy. PTH. For example. drug screening Pheochromocytoma 24-hour urinary metanephrine and normetanephrine Primary aldosteronism and other mineralocorticoid 24-hour urinary aldosterone level or excess states specific measurements of other mineralocorticoids Renovascular hypertension Doppler flow study. distinguished by the clinical setting and additional testing. polycystic kidney disease. Identifiable Causes of Hypertension Additional diagnostic procedures may be indicat. particularly Appropriate investigations should be conducted in patients whose (1) age. glucose intoler. and elevated creatinine or abnormal etiology especially in the absence of proteinuria Table 8. (2) an abdominal bruit especially if a ance.78–81 tory findings suggest such causes. Screening tests for identifiable hypertension Diagnosis Diagnostic Test Chronic kidney disease Estimated GFR Coarctation of the aorta CT angiography Cushing’s syndrome and other glucocorticoid History. pallor. dexamethasone suppression test excess states including chronic steroid therapy Drug induced/related (see table 18) History. parathyroid hormone. Detection. GFR. and truncal obesity. especially in the absence of absent femoral arterial pulses may indicate aortic family history. TSH. and hyper- Screening tests for particular forms of identifiable tensive nephrosclerosis. (6) renal failure of uncertain roidism). severity of hypertension. (3) BP begins to increase The most common parenchymal kidney diseases for uncertain reason after being well controlled. after age 55. thyroid-stimulating hormone 22 The Seventh Report of the Joint National Committee on Prevention. physical exami. glomerular filtration rate. a renal ultrasound is useful Pheochromocytoma should be suspected in in diagnosing polycystic kidney disease. (3) accelerated drome. (5) recurrent flash aldosteronism).

duplex Doppler flow Identifiable Causes of Hypertension 23 . an arteriogram will be performed using limited contrast to confirm In patients with suspected renovascular hyperten. renal failure precipitated by therapy with an While renal artery angiography remains the gold angiotensin converting enzyme inhibitor (ACEI) standard for identifying the anatomy of the renal or angiotensin receptor blocker (ARB) under artery. the stenosis and identify the anatomy of the sion. noninvasive screening tests include the renal artery. and magnetic resonance angiography. ACEI-enhanced renal scan. or moderate to severe volume depletion. and (7) acute studies. At the time of intervention. it is not recommend for diagnosis alone conditions of occult bilateral renal artery stenosis because of the risk associated with the procedure.or an abnormal urine sediment.

24 The Seventh Report of the Joint National Committee on Prevention. either alone or in joint these genetic mutations to BP levels in the general combination.83–85 ticoid excess. Detection. none of these various genetic abnormal- II. however. including mineralocorticoid..g. the syndrome of apparent mineralocor.82 The individual and joint contributions of ities has been shown. and remediable aldosteronism. Genetic portion of hypertension in the general population. beta. and pseudohypoaldosteronism type However. Evaluation.and DA-adrenergic recep- of hypertension. 11beta-hydroxylase genetic linkage studies have focused attention and 17alpha-hydroxylase deficiencies. genes contributing to primary hypertension. abnormalities associated with several rare forms alpha-adducin. and beta-3 subunit of G proteins). are very small. to be responsible for any applicable population. Genetics of Hypertension The investigation of rare genetic disorders association studies have identified polymorphisms affecting BP has led to the identification of genetic in several candidate genes (e. Liddle’s on several genomic sites that may harbor other syndrome. tors. and Treatment of High Blood Pressure . angiotensinogen.

94–96 Everyone who is able should engage in hypertension. organ damage. and decrease cardiovascular risk.99 Lifestyle modifica- Benefits of Lowering Blood Pressure tions reduce BP. no more than 1 oz (30 mL) of ethanol. In the added presence of CVD or target Hypertension is the most common primary diag. averaging 20–25 percent.86 Failure to prescribe body weight.4 g of sodi- morbidity and mortality. averaging >50 percent. though Lifestyle Modifications improved. Since most persons with um). may result in inadequate BP control.5 kg) reduces BP and/or prevents hyper- can be achieved in most patients who are hyper.Tr e at m e n t Blood Pressure Control Rates years will prevent 1 death for every 11 patients treated. vegetables. in women and lighter weight persons. sustained 12 mmHg reduction in SBP over 10 Treatment 25 . antihypertensive therapy has efficacy. Although effective BP control 10 lbs (4. regular aerobic physical activity such as brisk will reach the DBP goal once the SBP goal is walking at least 30 minutes per day most days of achieved. which was originally set as the Adoption of healthy lifestyles by all persons is year 2000 goal and has since been extended to critical for the prevention of high BP and is an 2010 (see table 1). adequate antihypertensive of the Dietary Approaches to Stop Hypertension drug doses. Treating SBP and DBP to tar.94 Combinations of two (or more) (3) HF. a 1.89 12 oz of beer.5 oz of ethanol (one drink) per day with hypertension and diabetes or renal disease.5 Current control rates (SBP <140 mmHg and DBP <90 mmHg).97. example. are still far below the Healthy People goal of 50 percent. For been associated with reductions in (1) stroke inci. (2) myocardial DASH eating plan has BP effects similar to single infarction (MI). the week. and 1.90 It is estimated lifestyle modifications can achieve even better that in patients with stage 1 hypertension (SBP results.92. or appropriate drug combinations (DASH) eating plan94 which is a diet rich in fruits. in some individuals. A drink is the BP goal is <130/80 mmHg.10 Weight loss of as little as than lowering DBP.5 oz of 80- proof liquor (see table 9).600 mg sodium dence. patients should be strongly counseled to additional cardiovascular risk factors.95 Dietary sodium should be reduced to sive therapy is to reduce cardiovascular and renal no more than 100 mmol per day (2. only nine patients would require nosis in America (35 million office visits as the such BP reduction to prevent one death. prevent or delay the incidence of hypertension. achieving a quit smoking. the majority will require two or more sons.98 Alcohol intake should be limited to ing the SBP goal. the equiv- gets that are <140/90 mmHg is associated with a alent of two drinks per day in most men and no decrease in CVD complications.93 BP is also benefited by adoption lifestyle modifications.28. especially those >50 years of age. content. averaging 35–40 percent. tension in a large proportion of overweight per- tensive. It is rich in potassium and calcium The ultimate public health goal of antihyperten. indispensable part of the management of those reducing SBP has been considerably more difficult with hypertension. and lowfat dairy products with a reduced content of dietary cholesterol as well as Goals of Therapy saturated and total fat (modification of whole diet). and drug therapy.91 primary diagnosis).100 For overall cardiovascular risk reduc- 140–159 mmHg and/or DBP 90–99 mmHg) and tion.29. the primary focus should be on attain. although the ideal is to maintain normal antihypertensive drugs.88. In the majority of patients. enhance antihypertensive drug In clinical trials.87 In patients more than 0. 5 oz of wine.

in Several randomized controlled trials have demon- ALLHAT. Lifestyle modifications to prevent and manage hypertension* Modification Recommendation Approximate SBP Reduction (Range)† Weight reduction Maintain normal body weight 5–20 mmHg/10kg92. CHD.104–108 However.107. 8–14 mmHg94. as compared be required. 24 oz beer. ARBs.28.95 vegetables.9 kg/m2). Dietary Approaches to Stop Hypertension. and lowfat dairy products with a reduced content of saturated and total fat. 10 oz wine. there are also excellent clinical trial data proving that lowering BP with other classes of drugs. which was not 26 The Seventh Report of the Joint National Committee on Prevention. in which CVD of the commonly used antihypertensive agents. Table 9. and only 30 percent overall were The European Trial on Systolic Hypertension controlled on one drug.101. stop smoking.93 (body mass index 18. † The effects of implementing these modifications are dose and time dependent. Dietary sodium reduction Reduce dietary sodium intake to no 2–8 mmHg94-96 more than 100 mmol per day (2.109–112 different drug classes. most days of the week). beta blockers (BBs). or 3 oz 80-proof whiskey) per day in most men. with placebo. 60 percent of those whose BP was strated reduction in CVD with BBs.4 g sodium or 6 g sodium chloride).108 more agents. events. SBP..5–24. Evaluation. DASH. and HF have and their usual dose range and frequency of been reduced by BP lowering.113 The Heart Outcomes Prevention Evaluation (HOPE) Study.101–103 For example. thiazide-type diuretics have been the basis A large number of drugs are currently available of antihypertensive therapy in the majority of for reducing BP.28 In hypertensive patients in the Elderly (Syst-EUR) showed significant with lower BP goals or with substantially elevated reductions in stroke and all CVD with the BP. Physical activity Engage in regular aerobic physical 4–9 mmHg97-98 activity such as brisk walking (at least 30 min per day. Moderation of alcohol Limit consumption to no more than 2–4 mmHg99 consumption 2 drinks (e.90. three or more antihypertensive drugs may dihydropyridine CCB. including strokes. administration. Adopt DASH eating plan Consume a diet rich in fruits. and could be greater for some individuals. and Treatment of High Blood Pressure . and to no more than 1 drink per day in women and lighter weight persons. Pharmacologic Treatment Since the first VA Cooperative Trial. but the bene- controlled to <140/90 mmHg received two or fits are less consistent than with diuretics. nitrendipine. and cannot be controlled on one drug and will require calcium channel blockers (CCBs) also reduces the two or more antihypertensive agents selected from complications of hypertension.g. systolic blood pressure * For overall cardiovascular risk reduction.87. published in 1967. Tables 10 and 11 provide a list placebo-controlled outcome trials. More than two-thirds of hypertensive individuals including ACEIs.107.102. Detection.

CCBs in hypertension morbidity trials. ramipril. losartan. Reduction in Hypertension (LIFE) Study. showed nor inferior to the older ones. One exception reductions in a variety of CVD events with the was the Losartan Intervention for Endpoint ACEI. There do Since 1998. CCBs.110 The differences in stroke but not CHD rates) with European Trial on Reduction of Cardiac Events the ARB. ed yet comparing an ARB with a diuretic.restricted to hypertensive individuals but which showed the newer classes were neither superior included a sizable hypertensive subgroup.115–118 Most of these studies recommended in the management of hypertension.5–5 1 Loop diuretics bumetanide (Bumex†) 0. compared with placebo in indi. On the with the “older” diuretics and/or BBs have been basis of other data. HydroDIURIL†) 12.5 1 metolazone (Mykrox) 0. and ARBs. and an ARB.102.114 diuretics and BBs. atenolol.0 1 metolazone (Zaroxolyn) 2.25–2. Table 10. although some specific out- comes may differ between the classes. was added to existent therapy in these trials together suggest broadly similar car- patients with stable coronary disease and without diovascular protection from BP-lowering with HF also demonstrated reduction in CVD events ACEIs.101.5–10 1 Potassium-sparing diuretics amiloride (Midamor†) 5–10 1–2 triamterene (Dyrenium) 50–100 1–2 Aldosterone receptor blockers eplerenone (Inspra) 50–100 1 spironolactone (Aldactone†) 25–50 1 BBs atenolol (Tenormin†) 25–100 1 betaxolol (Kerlone†) 5–20 1 bisoprolol (Zebeta†) 2.5–2 2 furosemide (Lasix†) 20–80 2 torsemide (Demadex†) 2.102 with Perindopril in Stable Coronary Artery There has not been a large outcome trial complet- Disease (EUROPA) study in which the ACEI. including CCBs. All of perindopril. Oral antihypertensive drugs* Class Drug (Trade Name) Usual Dose Range in Usual Daily mg/Day Frequency* Thiazide diuretics chlorothiazide (Diuril) 125–500 1–2 chlorthalidone (generic) 12. between dihydropyridine and nondihydropyridine ACEIs.5–50 1 polythiazide (Renese) 2–4 1 indapamide (Lozol†) 1. as with thiazide-type with ACEIs. short-acting CCBs are not completed.109. several large trials comparing not appear to be systematic outcome differences “newer” classes of agents.5–1. an alpha-1 receptor blocker. than with the BB.5–10 1 metoprolol (Lopressor†) 50–100 1–2 metoprolol extended release (Toprol XL) 50–100 1 nadolol (Corgard†) 40–120 1 propranolol (Inderal†) 40–160 2 propranolol long-acting (Inderal LA†) 60–180 1 timolol (Blocadren†) 20–40 2 BBs with intrinsic sympathomimetic acebutolol (Sectral†) 200–800 2 activity penbutolol (Levatol) 10–40 1 pindolol (generic) 10–40 2 Treatment 27 .112. in which viduals with prior CVD or diabetes mellitus CVD events were 13 percent lower (because of combined with other risk factor(s).5–25 1 hydrochlorothiazide (Microzide.

5–20 1 isradipine (Dynacirc CR) 2. Verelan PM) 120–360 1 CCBs—dihydropyridines amlodipine (Norvasc) 2.1–0.5–80 1–2 ACEIs.5–2 1 Direct vasodilators hydralazine (Apresoline†) 25–100 2 minoxidil (Loniten†) 2. † Available now or becoming available soon in generic preparations.1–0. 180–420 1 Dilacor XR. Trandate†) 200–800 2 ACEIs benazepril (Lotensin†) 10–40 1 captopril (Capoten†) 25–100 2 enalapril (Vasotec†) 5–40 1–2 fosinopril (Monopril) 10–40 1 lisinopril (Prinivil. 28 The Seventh Report of the Joint National Committee on Prevention. Accordingly. BP should be measured just prior to dosing to determine if satisfactory BP control is obtained. 57th ed. Montvale. Source: Physician’s Desk Reference. an increase in dosage or frequency may need to be considered.5–30 1 perindopril (Aceon) 4–8 1 quinapril (Accupril) 10–80 1 ramipril (Altace) 2. Oral antihypertensive drugs* (continued) Class Drug (Trade Name) Usual Dose Range in Usual Daily mg/Day Frequency* Combined alpha.5–20 1 trandolapril (Mavik) 1–4 1 Angiotensin II antagonists candesartan (Atacand) 8–32 1 eprosartan (Teveten) 400–800 1–2 irbesartan (Avapro) 150–300 1 losartan (Cozaar) 25–100 1–2 olmesartan (Benicar) 20–40 1 telmisartan (Micardis) 20–80 1 valsartan (Diovan) 80–320 1–2 CCBs—nondihydropyridines diltiazem extended release (Cardizem CD. Procardia XL) 30–60 1 nisoldipine (Sular) 10–40 1 Alpha-1 blockers doxazosin (Cardura) 1–16 1 prazosin (Minipress†) 2–20 2–3 terazosin (Hytrin) 1–20 1–2 Central alpha-2 agonists and other clonidine (Catapres†) 0. Detection. NJ: Thompson PDR. BBs. Isoptin†) 80–320 2 verapamil long acting (Calan SR. Tiazac†) diltiazem extended release (Cardizem LA) 120–540 1 verapamil immediate release (Calan. beta blockers. the antihypertensive effect may diminish toward the end of the dosing interval (trough effect). Evaluation.1–0.5–10 2 nicardipine sustained release (Cardene SR) 60–120 2 nifedipine long-acting (Adalat CC. Zestril†) 10–40 1 moexipril (Univasc) 7. These dosages may vary from those listed in the Physician’s Desk Reference (57th ed.and BBs carvedilol (Coreg) 12. CCBs. calcium channel blockers * In some patients treated once daily. Table 10. and Treatment of High Blood Pressure .000 2 reserpine (generic) 0. angiotensin converting enzyme inhibitors.8 2 centrally acting drugs clonidine patch (Catapres-TTS) 0.5–50 2 labetalol (Normodyne.). Isoptin SR†) 120–480 1–2 verapamil (Coer. 2003. Covera HS.3 1 wkly methyldopa (Aldomet†) 250–1.25 1 guanfacine (Tenex†) 0.5–10 1 felodipine (Plendil) 2.

Zestoretic Moexipril-hydrochlorothiazide (7. 20/25) Accuretic ARBs and diuretics Candesartan-hydrochlorothiazide (16/12.5. 50/15. Rationale for Recommendation of Thiazide-Type dence was greater with lisinopril than chlorthali- Diuretics as Preferred Initial Agent done therapy. 300/12.5. Combination drugs for hypertension Combination Type* Fixed-Dose Combination.5. 100/25) Lopressor HCT Nadolol-bendroflumethiazide (40/5. and Whites. or the CCB. 20/12.125/25.125/50) Hydropres Diuretic and diuretic Amiloride-hydrochlorothiazide (5/50) Moduretic Spironolactone-hydrochlorothiazide (25/25. the ACEI.5.5. 100/25) Hyzaar Olmesartan medoxomil-hydrochlorothiazide (20/12. 10/6. which compared primary CHD outcome or mortality between the the effects of an ACEI-based regimen against thiazide-type diuretic. diuretics-based therapy in 6. 5/10.5) Atacand HCT Eprosartan-hydrochlorothiazide (600/12.5.25. 160/25) Diovan-HCT BBs and diuretics Atenolol-chlorthalidone (50/25.5. 80/5) Corzide Propranolol LA-hydrochlorothiazide (40/25.5.Table 11.5/25. individuals.000 White hypertensive lisinopril. mg† Trade Name ACEIs and CCBs Amlodipine-benazepril hydrochloride (2. angiotensin converting enzyme inhibitors. 80/25) Inderide LA Timolol-hydrochlorothiazide (10/25) Timolide Centrally acting drug and diuretic Methyldopa-hydrochlorothiazide (250/15. 20/12. 500/50) Aldoril Reserpine-chlorthalidone (0. 32/12.5.5. 80/12. 20/25) Lotensin HCT Captopril-hydrochlorothiazide (25/15. 0. In the Second Australian National sive individuals.125/250. 0. incidence of HF was greater in CCB-treated and ly unsurpassed in preventing the cardiovascular ACEI-treated individuals as compared with those complications of hypertension. 50/25) Capozide Enalapril-hydrochlorothiazide (5/12.25/50) Demi-Regroton.5.5/12.5. 75/50) Dyazide. chlorthalidone. diuretics have been virtual. 20/12.25/500) Diupres Reserpine-hydrochlorothiazide (0. 10/25) Vaseretic Fosinopril-hydrochlorothiazide (10/12. BBs. Maxzide * ACEIs. but these differences were present primarily in African Americans who also had less In trials comparing diuretics with other classes of BP lowering with lisinopril than diuretics.5. angiotensin receptor blockers. amlodipine. Regroton Reserpine-chlorothiazide (0. In the ALLHAT receiving the diuretic in both African Americans study.5) Monopril/HCT Lisinopril-hydrochlorothiazide (10/12.109 there were no differences in the Blood Pressure (ANBP2) Study.125/25.5. which involved more than 40. 50/50) Aldactazide Triamterene-hydrochlorothiazide (37.25) Ziac Metoprolol-hydrochlorothiazide (50/25. 10/20) Lotrel Enalapril-felodipine (5/5) Lexxel Trandolapril-verapamil (2/180. 15/25) Uniretic Quinapril-hydrochlorothiazide (10/12. calcium channel blockers † Some drug combinations are available in multiple fixed doses.5/10.5. Each drug dose is reported in milligrams. 2/240. beta blockers. 160/12. CCBs. 10/12.5. 1/240. Stroke inci. 40/12. 100/25) Tenoretic Bisoprolol-hydrochlorothiazide (2.5) Avalide Losartan-hydrochlorothiazide (50/12.000 hyperten. 40/25) Benicar HCT Telmisartan-hydrochlorothiazide (40/12. 0. ARBs.25. 600/25) Teveten-HCT Irbesartan-hydrochlorothiazide (150/12. 500/30. 5/20. 250/25. 4/240) Tarka ACEIs and diuretics Benazepril-hydrochlorothiazide (5/6. 25/25.5) Micardis-HCT Valsartan-hydrochlorothiazide (80/12. 20/12.25. 5/6. The antihypertensive agents.5.5/6. 20/25) Prinzide. cardiovascular outcomes were less in Treatment 29 .5.

Therapy begins the study. classes proven to reduce cardiovascular events vascular events in the diuretic group than with should be substituted.127 Despite potential mg of chlorthalidone. although as members of Uric acid will increase in many patients receiving a other classes of drugs have become available in diuretic. other studies have “low-dose” diuretics were generally the equivalent not demonstrated increased ventricular ectopy as a of 25–50 mg of hydrochlorothiazide or 12. with the favorable effect apparent ventricular ectopy and possible sudden death. either alone or in difference in the occurrence of sexual dysfunction combination with one of the other classes (ACEIs.1 percent with lisinopril. Trial. the ACEI group.119–122 Thiazide diuretics are less expensive than other antihypertensive drugs. only in men. However. The algorithm for the treatment of hypertensive dence of erection problems through 24 months of patients is shown in figure 16. ACEI treatment. ARBs. and are sion.125 In ALLHAT. their cost has been reduced.109 Thiazide. with laborato- initiated at lower doses and titrated to these doses ry monitoring. use of a specific drug. thiazide-type diuretics should be used as Cooperative study did not document a significant initial therapy for most patients. CCBs) that have also been shown to pertensive medications103 (see section on erectile reduce one or more hypertensive complications in dysfunction). but it was 1.5mmol/L. In the Treatment of Mild Hypertension Patients Study (TOMHS).109 traindicated. diabetes incidence one of these other agents as initial therapy is rec- after 4 years of therapy was 11.124. consideration should induced hypokalemia could contribute to increased be given to initiate therapy with two drugs. thiazide-type diuretics are effective if tolerated. Adverse metabolic effects may occur randomized controlled outcome trials.103. and if BP goal is not months was similar to placebo.123 The VA achieved. either as 30 The Seventh Report of the Joint National Committee on Prevention.128 described an increased degree of sexual dysfunction when thiazide diuretics (particularly at high doses) Achieving Blood Pressure Control in Individual are used. then a drug from one of the other Those who were already diabetic had fewer cardio. If the those differences did not translate to fewer cardio. Despite with dosages ≤50 mg/day of hydrochlorothiazide the various benefits of diuretics. initial drug selected is not tolerated or is con- vascular events for the ACEI or CCB groups. Some reports have underutilized. addition of a second drug from a dif- cholesterol did not increase from baseline in any ferent class should be initiated when use of a single group. the incidence rate at 48 with lifestyle modification.109 The doses of thiazide-type not apparent when serum potassium levels were diuretics used in successful morbidity trials of below 3. a compelling indication is present that requires the ine. the positive benefits of diuretic therapy were ally well tolerated.5–25 result of diuretic therapy. although therapy may be adverse metabolic effects of diuretics. as listed in table 12. Evaluation. absence of a potassium-sparing agent. and 8. participants randomized to chlorthalidone reported a significantly higher inci.8 percent with ommended when a diuretic cannot be used or when chlorthalidone therapy. serum their BP goals.6 percent with amlodip. Trials of longer than 1 year’s duration using modest doses of diuretics generally Since most hypertensive patients will require two have not shown an increase in serum cholesterol in or more antihypertensive medications to achieve diuretic-treated patients.121 In the Systolic Hypertension in the Elderly Program (SHEP) Clinical trial data indicate that diuretics are gener. and Treatment of High Blood Pressure . In ALLHAT. Detection. but the occurrence of gout is uncommon generic form.126 However. however. Selection of with diuretics. 9. they remain or ≤25 mg of chlorthalidone. using diuretics when compared with other antihy.6 mg/dL lower in the CCB agent in adequate doses fails to achieve the goal. BBs. mmHg above diastolic goal. associated with more hypokalemia and other adverse effects.2 mg/dL lower in the ACEI group When BP is >20 mmHg above systolic goal or 10 than in diuretic-treated patients. group and 2. Higher doses have been shown to add and relatively safe for the management of hyperten- little additional antihypertensive efficacy.112 CVD outcome data comparing particularly with high doses of thiazides in the ARB with other agents are limited.

ARB. and may cost less than the individual components pre- The initiation of therapy with more than one drug scribed separately. beta blocker. May consider drugs (diuretics. Consider consultation with hypertension specialist. ARB. diastolic blood pressure. angiotensin receptor blocker.130 combinations is usually below the doses used in Figure 16. SBP.129.separate prescriptions or in fixed-dose combina. CCB. Treatment 31 . BB. BB. calcium channel blocker. DBP. The starting dose of most fixed-dose side effects. The use of multidrug combi. angiotensin converting BLOOD PRESSURE enzyme inhibitor. ACEI. or BB. systolic Optimize dosages or add additional drugs blood pressure until goal blood pressure is achieved. fixed-dose doses of the component agents. of separate prescription of multiple drugs available nations often produce greater BP reduction at lower generically may be less than nongeneric. most (usually thiazide- ACEI. CCB) as needed type diuretic and ACEI. Algorithm for treatment of hypertension LIFESTYLE MODIFICATIONS Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling With Compelling Indications Indications Stage 1 Stage 2 Drug(s) for the Hypertension Hypertension compelling indications (SBP 140–159 (SBP >160 or DBP (see table 12) or DBP 90–99 mmHg) >100 mmHg) Thiazide-type diuretics Two-drug combination for Other antihypertensive for most. resulting in fewer combinations. or ARB. or combination ARB.129 (See figure 16. CCB. Use of generic drugs should be increases the likelihood of achieving BP goal in a considered to reduce prescription costs.) convenient and simplify the treatment regimen. and the cost more timely fashion. The use of fixed-dose combinations may be more tions. or CCB) NOT AT GOAL ACEI. BB.

After BP is at goal and stable. and tobacco avoidance Once antihypertensive drug therapy is initiated. associated diseases with autonomic dysfunction.to 6-month intervals. such as diabetes. and the doses of these agents tension or with complicating comorbid should be titrated upward to achieve the BP goal conditions. Evaluation. per year. followup particularly in some older persons and in those at visits can usually be at 3. not controlled. risk for orthostatic hypotension. Other cardiovas- Followup and Monitoring cular risk factors should be monitored and treated to their respective goals. However. Detection. Low-dose aspirin most patients should return for followup and therapy should be considered only when BP is adjustment of medications at monthly intervals or controlled because of the increased risk of until the BP goal is reached. Serum potassium and creatinine before adding other drugs. such as diabetics Comorbidities such as HF.131 32 The Seventh Report of the Joint National Committee on Prevention. and the need for laboratory tests influence the frequency of visits. caution is should be monitored at least one to two times advised in initiating therapy with multiple agents. and Treatment of High Blood Pressure . More frequent visits hemorrhagic stroke when the hypertension is will be necessary for patients with stage 2 hyper. clinical outcome trials. must be promoted vigorously.

Clinical trial and guideline basis for compelling indications for individual drug classes Compelling Indication* Recommended Drugs Clinical Trial Basis† Aldo ANT Diuretic ACEI ARB CCB BB Heart failure ● ● ● ● ● ACC/AHA Heart Failure Guideline. Carvedilol Prospective Randomized Cumulative Survival Study. BHAT. Reduction of Endpoints in Non-Insulin Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan Study. Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction.101 EUROPA. ValHEFT. INVEST. Special Situations in Hypertension Management 33 .138 ValHEFT.89 Captopril Trial.S p e c i a l S i t u at i o n s i n H y p e r t e n s i o n M a n a g e m e n t Compelling Indications therapy on the natural history of the associated condition (table 12). Studies of Left Ventricular Dysfunction. European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease.135 SOLVD.88. SOLVD. angiotensin converting enzyme inhibitor. Losartan Intervention for Endpoint Reduction in Hypertension Study. angiotensin receptor blocker. AIRE. IHD.145 EPHESUS146 High coronary disease risk ● ● ● ● ALLHAT.112 LIFE.140 CHARM141 Postmyocardial infarction ● ● ● ACC/AHA Post-MI Guideline.142 BHAT. National Kidney Foundation-American Diabetes Association. Randomized Aldactone Evaluation Study. can be direct sequelae of hypertension (HF. EUROPA.137 TRACE. RENAAL. † Conditions for which clinical trials demonstrate the benefit of specific classes of antihypertensive drugs used as part of an antihypertensive regimen to achieve BP goal to test outcomes. Trandolapril Cardiac Evaluation Study.110 ANBP2. UKPDS. calci- um channel blocker. CCB.136 AIRE. ARB. Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity. HOPE. Capricorn. RALES.133 COPERNICUS.151 REIN. Controlled Onset Verapamil Investigation of Cardiovascular End Points. Valsartan Heart Failure Trial * Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines. CONVINCE. ANBP2.109 HOPE. LIFE. Cardiac Insufficiency Bisoprolol Study. American College of Cardiology/American Heart Association. Heart Outcomes Prevention Evaluation Study. Table 12. NKF-ADA. ß- Blocker Heart Attack Trial. African American Study of Kidney Disease and Hypertension. ALLHAT. ACEI.149 RENAAL.134 CIBIS. recurrent stroke) or com- clinical trial data demonstrating benefits of such monly associated with hypertension (diabetes. ACC/AHA.144 Capricorn. EPHESUS. Compelling indications for Hypertension may exist in association with other specific therapy involve high-risk conditions that conditions in which there are compelling indica.148 ALLHAT109 Chronic kidney disease ● ● NKF Guideline.150 IDNT. tions for use of a particular treatment based on chronic kidney disease. REIN. COPERNICUS. Peridopril Protection against Recurrent Stroke Study. SAVE. Ramipril Efficacy in Nephropathy Study. Survival and Ventricular Enlargement Study. Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study. MERIT-HF.89 UKPDS. United Kingdom Prospective Diabetes Study. Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure.143 SAVE.114 INVEST147 Diabetes ● ● ● ● ● NKF-ADA Guideline. TRACE. CIBIS. The International Verapamil-Trandolapril Study.132 MERIT- HF. Aldo ANT. BB.102 CONVINCE. aldosterone antagonist. Irbesartan Diabetic Nephropathy Trial. Acute Infarction Ramipril Efficacy.139 RALES. beta blocker. Second Australian National Blood Pressure Study. PROGRESS. CHARM. IDNT. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. the compelling indication is managed in parallel with the BP.152 AASK153 Recurrent stroke prevention ● ● PROGRESS111 AASK.

In HF lowering. or if BBs are contraindicated. Evaluation. lipid conditions may dictate different strategies. high-degree AV block. The reduced a lack of information for a particular drug class. in part by because of their potential to increase mortality. improve mortality. with symptoms of HF may have preserved systolic Patients with occlusive CAD and/or LVH are put function. exercise training. In the Perindopril Protection against Recurrent or the sick sinus syndrome. peripheral arterial disease. Detection. One caveat particularly in the setting of acute MI. Treatment should also include employing CCBs or ARBs. includ. CCBs decrease total peripher- was added to ACEI background therapy. pharmaco- in such individuals should be directed at both the logic therapy should be initiated with a BB. Different stages of the smoking cessation. and weight reduction in obese patients. mended for reducing the incidence of HF but not in lengthening survival in individuals who already If angina and BP are not controlled by BB therapy have the condition. The absence of a positive indication can signify heart rate. Therapy is nervous systems may be activated in response directed toward preventing MI and death and to the left ventricular dysfunction. accommodate tissue perfusion and metabolic ing MI. in the SHEP study. widespread alone. and reduce cardiac output. as in the use of combination therapy in clinical trials con. A variety of neurohormonal systems. reduce symptoms of angina. greater because of the increased impedance to left nitrates can be added. while myocardial oxygen demand is often is still not controlled on this two-drug regimen. antiplatelet agents. These patients are more likely to have at risk of coronary events if DBP is low.157 caused if BP is aggressively treated. management of diabetes. thiazide-type diuretics are recom. Overall. Unless contraindicated. but such reducing symptoms of angina and the occurrence activation may lead to abnormal ventricular 34 The Seventh Report of the Joint National Committee on Prevention. severe founds interpretation of the effects of single drugs. al resistance. Forty to fifty percent of patients (a J-shaped curve) has been observed with SBP. Furthermore. LVH. long- Myocardial oxygen supply in hypertensive indi. but these should be used ventricular ejection and the frequent presence of with caution in patients taking phosphodiesterase- left ventricular hypertrophy (LVH). management.141. Nondihydropyridine CCBs also can Hypertensive patients are at increased risk for decrease heart rate.142. reducing myocardial oxygen demand. For example. in recurrent stroke. If angina or BP (CAD). many more events are prevented than tion. Therapeutic decisions of ischemia. and isolated diastolic dysfunc- however. Short-acting both SBP and DBP reduces ischemia and prevents dihydropyridine CCBs should not be used CVD events in patients with CAD. high coronary disease risk). presence of severe reactive airways disease. with respect to antihypertensive treatment in patients with CAD is the finding in some studies Heart Failure of an apparent increase in coronary risk at low levels of DBP. acting dihydropyridine CCBs are preferred for viduals may be limited by coronary artery disease combination therapy with BBs. when in combination with a MI or other major coronary events and may be BB however.154 Lowering 5 inhibitors such as sildenafil. The HF syndrome occurs when the heart is lowering DBP to <55 or 60 mmHg was associated incapable of maintaining sufficient flow to with an increase in cardiovascular events. Therefore. CCBs also decrease coronary Ischemic Heart Disease resistance and enhance post-stenotic coronary perfusion. and are more likely to be women. or high degrees of heart block. there is no study oxygen demand. BBs will lower BP. and AV conduction. inotropy and heart rate decrease myocardial For example. either long-acting Stroke Study (PROGRESS).155 No similar increase in coronary events requirements. especially the renin-angiotensin-aldosterone and sympathetic Stable angina and silent ischemia. hypertension. they may cause severe bradycardia at higher risk of death following an acute MI. which leads to reduction in BP and in wall tension. and Treatment of High Blood Pressure .156 compelling indication and BP lowering. recurrent stroke rate dihydropyridine or nondihydropyridine type was reduced only when a thiazide-type diuretic CCBs may be used.

ease progression.to threefold. biventricular pacemak- effective therapy with ACEIs.160 Special Situations in Hypertension Management 35 . among women over the past 50 years. or transplantation. ers. low dose spironolactone (12. but did reduce HF disease. eplerenone reduced mortality by 15 per- guidelines are available to manage HF. be desirable in some HF patients. The inexorable with stage D HF (NYHA class IV) may require progression to more severe stages of left ventricu. treatment should include nists even at low doses (especially since most fastidious risk-factor management to control BP.5 mg/dL and monitor- on mortality in patients at high risk for CVD. usually late stage C (NYHA class prevalent in the future as our population ages. CAD is the cause with all stages of HF (table 12). Stage C HF patients in patients with SBP >85 mmHg. specialized HF disease-management programs and decreased mortality by 34 percent. The true incidence of HF recommended in HF because of clinical studies has been unchanged in men and has declined demonstrating decreased morbidity and mortality. advanced care. BBs. BBs are also in the United States.remodeling. In the Radomized Aldactone Evaluation Study (RALES). In most successful trials.109 In stage B HF (NYHA class but lowering SBP is almost uniformly beneficial. systolic blood pressures ular function (ejection fraction [EF] ≤40 percent) were lowered to the range of 110–130 mmHg. ACEIs incidence can be reduced by limiting therapy to may be appropriate due to their beneficial effects patients with serum Cr <2. HF hospitalization rates have more than doubled in the past 20 years159 because of the Aldosterone antagonists may provide additional improved therapy resulting in increased life benefit in patients with severe left ventricular expectancy. it did not control volume retention.. ARBs may be used. BP targets in HF have not been firmly established. Digoxin continues to be used in HF despite incon- tion. [NYHA] class I). However. there is no reduce mortality in NYHA class II–III patients evidence that diuretics prevent progression of taking ACEIs and diuretics. and diuretics can also increase serum symptoms and hospitalizations.114 ing serum potassium carefully. American Heart Failure Efficacy and Survival Study (EPH- College of Cardiology/American Heart Association ESUS). HF will probably become even more dysfunction. such as inotropic drugs. but its hypercholesterolemia. ACEIs One trial demonstrated benefits of beta blockade and BBs are recommended. In patients intoler- of HF in approximately two-thirds of HF patients ant of ACEIs. lar dysfunction can be significantly reduced by implantable defibrillators. Hypertension HF is a “compelling indication” for the use of is especially important in HF affecting African ACEI.140 with no demonstrable clinical symptoms or left Hyperkalemia is a risk with aldosterone antago- ventricular dysfunction. further left ventricular enlargement.g.134 suggesting (NYHA class II–III) manifest left ventricular dys. and hyperglycemia. approximately 90 percent of patients and increas- es risk for HF by two.132 In the cent in patients following a recent MI with left stage A group (New York Heart Association ventricular ejection fraction (LVEF) ≤40 percent. ACEIs and BBs are again indicated. in otherwise asymptomatic individuals. for those at high risk for HF but 90 percent of whom had HF symptoms. Patients and reduced cardiac contractility. Abundant evidence exists to justify their use American and elderly persons. in addition to the treatment described above for Hypertension precedes the development of HF in stage C patients. creatinine levels when used in excess.158 and improvement in HF symptoms (table 12). that very low BPs (e. when added to standard therapy. mechanical-assist devices. The ALLHAT study also has suggested that thi- azide-diuretic therapy is useful in preventing dis. in these individuals. defined by the presence of reduced left ventric. I).5–25 Optimal therapy for HF may require the use of mg daily).140 Loop diuretics are often necessary to sistent clinical results. However. III–IV).140 In the utilization of a variety of health professionals to Eplerenone Post-Acute Myocardial Infarction reinforce treatment recommendations. and diuretics. SBP <100 mmHg) may function and overt symptoms. In the DIG trial. patients also are taking ACEIs or ARBs). Aldosterone antagonists also may be of value in this situa.110.

180 Therapy with an ACEI also is an important com- Microalbuminuria (30–300 mg/day) is associated ponent of most regimens to control BP in diabetic with increased CVD risk in diabetics and other patients.182. therapy that began with chlorthalidone reduced thy or nephropathy (13 percent).183 age 20 is 14.177.172.164.175. (15 percent). especially stroke.179 ACEIs may be used alone high-risk patients. Of potential concern is the tendency Optimal Treatment (HOT) Trial.88.175.177.67.179 diabetic patients will require two or more drugs The United Kingdom Prospective Diabetes Study to achieve BP control.177.178.180 The question age of the two conditions with all CVD.87. Hypertension amlodipine.164.109.171.173. Randomized the primary endpoint of fatal CHD and MI to controlled trials that have included large diabetic the same degree as therapy based on lisinopril or populations including UKPDS. higher in diabetics.5 mg/dL in mended ACEIs for diabetic patients older than 55 men or >1.183 both hypertensive and normotensive individu- The rate of decline in renal function among als.184 (UKPDS)174 demonstrated that each 10 mmHg decrease in SBP was associated with average Thiazide-type diuretics are beneficial in diabetics. Whatever the goal level. years of age at high risk for CVD.109.88 In the Micro-Hope patients. and BBs for ence of chronic kidney disease (CKD) in diabetic those with known CAD.164 which has also recom- ated with a 70–80 percent chance of premature mended that BP in diabetics be controlled to levels death from CVD and stroke.88.169. antihypertensive drugs. pressure down to approximately 125–130 mmHg betes and impaired fasting glucose in those over SBP and 70–75 mmHg DBP.67 HOPE Study.178. clinical as LVH and microalbuminuria. SBP correlates better than DBP with subanalysis of the HOPE Study.88. and Treatment of High Blood Pressure .161–165 Type 2 diabetes comprises >90 per.178.178. have glycemia.168. In the prespecified diabetic subgroup of ALLHAT.3 mg/dL in women) defines the pres. BBs.164. the progression of diabetic nephropathy to op diabetes within 5 years.181 Overt albuminuria (>300 for BP lowering but are much more effective when mg/day or >200 mg/g creatinine on spot urine) or combined with a thiazide-type diuretic or other renal insufficiency (estimated GFR <60 mL/min.67.177. myocardial infarction (11 percent).182. SHEP. hypertension is disproportionately level of 130/80 mmHg). ACEIs.171 while persons with elevated rigorous control of BP is paramount for reducing BP are two and a half times more likely to devel. Diabetes and Hypertension patients with diabetic nephropathy has been reported to be a continuous function of arterial The combined unadjusted prevalence of total dia. Detection. reductions in rates of diabetes-related mortality either alone or as part of a combined regimen.87. with guidelines from the American Diabetes cent of diabetes in the United States and is associ. but this effect tended to be small and demonstrated that adequate BP control improves did not produce more cardiovascular events CVD outcomes. which included renal disease progression in diabetics.88.109. ESRD. The JNC 7 recommendations are consistent tions. ARBs.185 BP targets are achieved.172. and ALLHAT.165.169 of which class of agent is superior for lowering stroke.186 high-risk diabetic patients treated with 36 The Seventh Report of the Joint National Committee on Prevention. of 130/80 mmHg or lower (although available dance of hypertension and diabetes is increased in data are somewhat sparse to justify the low target the population.171.168.87. and nontraumatic amputa. The ADA has recom- corresponding to serum creatinine >1. for thiazide-type diuretics to worsen hyper- EUR.174–176 progression of renal BP is somewhat moot because the majority of disease. and type 2 diabetics.171 trials with diuretics.166–170 The concor.110. Association (ADA).4 percent and is the leading cause of blindness.164. and calcium antagonists have a demonstrated benefit The coexistence of hypertension in diabetes is in the treatment of hypertension in both type 1 particularly pernicious because of the strong link. and the microvascular complications of retinopa. when aggressive compared to the other drug classes.173 The common ESRD.178 and diabetic retinopathy.110 LIFE.181–183 absence of normal nocturnal “dipping” of BP in diabetics is linked to other CVD surrogates such Regarding the selection of medications. Evaluation. the Syst.175.

as represented by GFR. race. deteriorates with age United States had elevated serum creatinine val- beginning in the third or fourth decade of life. mended both ACEIs and ARBs for use in type 2 diabetic patients with CKD because these agents CKD is defined as either: (1) reduced excretory delay the deterioration in GFR and the worsening function with an eGFR <60 mL/min/1.191 Chronic Kidney Disease Therapy. found that the dihydropyridine nitrendipine was Individuals with eGFR <60 mL/min have an inferior to lisinopril in reducing the incidence approximate 16 percent increase in CVD mortali- of ischemic cardiac events. Special Situations in Hypertension Management 37 . but 200 mg/g creatinine). With respect to transplantation. CVD is the most common Blood Pressure Control in Diabetes (ABCD) Trial cause of death in individuals with CKD.66 The measurements in diabetics. 3 percent of adults (5. and the albumin/creatinine ratio (ACR) deter- They were shown to reduce CVD events in diabet. and CKD in diabetics was stopped prematurely when it was is an independent risk factor for CVD. By ues.73 m2 of albuminuria. Renal excretory func. ACR values >200 mg albumin/g crea- ALLHAT. collections for creatinine clearance. spot urine samples may be used as part of combination therapy to control BP.101.118 In the diabetic cohort of creatinine.109 The Appropriate CVD risk in CKD. and 70 percent of these people had hyperten- the sixth decade. a 350 percent increase. are benefi. NHANES III data indicated that about Age and kidney function.181 (approximately corresponding to a creatinine of >1. mined. To avoid inaccuracies associated with 24-hour CCBs may be useful to diabetics. coexistent renal diseases. and the rate elevated serum creatinine had BPs <130/85 mmHg. especially beta1-selective agents.164. These algorithms can cause adverse effects on glucose homeostasis are available on Web sites. these problems are usually easily managed and are Urinary albumin excretion has diagnostic and not absolute contraindications for BB use.88.190 CVD risk also exhibits a nitrendipine was equivalent to lisinopril in stroke continuous relationship with albuminuria.5 mg/dL in men or >1.187 Although BBs ments for gender. Microalbuminuria is present when the ics compared to placebo in several clinical out.113.ACEI added on to conventional therapy showed a of GFR deterioration can accelerate to 4–8 reduction in combined MI. In a number of laboratories. GFR commonly declines by 1–2 sion. including worsening of insulin appear to be of greater value than 24-hour urine sensitivity and potential masking of the epineph. stroke. only 11 percent with hypertension and function is proportional to BP level. where it was significantly inferior. A BB is serum creatinine is being replaced as an index of indicated in a diabetic with IHD but may be less renal function by eGFR.171. the prevention and in retardation of the development presence of microalbuminuria confers a 50 per- of albuminuria. the values of which are effective in preventing stroke than an ARB as derived from newer algorithms that include adjust- was found in the LIFE study. 30 percent increase. chlorthalidone in all categories except HF.192 While 75 percent of individuals received mL/min per year. and individuals with eGFR <30 mL/min have a normotensive diabetics in the ABCD2 Trial.3 mg/dL in women). particularly urine collections. rine-mediated symptoms of hypoglycemia.188 However. (2) the presence of albuminuria (>300 mg/d or cial to diabetics as part of multidrug therapy.189 cent increase in risk and the presence of macroal- buminuria. and age. their value as monotherapy is less clear. in ty. and CVD mL/min per year if SBP remains uncontrolled. amlodipine was as effective as tinine signify the presence of CKD.6 million people) in the tion. the ADA has recom. prognostic value equivalent to reduced eGFR. or BBs. This age-related loss of renal treatment.87. spot urine ACR is between 30–200 mg albumin/g come trials. especially in those with other microvascular complications.165 death of about 25 percent and a reduction in Such rates of deterioration may lead to the devel- stroke by about 33 percent compared to placebo opment of ESRD and the need for dialysis or plus conventional therapy.

193 No specific agent has been proven to be clearly In the prevention of CKD. diuretic. lower albumin excretion ratio (AER) (<1. perindopril. Given the population distribution of BP. to the ACEI. individuals with dence was 15 percent greater with ACEI than with proteinuria had slower rates of progression to thiazide-type diuretic or dihydropyridine CCB.198 The risk of clinical complications of cerebrovascu- lar disease including ischemic stroke. there were fewer strokes in the losar- those individuals with the greatest degrees of tan-treated group than in the group treated with albuminuria. PROGRESS demonstrated that addition of the and the presence of ACEI therapy. As a result. especially in the first 24 38 The Seventh Report of the Joint National Committee on Prevention. BP is often elevated in the The joint recommendations of the American immediate poststroke period and is thought by Society of Nephrology and the National Kidney some to be a compensatory physiologic response Foundation provide useful guidelines for manage. carefully monitored Patients With Cerebrovascular Disease infusion of sodium nitroprusside should be used to reduce the BP by 10–15 percent.0 g/day). effective in slowing progression of CKD than other antihypertensive regimens. There still are no large clinical studies guidelines indicate that most patients with CKD upon which to base definitive recommendations. They tissue. should receive an ACEI or an ARB in combina. be monitored closely. the BP reduction in the lisinopril group was also A meta-analysis of individuals with CKD and less than with chlorthalidone or amlodipine. Once a incidence of ischemic or hemorrhagic stroke is thrombolytic agent has been initiated.196 Many tensive. and dementia increases as a function of BP in ischemic stroke. it has been common practice recommend a goal BP for all CKD patients of after acute cerebral infarction to reduce or with- <130/80 mmHg and the need for more than one hold BP treatment until the clinical condition has antihypertensive drug to achieve this goal. and Treatment of High Blood Pressure . in the African American Study of Kidney Disease caused a 43 percent reduction in stroke and Hypertension (AASK) study of African occurence. If the DBP is >140 mmHg.109 albuminuria found that positive predictors of outcome were lower SBP levels (110–129 mmHg). the value of vigorous superior to all others for stroke protection. cautious reduc- progression of CKD and CVD risk reduction. logic deterioration related to the lower pressure. Detection. Nevertheless. appeared related to the BP reduction obtained ing a mean BP of 128/78 mmHg experienced by the combination therapy even though many renal deterioration at the same rate as those patients on entry into the study were not hyper- achieving a mean of 141/85 mmHg. tion of BP by about 10–15 percent is suggested. pressures >110 mmHg are contraindications to most ischemic strokes occur in individuals with the use of tissue plasminogen activator (tPA) with- prehypertension or stage 1 hypertension. Evaluation. those achiev. hemorrhagic BP control affects the use of thrombolytic agents stroke. individual decision making is recommended based while carefully monitoring the patient for neuro- on risk stratification. In addition. if with recent ischemic stroke whose SBP is >220 there is a conflict between the goals of slowing mmHg or DBP 120–140 mmHg. The stabilized. indapamide.149–152. In the antihypertensive therapy is most pronounced in LIFE study.196 The management of BP during an acute stroke remains controversial.197 No significant reduction was present studies demonstrate that antihypertensive regi. the stroke inci- Renal Disease (MDRD) Study. SBP >185 mmHg or diastolic levels. The in the first 3 hours of an ischemic stroke.194. and many will require a loop provided the following guidelines: in patients diuretic rather than a thiazide. the American Stroke Association has tion with a diuretic.102 In the ALLHAT study.111 The reduced incidence of stroke Americans with hypertensive CKD. in those on perindopril alone whose BP was only mens that include an ACEI or ARB are more 5/3 mmHg lower than in the control group. to improve cerebral perfusion to ischemic brain ment of hypertensive patients with CKD.195 However. and only 27 percent had BPs <140/90 mmHg. but ESRD if their SBP values were <130 mmHg. BP should reduced substantially by treatment of hypertension. With respect to the prevention of recurrent stroke. In the Modification of Diet and atenolol.

212 groups.109 The interracial differences in BP lowering observed The prevalence.200 Americans and Asians have a three. or syndrome” describes a constellation of cardiovas- ARBs lowers BP to a somewhat lesser degree in cular risk factors related to hypertension. Americans. potassium. occurred in African Americans with hypertensive diovascular risk factors. especially obesity.201.200. in minority groups sive patients but may be particularly effective in the use of combination or multiple antihyperten- minorities. a significant consideration in the choice of indi- ommended for all prehypertensive and hyperten. when medica. Unfortunately. develops at Racial differences in the incidence of antihyper- an earlier age. population.109. and deficits in accurate health-related numbers of Mexican Americans. or Asian/Pacific tions and provider services were provided free of Islanders have not been included in most of the charge. ACEIs.to fourfold Mexican Americans and Native Americans have higher risk of angioedema109.199 than either the thiazide-type diuretic or the CCB. body weight. cardiovascular percent reduction in mortality was observed in reactivity. and 19 percent greater risk of CVD in those random- Minorities ized to the ACEI versus the diuretic. hyper- tension is more common. with these drugs are abolished when they are sion differ across racial and ethnic subgroups of combined with a diuretic. The salt content of some minorities’ sive drug therapy that usually includes a thiazide- traditional diets may be very high. or attitudes.202 The pathogenesis of hypertension in different racial subgroups may Several other benefits of treatment have been differ with respect to the contributions of such demonstrated in minority populations.205 The low. lowering BP prevents sequelae of hypertension in all racial or ethnic groups.200. nephron number. impact. Native Americans. as in the Hypertension Detection and major clinical trials to allow reaching strong con- Follow-up Program.203 nephrosclerosis treated with a regimen containing Much of the variance in hypertension-related an ACEI compared to a BB or a calcium antago- sequelae across racial or ethnic groups may be nist. stress.200.hours after initiation of treatment. access to healthcare services. and control of hyperten. type diuretic will lower BP and reduce the burden sodium DASH eating plan was associated with of hypertension-related CVD and renal disease. A 28 factors as salt. the etiology is multifactorial.000 Blacks.S. In African Americans.208 the U.203 African A greater degree of preservation of renal function Americans have a greater prevalence of other car. actually benefited more than Whites. SBP ≥180 African Americans than Whites. greater reductions in BP in African Americans than in other demographic subgroups.200. The term “metabolic Nonetheless. therapy with intravenous agents to prevent ACEI was less effective in lowering blood pressure intracerebral bleeding. and leads to more clinical sequelae tensive drug side effects may occur. sodium African Americans who received BB therapy after handling. monotherapy with BBs. clusions about their responses to individual anti- ed with the intensive “Stepped-Care Approach” hypertensive therapies. African than in age-matched non-Hispanic Whites.109. African American men treat.206–208 In the mmHg or DBP ≥105 mmHg usually necessitates ALLHAT trial with more than 15. This was associated with a 40 percent greater risk Other Special Situations of stroke. 32 percent greater risk of HF.196 No large outcome studies have been car- attributable to differences in socioeconomic condi.209. more severe. or hormonal systems. but in all sub.211 African Americans.94 In Metabolic Syndrome clinical trials.204 Irrespective of whether race or ethnicity should be Weight reduction and sodium reduction are rec. vidual antihypertensive drugs.203 Definition and associations. other Hispanic information.203 For example.210 and have more lower control rates than non-Hispanic Whites and cough attributed to ACEIs than Caucasians. other minority patients.203. acute MI compared to those not receiving a BB. sufficient beliefs. Special Situations in Hypertension Management 39 . ried out with ARBs in African American and tions.

221 BMI.1% Obese >30 59. Clinical criteria defining the metabolic is related to the metabolic syndrome in both men syndrome in Adult Treatment Panel III and women (table 14). JAMA 2001. and obese men and women in the National Health and Nutrition Examination Survey III Metabolic Syndrome Prevalence. This becomes important in overweight individuals with a BMI of 25–29. ■ Fasting glucose: >110 mg/dL or 6.222 In addition. Evaluation.0% BMI.215 heightened magnitude Treatment Panel [ATP] III) guidelines in 200121 is of oxidative stress.216.4% 28.6% 50.220 bolic syndrome. body mass index Source: Park YW. The health prob- ■ HDL-cholesterol: lems related to the metabolic syndrome will likely <40 mg/dL (1. kg/m2 Table 13. high-density lipoprotein Source: Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection. including hyperinsulinemia.2% Overweight 25. et al. overweight.04 mmol/L) in men escalate dramatically. 40 The Seventh Report of the Joint National Committee on Prevention. The metabolic syndrome: Prevalance and associated risk factor findings in the US popula- tion from The Third National Health and Nutrition Examination Survey. kg/m2 Men Women Normal weight <25.9 kg/m2 and ■ Blood pressure: >130 mmHg systolic and/or large waist circumference (>40 inches in men. Table 14.7 percent or about 47 million individuals. The World Health Organization activation of the renin-angiotensin-aldosterone has a somewhat different definition of the meta. abnormalities in autonomic regulation.214 resistance. Detection.0–29. axis. <50 mg/dL (1.218 the presence of three or more of the five risk fac. abdominal obesity. 1988–1994. Prevalence Several other associated features have been report.217 microalbuminuria. and Treatment of High Blood Pressure . ATP III uses it rather than >88 cm (>35 inches) for women BMI.29 mmol/L) in women HDL. dyslipidemia. Percent Category BMI. JNC 7 has adopted the ATP III definition. primarily because >150 mg/dL or 1.213 prevalence of the metabolic syndrome in adults The metabolic syndrome has also been associated in the United States was estimated at 23.6% 6. from the NHANES III survey (1988–1994).219 and tors (table 13). >85 mmHg diastolic >35 inches in women) who may have metabolic syndrome despite not being obese. Evaluation.0 4.285:2486–97. because ■ Waist circumference: abdominal obesity is also correlated with the >102 cm (>40 inches) for men metabolic syndrome. the and higher density of LDL-cholesterol particles.1 mmol/L The metabolic syndrome will likely increase ■ Triglycerides: further in the next several years. insulin resistance.69 mmol/L of the rapid increase in obesity. The definition adopted by the reduced fibrinolysis (including elevated plasmino- National Cholesterol Education Program (Adult gen activator inhibitor-1). but for consistency. and insulin with high levels of inflammatory risk markers.9 22. and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Estimated prevalence of the metabolic syndrome using the Adult Treatment Panel III definition among normal weight.163:427–36. When the ATP III criteria were applied to the data ed. Arch Intern Med 2003.

21 percent or more among Americans over age 60. impaired fasting glucose and diabetes. Lifestyle at nearly double the rate in ethnic minorities modification is the cornerstone of management compared to Caucasians. fold increased risk of developing diabetes.223 The metabolic syndrome is associated Lipids with increased CHD risk in women. 1999–2000. (figure 16). individuals.5 percent. Evaluation.230 cholesterol. with no Physical activity. culturally diverse. but if BP exceeds 140/90 United States is another factor that will lead mmHg. Elevated triglycerides and reduced HDL are typical lipid abnormalities in metabolic syn- The prevalence of the metabolic syndrome is drome. and family history of CHD. Elevated LDL is not a prime feature of highly age dependent. All patients with lipid abnormalities for LDL. Obese subjects. even after adjustment for age. Native Americans.231 (See Prevention and Lifestyle Modification for Overweight and Obesity. adults using key principles in the Clinical Guidelines on increased from 22. Special Situations in Hypertension Management 41 .227 kg/m2) increased from 55.224 Patients with the metabolic syndrome have a five. obesity (BMI ≥30 kg/m2) among U. A prevalence of 7 percent metabolic syndrome but is important in clinical among adults 20–29 years of age rises to 40 management. the age-adjusted prevalence of and obesity is summarized in the next section. pharmacological therapy is indicated as to a rise in the prevalence of obesity and its described in the hypertension treatment algorithm complications unless effective. Using the NHANES databases for the periods 1988–1994 Overweight and obesity.S.to nine. The metabolic syndrome can other risk factors.226 HDL.225. Prevalence and epidemiology.) Obesity occurs more often among Hispanics. Treatment of overweight vs.229 Management guidelines published and a twofold greater risk of CVD and all-cause by the ADA are appropriate for individuals with mortality. and African Americans than Prehypertension and hypertension.233 The rapid increase in all patients with prehypertension or with the in the population of ethnic minorities in the metabolic syndrome.5 per- cent. These demo- majority of individuals with the metabolic graphic differences extend to children. Impaired glucose tolerance and diabetes. and Treatment of while the prevalence of overweight (BMI ≥25 Overweight and Obesity in Adults. or triglycerides should be treated according to the ATP III recommendations.33 the Identification. have increased relative risk for improve with increased physical activity.232.9 percent to 30. smoking.9 percent to 64. Modest Clinical Impact lifestyle change including healthful nutrition and increased physical activity can reduce the develop- The metabolic syndrome is associated in men ment of diabetes by nearly 60 percent in high-risk with a fourfold increase in risk for fatal CHD. The vast Caucasians in the United States. where syndrome will fall into the categories of obesity and related health problems are increasing prehypertension or stage 1 hypertension.Age Trends Lipids. population-based health promotion strategies are encouraged. especially men.228 CVD (table 15).21 Clinical Management of the Metabolic Syndrome Overweight and Obesity The cornerstone for clinical management in adults is appropriate lifestyle changes. LDL.

and Treatment of Overweight and Obesity in Adults—The Evidence Report. prehypertensive individuals.3 30. or spending time online.0 1. success. Arch Intern Med 2001.0–24. Obes Res 1998. and Treatment of High Blood Pressure .239 risk factors. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. of the week (see table 9). hypertension. and stroke over the next decade among men initially free of disease stratified by baseline body mass index BMI Diabetes Hypertension Heart Disease CVA 18. 60–90 minutes per week of television or being online. increase in physical activity. the related rate of weight gain. biking. Evaluation. including decrease in sedentary activi.9 5.2 3. basketball.5–21.1 1. body mass index. predictor of benefit was walking time.4 2. Prevention and lifestyle modifications for over.236 The CVD benefits of slow walking rate. et al. Based on the available evidence. and reduce LDL. In addition. and the presence of physical activity and poorer aerobic fitness of coexisting heart disease. diabetes. and increasing time walking can reduce CHD mortality by about 50 spent walking or in activities that raise the heart percent. Evaluation.4 1.234 bic fitness may negate much of the cardiovascular risk associated with obesity. For example. BP. and other than leaner individuals. vascular risk of about 40 percent. Lifestyle changes beneficial in heart healthy foods that can be used to promote reducing weight* weight loss. National Institutes of Health.2 2. weight and obesity.237 Although aero- obese subjects. Physical activity is a key feature of treatment. The benefits of modest lifestyle changes on cardio.6(suppl)2:51S–209S. CVA. This challenging task recommendation is to engage in regular physical will require a complex combination of healthy activity at least 30 minutes per day. In the tennis.1 >35. ■ Reduce portion sizes or frequency of consumption of calorie- greater was associated with reductions in cardio- containing beverages. Simple yet practical loss and is important for overall reduction in suggestions include reducing time spent watching cardiovascular risk.9 18.238 studies report that Specific nutrient intakes for individuals should be individuals who are obese have much lower levels based on lipoprotein levels.0 1. most days behaviors. is essential to weight loss overweight and obesity is to reduce the age. Relative 10-year risk for diabetes.2 4. physical ties. reduce BP in both hypertensive and ■ Decrease time in sedentary behaviors such as watching television. ■ Increase physical activity such as walking.0–34. Increased physical activity.2 2.8 1. suggesting that the most important intake and a regular pattern of physical activity. 42 The Seventh Report of the Joint National Committee on Prevention. playing video games. Detection.5 BMI. weight loss of 5 lbs or ■ Decrease portion sizes for meals and snacks.227 Identification.8 2. The major goal of manage.0–29. Table 15. and are associated with overall reductions in CVD High-sodium diets may be especially deleterious in outcomes by about 50 percent. adoption of the well- studied low sodium DASH eating plan94 provides Table 16. aerobic dancing.7 1. soccer. not speed.0 1.161:1581–6.235 A 10 percent reduction in body weight can reduce disease risk * For more detailed information refer to the Clinical Guidelines on the factors.9 1. cerebrovascular accident Source: Field AE.6 2. Framingham Heart Study.9 1.0 22.0 41. vascular risk factors are well documented. etc. Reducing food portion sizes and limiting fat Exercise programs appear beneficial at any age intake can assist in reducing overall calorie intake. heart disease. The emphasis for weight management appear to be comparable to those of walking should be on avoidance of excess total energy more quickly. and reduction activity is critical to the maintenance of weight in calorie intake (table 16). when combined with ment of both the metabolic syndrome and a reduction in calories.1 25.5 1.

caused by the creation of a “steal” phenomenon where blood flow increases in nondiseased vascu- Therapy.Left Ventricular Hypertrophy reduction during treatment were higher pretreat- ment left ventricular mass. and direct vasodilators do not improve high false-positive rate in African Americans and walking distance or symptoms of claudication. and intermediate benefits occurred for subclasses can be characterized generally by the diuretics and calcium antagonists. Several studies suggest that LVH regres.246 The LIFE large end-diastolic volumes. the least reduction occurred with a different prognosis and therapy. CCBs. each achieved with ACEIs. was myofibrils (eccentric hypertrophy). and smoking. and longer duration of treatment. untreated or poorly treated individuals. left ventricular mass reduction. more intensive screening for these becomes a major risk factor for dilated cardiomy. and BP lowering with the occluded areas by BP reduction. 30–50 percent of indi. CAD.243 The attributable risk of LVH for all. or (3) sion is associated with a lower overall CVD risk. LVH Therefore. viduals with stages 1 and 2 hypertension have Symptomatic PAD is associated with a greatly impaired left ventricular relaxation.244 In these effect on walking distance or calf blood flow in studies. LVH can occur in endurance athletes diuretic therapy achieved the greatest benefit in with normal or supranormal systolic function. salt restriction. detection of LVH although ECG-LVH is a highly specific indicator for the condition. and renovascular have abnormal left ventricular relaxation. and elongation of study found that LVH. defined by ECG. alpha-adrenergic Current ECG algorithms defining LVH produce a blockers. claudication in individuals with PAD. Fifty studies of LVH regression conducted before recent studies have shown that BBs have little 1996 were subjected to meta-analysis.102 hypertrophy of myofibrils. and in more increased risk of death from CVD.242. and the end-diastolic and the VA Cooperative Monotherapy trial.241 persons with PAD. are more than twice as likely to suffer relieving the symptoms of PAD. In Major risk factors for peripheral arterial disease population-based samples. in relative wall thickness. of maximally dilated diseased vessels to dilate fur- cause mortality is greater than that of single or ther during exercise. chamber size. increased relative wall thickness. greater fall in SBP or The common feature of all forms of LVH is DBP. LVH due reduced significantly more by a losartan-based to hypertension is usually characterized by than atenolol-based regimen despite equivalent “concentric” hypertrophy with circumferential BP lowering. predictors of left ventricular mass patients with intermittent claudication. This lack of efficacy may be due to: (1) inability tion. and at times. The most increased left ventricular mass. but certain trends have emerged. normal or increased contractility. However. and vasodilator premature cardiovascular events or death. (2) redistribution of flow multivessel coronary artery disease or low EF. although there are consistent reduction in left ventricular mass was many different presentations and subtypes. Renovascular hypertension should be strongly considered in this population if Detection and risk. (PAD) are hypertension. impaired relaxation (“diastolic dysfunction”). cause peripheral vasoconstriction and have the sion. the presence or absence both the Treatment of Mild Hypertension study of reduced contractility. BBs may most antihypertensive agents produce LVH regres.250 Thus. In disease frequently coexist in these patients. diabetes. alteration of pressure-flow relationships distal to Weight loss. agents such as ACEIs. Peripheral Arterial Disease mal or low end-diastolic volumes. lar beds at the expense of diseased beds. about two-thirds diffuse atherosclerosis. Echocardiography is much BP is uncontrolled and if ACEI or ARB treatment more sensitive than electrocardiography (ECG) for is being considered. Selection of individual drugs appears to be potential to increase the frequency of intermittent less important. nor.240 LVH with BBs.247–249 overestimate the prevalence of LVH in this popula. in part because severe forms of hypertension. However. related cardiovascular disorders is appropriate in opathy and HF. Individuals Antihypertensive drug treatment is ineffective in with LVH. Special Situations in Hypertension Management 43 .245.

the basis of the presence or absence of compelling ■ Prevent or control diabetes. Source: Franklin SS. ■ Stop smoking.254 Smoking cessation may be the continue to rise. Lipid abnormalities should the proportion of hypertensives with isolated SBP be controlled using lifestyle modification or drugs elevation (ISH) (figure 17).37:869–74. CCBs can be used. BBs can be used in PAD patients. Treating hypertension in PAD patients Hypertension in Older People reduces the risk of MI. by age 75. If Raynaud’s phenomenon is present. DBP as appropriate. Analysis based on National Health and Nutrition Examination Survey (NHANES III). clopidogrel. Detection. Patients should be encouraged and assist. stroke. Coexisting glucose intolerance or increases in parallel with SBP until about age 55. By diabetes is indicated. ■ ISH (SBP >140 mmHg and DBP <90 mmHg).2 million to 32. Hypertension 2001. heart failure. indications. antihypertensive drug choices should be made on ■ Control lipids (goal: low-density lipoprotein <100 mg/dL). about two-thirds of those with hyperten- therapies of PAD. strated for any individual class of antihypertensive ■ Engage in structured exercise program. Therapy. sion have ISH. ■ Achieve goal blood pressure. Frequency distribution of untreated hypertensive individuals by age and hypertension subtype 17% 16% 16% 20% 20% 11% 100% Fr eq u e n c y o f H y pe rt e n s i o n S u b t y pe s i n a l l U n t r e at e d S u b j ec ts ( % ) 80% 60% 40% 20% 0% < 40 40–49 50–59 60–69 70–79 80+ AGE ( YEARS) Frequency distribution of untreated hypertensive individuals by age and hypertension subtype. Predominance of isolated systolic hypertension among middle-aged and elderly US hyperten- sives. No selective outcome benefit has been demon. 44 The Seventh Report of the Joint National Committee on Prevention.251 LDL lowering will reduce ■ Consider use of Cilostazol for symptoms of claudication if exercise the risk for CVD events in people with PAD. and Treatment of High Blood Pressure . Evaluation. Medical therapies of peripheral arterial disease needed for treatment of CAD or HF.109 Therefore. insulin resistance calls for increased exercise and after which it declines as a manifestation of age- weight reduction. Numbers at the tops of bars represent the overall percentage distribution of untreated hypertension in that age group. or both). medication in patients with PAD. and death. Table 17 outlines medical age 60.192 In contrast. et al. and aggressive management of related increases in central arterial stiffness.255 SBP increases almost linearly single most important factor whether PAD pro.252 alone is ineffective.6 walking distance in patients with intermittent million from 1980 to 2000 and is expected to claudication.253 A structured walking program has been The number of Americans 65 years of age or shown to increase the pain-free and maximum older has increased from 24. ■ SDH (SBP >140 mmHg and DBP >90 mmHg). ■ IDH (SBP <140 mmHg and DBP >90 mmHg). almost all hypertensive Figure 17. does the overall prevalence of hypertension and ed to stop smoking. ■ Administer antiplatelet therapy (aspirin. ■ Achieve ideal body weight. with age in industrialized societies (figure 12) as gresses. especially if Table 17.

192 Pulse pressure (PP) (SBP–DBP) is point of stroke (36 percent). PP generally decreases as a result of SBP the Syst-EUR study compared a regimen based lowering. stiff.16 thickened. there remains a lifetime risk of to relative inability of the BP cuff to compress a developing hypertension that exceeds 90 percent.258 Benefits of therapy not be withheld in these patients. and about 40 percent of those on the low-salt diet Special Situations in Hypertension Management 45 . classified the BP stage in 94 percent of adults over individuals treated with chlorthalidone (with or the age of 60.individuals have systolic hypertension and about often due to stiff large arteries and age-related three-fourths have ISH. Weight loss and reduced sodium intake are particularly beneficial in older people.18 group. reduction in stroke (41 percent) as well as overall on balance. smokers. strokes (30 percent). and overall CVD cation in individuals over age 60.S. MI (27 percent). most commonly due to tolic <140 mmHg and diastolic <90 mmHg) are renovascular disease. Using a similar design and sample size. which is seen most often in only about 20 percent in older hypertensive indi. But this increase in CVD risk in older compared to younger condition should be strongly considered if usual individuals. BP control rates (sys. Exaggerated BP drops may occur in the elderly during postural Individuals over age 60 represent the most rapidly change (see next section). form of hypertension. and therapy have been demonstrated even in individuals over should not be withheld on the basis of age.116. or calcified brachial artery is an At the same time. has conclusively proven the benefits of treatment vascular deaths (18 percent).256 Currently. largely due to poor control of SBP. reducing sodium to 80 mmol (see Accurate Blood Pressure Measurement in the (2 grams) per day reduced BP over 30 months. but under age (32 percent)24 as compared with the placebo 60. These facts prompted the NHBPEP to treatment does not reduce BP.257 SBP provides more appropriate classification and Treatment benefits.97 Pseudohypertension. after meals.24. In the SHEP study involving risk stratification than DBP in the elderly. patients followed for 4 years found that active antihypertensive treatment reduced coronary Although no randomized prospective clinical trial events (23 percent). and even exercise. Accurate and representative BP measurement can In the Trial of Nonpharmacologic Interventions in pose special problems in some older individuals the Elderly (TONE). as well as HF events only marginally stronger than SBP for risk stratifi- (54 percent).693 elderly ment in older persons.261 A relatively small the diagnosis and management of older people with percentage of elderly patients have a reversible hypertension. especially in those issue a clinical advisory statement in May 2000 patients who complain of symptoms consistent stating that SBP should be the primary target for with postural hypotension. there is a three. SBP is superior to PP and DBP as a CVD events (31 percent). PP is not useful as a CVD risk predictor. Thus.263 but no prospective clinical trial has on nitrendipine to placebo and found a significant used PP as the primary clinical endpoint. while DBP alone correctly classified without BB) had reductions in the primary end. BP is more variable in older patients.113 A meta-analysis of way to stratify patients and as a target for treat- eight placebo-controlled trials in 15. 66 percent. Office). decreases in baroreflex buffering.155 less important than the degree of BP reduction achieved.259 Analyses of treatment trials is no definitive evidence of an increase in risk of in the elderly by the Hypertension Trialists group aggressive treatment (a J-curve) unless DBP is have suggested that the choice of initial agent is lowered to <55 or 60 mmHg by treatment. hypertension therapy should those older than 70 years.262 viduals.to fourfold uncommon condition in older persons. SBP alone correctly pretreatment SBP >160 and DBP <90 mmHg. There 80 years of age. where cuff BP in those who remain normotensive between 55 and overestimates the actual intra-arterial pressure due 65 years of age. population.90 Treatment. cardio. and total deaths in individuals with stage 1 systolic hypertension (13 percent). with the benefit particularly great in (140–159 mmHg). In the hypertensive individuals over age 60 with Framingham Heart Study.260 and after growing segment of the U.

This can be documented by home BP or ambulatory BP readings (see prior BP measurements are typically recorded in the sections). and certain venodilator anti. while convenient for the practitioner. full doses of an appropriate three-drug regimen that includes a diuretic. or “white-coat” hypertension may also lead to transient high readings that are not experienced Orthostatic Hypotension throughout the day. and carried with it a 64 percent result of reluctance on the part of the patient or increase in age-adjusted mortality compared with practitioner to use effective medication doses. Use of specific drug classes in older people is drug therapy should be adjusted accordingly and largely similar to that recommended in the general appropriate warnings given to patients. if the systolic goal is Resistant hypertension is defined as the failure to achieved. auto. OH is present diuretics. difficult to detect unless the patient is asked open- nomic insufficiency. baroreflex dysfunction. Combination therapy with two or more Resistant Hypertension drugs is generally needed to achieve optimal BP control. a control population. if present. and Treatment of High Blood Pressure . once recog- small increase in DBP and a small decrease in SBP nized.265-267 The causes of OH include severe Drug interactions that induce resistance may be volume depletion. widely variable BP with exaggerated high and low extremes. algorithm and for individual compelling indica- tions. Evaluation. dizziness. In routine practice. a loop diuretic is often required for patients who There is more OH in diabetic individuals. limits the ability to diagnose Inadequate diuretic therapy is common in resis- OH. the diastolic goal will almost always be achieve goal BP in patients who are adhering to reached as well. sitting position. the readings may also be observed in those whose misperception that many elderly have “brittle brachial arteries are heavily calcified or arterio- hypertension” has contributed to widespread inade. OH is a common barrier to intensive BP con- trol that should be clearly documented. and supplements 46 The Seventh Report of the Joint National Committee on Prevention. occurred in about 7 percent of men over 70 years of age in the Honolulu Heart Study. 50. seen. Such individuals deserve consideration for Improper BP measurement can lead to overestima- a slow titration approach as do individuals with a tion of intra-arterial pressure (see Accurate Blood history of medication side effects and those with Pressure Measurement in the Office). While a thiazide-type diuretic is recom- when there is a supine-to-standing BP decrease mended for the majority of hypertensive patients. Several causes of resis- A significant number of elderly individuals have tant hypertension may be present. >20 mmHg systolic or >10 mmHg diastolic. death as well as increased incidents of falls and fractures.268 Clinic quacy of drug titration and to poor BP control. standing is accompanied by a tant hypertension. were able to discontinue their antihypertensive In treating older hypertensive patients. Unfortunately. Causes and approaches to nonadherence are dis- tion between the severity of OH and premature cussed in subsequent sections. Internet-purchased medications. or even fainting. Diuretics and nitrates may health-food preparations.264 When weight loss was combined should be alert to potential OH symptoms such as with salt reduction. was highly Failure to receive adequate medications can be the age-dependent. Falsely high orthostatic hypotension (OH). Volume overload. over-the-counter and further aggravate OH. clinicians medications. an additional BP decrease was postural unsteadiness. ended questions regarding what they take when hypertensive drugs. especially alpha blockers and experiencing pain and what food supplements.265 There is a strong correla. Older persons should also be encouraged to Lying and standing BPs should be obtained peri- avoid excessive alcohol intake and to remain as odically in all hypertensive individuals over age physically active as is feasible. This practice. OH have a decreased GFR or HF. alpha-beta blockers. can be managed by use of appropriate when compared to supine values. Normally. Detection. sclerotic and cannot be fully compressed.

tribute to hypoperfusion. then a concerted search for a cause of Narrowing and sclerosis of small penetrating secondary hypertension should be conducted arteries in the subcortical regions of the brain are (table 7). and extracellular fluid accumulation than in age-matched controls. or ■ Nonadherence ■ Inadequate doses executive function. nasal vasodilators. ventricular enlarge- ment. They usually can be identified by microinfarction. once established.288 In the SystEUR trial. Magnetic appropriate evaluation.275. existing ■ Oral contraceptive hormones white matter changes. CCB therapy was superior to placebo in slowing the decline Associated conditions in cognitive function.287–289 ■ Inappropriate combinations ■ Nonsteroidal anti-inflammatory drugs.269. loss of autoregulation. and once identified. in table 18.276.271–274 These changes are believed to con- step. do not ■ Adrenal steroid hormones appear to be reversible. Reduced prescribed medications. consultation common findings on autopsy in chronic hyperten- with a hypertension specialist is the next logical sion. other illicit drugs reduces the risk of developing significant white ■ Sympathomimetics (decongestants. The preva. and ulti- Specific causes of resistant hypertension are listed mately to subcortical white matter demyelination. cyclooxygenase 2 inhibitors Effective antihypertensive therapy strongly ■ Cocaine.278.291. ma huang.270 corrected. can resonance imaging (MRI) studies in persons with almost always be treated effectively.292 The optimal ■ Cyclosporine and tacrolimus SBP/DBP to prevent cognitive decline in older ■ Erythropoietin ■ Licorice (including some chewing tobacco) individuals is thought by some to be in the SBP ■ Selected over-the-counter dietary supplements and medicines 135–150 mmHg and DBP 70–79 mmHg (e. driving. and ■ Volume retention from kidney disease preparing meals. amphetamines. Special Situations in Hypertension Management 47 . such as impaired Drug-induced or other causes attention. anorectics) matter changes on MRI. bitter orange) range. and some nontraditional remedies Dementia and cognitive impairment occur more may counter the antihypertensive effects of commonly in people with hypertension. If resistance still persists. chronic hypertension have revealed greater num- lence of truly resistant hypertension is small.g. Nonsteroidal anti-inflammatory drugs Cognitive Function and Dementia and pressor agents in cold remedies.they use. preventing cognitive decline. verbal fluency. compromise of the blood-brain barrier.293 but no comparative data ■ Obesity are available regarding whether certain classes of ■ Excess alcohol intake antihypertensive drugs are superior to others in Identifiable causes of hypertension (see table 7). astrogliosis. Causes of resistant hypertension between normal aging and mild dementia in Improper Blood Pressure Measurement which patients exhibit signs of poor recent Volume overload memory but can still perform daily tasks such ■ Excess sodium intake as managing finances.286 Hypertension and hypercho- ■ Inadequate diuretic therapy lesterolemia are risk factors for MCI and for other signs of cognitive decline. ephedra. and cognitive decline.275–285 Mild cognitive impairment (MCI) is a diagnostic category that represents a transitional state Table 18. bers of subcortical white matter lesions and microinfarcts. reaction time. shopping..290 However.287. If resistant hypertension progression of cognitive impairment may occur persists after remediable causes are identified and with effective antihypertensive therapy.

treatment. The effect of in SBP over time than nonusers. Hypertension in Women postmenopausal women had higher SBP (4–5 mmHg) than pre. weight gain. Further. Overall.298 incidence of hypertension increases more rapidly in women than men. the rate of rise in SBP tended to be studies suggest that HRT improves or restores the steeper in postmenopausal compared to pre. or a combination hypertension is less common among women than of these and other yet undefined neurohumoral men. but DBP was not menopause on BP is controversial.300 were being treated with antihypertensive medica- tions. the largest longitudinal study to address percent of women older than 75 years of age.and postmenopausal women Sexual dimorphism of BP and hypertension preva. HRT-related change in BP is likely to be premenopausal women. there is lence in women. Such an effect would tend to reduce total BP load reported that. but only 44 percent of men.301 In small studies that used 24-hour found significantly higher SBP and DBP in post. 61 percent of with a >25 percent likelihood of having hyperten- hypertensive women.299 There treated. women receiving HRT had a significantly smaller increase Menopause and blood pressure. sion compared to past use or no prior use.and perimenopausal controls. after the fifth decade of life.296 In a prospective study modest and should not preclude hormone use in of conventional and ambulatory BP levels. in the WHI cross- Black and White women were aware of their high sectional analysis of almost 100. overproduction of regardless of age. Longitudinal Study on Aging (BLSA). The highest preva. and Treatment of High Blood Pressure . current hormone use was associated in these ethnic groups.1 In NHANES was no difference in DBP between the hormone III. and the prevalence of hyperten.6 years of followup among 8. ABPM to evaluate the effects of HRT on BP. than in the premenopausal group.295 this question. sion in women is equal to or exceeds that in men Results of studies evaluating the effects of hor- during the sixth decade of life. while the opposite menopause. and to have it controlled. the influences. In the Baltimore contact. includ- be just marginally lower in women than men ing estrogen withdrawal. several of the NHANES III. Women are more likely than men to ed equine estrogen and medroxyprogesterone know that they have hypertension.506 Awareness. normotensive or hypertensive women. normal nighttime reduction (“dipping”) in BP that menopausal women until the sixth decade. Longitudinal affected. Postmenopausal hormone therapy and BP.298 and BMI. such that women have lower SBP levels than ularly SBP) seen later in life in women is due to men during early adulthood. mone replacement therapy (HRT) on BP have lence rates of hypertension are observed in elderly been inconsistent. pituitary hormones. The Postmenopausal Estrogen/Progestin studies have not documented a rise in BP with Intervention trial showed no effect of HRT on menopause. while menopausal versus premenopausal women. A menopause-related increase in BP is true after the sixth decade of life. found an average 1 mmHg increase in SBP over 5. in early adulthood.294 Similarly. Detection. and control of high BP in postmenopausal women randomized to conjugat- women.297 Nonpregnant Women The increase in SBP per decade was 5 mmHg greater in the peri. DBP tends to has been attributed to a variety of factors. even after adjustment for age and thereby reduce target organ damage.294 In overall results were inconsistent. Evaluation. the rate of increase tended to slow. Thus. to have it acetate as compared to a placebo group. However. postmenopausal women are more than twice as likely to have hypertension as Overall. The Women’s Health Initiative black women. when may be diminished in postmenopausal women. All hyper- 48 The Seventh Report of the Joint National Committee on Prevention. with hypertension occurring in >75 (WHI). Staessen et al. while cross-sectional studies have SBP or DBP.000 women 50–79 BP in contrast to 65 percent of hypertensive men years of age. There is a sexual dimorphism in evidence that at least part of the rise in BP (partic- BP. The higher treatment rates in women have Smaller observational and interventional studies been attributed to increased numbers of physician have found different results. approximately 75 percent of hypertensive treatment groups.

While women generally respond to antihyperten- cantly increased (relative risk [RR]=1. or CCBs to diuretics and BBs in older. but such chronic hypertension. Outcomes of antihypertensive trials in women. Family more common in women taking a diuretic. Similarly. ARBs. of CCB-related peripheral edema and minoxidil- tion of oral contraceptive use increase susceptibility induced hirsutism. and dura. The Nurses’ Health Study found that Choice of antihypertensive drugs for women. and to plan treatment strategies.304 More recent 6-month intervals.3) risk of ations may dictate treatment choices for women. Prepregnancy assessment. to assess its severity.113. not appear to differ between the sexes. with modern preparations that contain only 30 µg estrogen. This is true even in decisions about whether to treat high BP. demonstrated a return of BP to pretreatment Some antihypertensive drugs have gender-specific levels within 3 months of discontinuing oral adverse effect profiles.5–2. Diuretics are particularly useful in elderly individ- ceptive use. including preexisting induced cough is twice as common in women as pregnancy-induced hypertension.303 Many hypertensive women who plan to become Absolute risk reduction for stroke was also similar pregnant should be screened for pheochromocy- in men and women.305 Women are more likely to develop diuretic-induced hyponatremia. of this condition if not diagnosed antepartum.7. Hypokalemia is accelerated or malignant hypertension.109 The current evidence indicates increase in BP. if other contraceptive methods are not suit. Withdrawal of the offending con. Special Situations in Hypertension Management 49 . For example. Hypertensive disorders in pregnancy are a major Regular monitoring of BP throughout contracep. fied into one of five categories (table 19). specific syndrome of exaggerated vasoconstriction traceptive agent is generally desirable in cases of and reduced organ perfusion. cause of maternal. and if hypertensive. and neonatal morbidity tive therapy is recommended.g.306 therapy may have to be continued in some women (e. obesity. and men Oral contraceptives occasionally may precipitate are more likely to develop gout. evaluated prior to conception to define their BP status. possible secondary causes. a pregnancy- reevaluations. outcome trials comparing ACEIs. and presence of target Relative benefits of antihypertensive therapy do organ damage. from pre-existing contraceptive-induced hypertension. person/years could be attributed to oral contra. 95 sive drugs similarly to men. potency of the preparation. a small percentage experience the that the sex of the patient should not play a role onset of frank hypertension. Hypertension in pregnancy is classi- suggested that contraceptive prescriptions be lim.tensive women treated with HRT should have controlled trial of CCB treatment showed treat- their BP monitored closely at first and then at ment benefits for both sexes. hypertension compared with those who had never ACEIs and ARBs are contraindicated for women used oral contraceptives. middle age (>35 years). indicating that their BP effect is TOMHS. effects as men. Pregnant Women not the estrogenic..302 Absolute risk was who are or intend to become pregnant because small: only 41. Contraceptive-induced hyperten- sion appears to be related to the progestogenic. Women should be able) and combined with antihypertensive therapy. and it is ited to 6 months to ensure at least semiannual critical to differentiate preeclampsia. in the contraceptives.000 of the risk of fetal developmental abnormalities. women reported twice as many adverse readily reversible. and it has been and mortality. current users of oral contraceptives had a signifi. fetal. Many women taking have generally shown similar benefits for women oral contraceptives experience a small but detectable and men.5 cases of hypertension per 10.101. high-risk patients Oral contraceptives and BP.8. occult renal in men. but for coronary events. toma due to the high morbidity and mortality it was greater in men. a placebo.102. some special consider- percent confidence interval [CI]=1. and women are more likely to complain disease. to hypertension. ACEI- history of hypertension. Controlled prospective studies have uals because of a decreased risk of hip fracture.

Table 19. Evaluation. increase the risk of preeclampsia. aspartate aminotransaminase. alanine aminotransferase. therefore. Treatment of chronic hypertension during preg- nant. Those with progressive outcomes. Mild renal disease (serum ications.to threefold increase in proteinuria ■ Sudden increase in BP ■ Thrombocytopenia ■ Elevated AST or ALT Gestational hypertension ■ Hypertension without proteinuria occurring after 20 weeks gestation ■ Temporary diagnosis ■ May represent preproteinuric phase of preeclampsia or recurrence of chronic hypertension abated in midpregnancy ■ May evolve to preeclampsia ■ If severe. aerobic exer- creatinine <1.4 g sodium intake recommended for those with 50 The Seventh Report of the Joint National Committee on Prevention. ACEIs and ARBs should be discontinued cation therapy only. renal disease Chronic hypertension with ■ New onset proteinuria after 20 weeks in a woman with hypertension superimposed preeclampsia ■ In a woman with hypertension and proteinuria prior to 20 weeks gestation ■ Sudden two. even in obese pregnancy may accelerate both hypertension and pregnant women. Although the data on pregnant the underlying disease and markedly reduce fetal women are sparse. and the underlying renal disease cerns that inadequate placental blood flow may does not generally worsen during pregnancy.4 mg/dL) has a minimal effect on cise should be restricted based on theoretical con- fetal survival. BP usually falls during the renal diseases should be encouraged to complete first half of pregnancy. multiple gestation. BP. may be easier to control with reduced or no med- atively well preserved. such as methyldopa or pregnancy and are candidates for lifestyle modifi- BBs. family history of preeclampsia. it may be prudent prior to conception to nancy. With lifestyle modification. and Treatment of High Blood Pressure . women with hypertension for >4 years. Detection. as there is no evidence that prior to attempts at conception or as soon as pharmacologic treatment improves neonatal pregnancy is confirmed. hypertension their childbearing while their renal function is rel. restriction of sodium intake to the same 2. moderate or severe renal insufficiency in reduction should not be attempted. may result in higher rates of premature delivery and growth retardation than mild preeclampsia Transient hypertension ■ Retrospective diagnosis ■ BP normal by 12 weeks postpartum ■ May recur in subsequent pregnancies ■ Predictive of future primary hypertension ALT. blood pressure In hypertensive women planning to become preg. many experts recommend survival. Classification of hypertension in pregnancy Chronic hypertension ■ BP >140 mmHg systolic or 90 mmHg diastolic prior to pregnancy or before 20 weeks gestation ■ Persists >12 weeks postpartum Preeclampsia ■ BP >140 mmHg systolic or 90 mmHg diastolic with proteinuria (>300 mg/24 hrs) after 20 weeks gestation ■ Can progress to eclampsia (seizures) ■ More common in nulliparous women. Further. hypertension in previous pregnancy. and weight However. Women with stage 1 hypertension are at change to antihypertensive medications known to low risk for cardiovascular complications during be safe during pregnancy. AST.

damage or a prior requirement for multiple anti- hypertensive agents for BP control. Aggressive treatment of severe chronic Prevention of preeclampsia relies on: (1) identifica- hypertension in the first trimester is critical. Use of antihypertensive drugs in pregnant women Further. if proteinuria is present early in pregnancy. Treatment of chronic hypertension in pregnancy Agent Comments Methyldopa ■ Preferred based on long-term followup studies supporting safety BBs ■ Reports of intrauterine growth retardation (atenolol) ■ Generally safe Labetalol ■ Increasingly preferred to methyldopa due to reduced side effects Clonidine ■ Limited data Calcium antagonists ■ Limited data ■ No increase in major teratogenicity with exposure Diuretics ■ Not first-line agents ■ Probably safe ACEIs. a history of hypertension for 4 years prevent increases in BP to very high levels during or longer.310 Other However. angiotensin converting enzyme inhibitors. angiotensin II receptor antagonists ■ Contraindicated ■ Reported fetal toxicity and death ACEIs. and duration of therapy. increase at serum creatinine levels >1. treatment should be dence of approximately 25 percent. Risk factors re-instituted once BP reaches 150–160 mmHg for superimposed preeclampsia include renal systolic or 100–110 mmHg diastolic.4 mg/dL at This approach reflects concern about the safety of conception. and hypertension in a previous pregnancy.7 Use of alcohol and tobac. Methyldopa is preferred by many arterial pressure and the proportion of small-for. based on reports of stable gestational-age infants. pregnancy. hypertensive agent(s) is largely driven by the safe- ship between treatment-induced fall in mean ty of the fetus. BBs. type of ics and the absence of long-term (7. and Table 20. The primary studies of treatment with several classes of antihy.5-year fol- antihypertensive agent. beta-blockers Special Situations in Hypertension Management 51 . A meta-analysis of 45 randomized controlled Antihypertensive drug selection. Fetal tensive medications while maintaining close obser. with an inci- to control BP. since tion of high-risk women. In all cases. lowup) adverse effects on development of children exposed to methyldopa in utero. (2) close clinical and labo- fetal loss rates of 50 percent and significant ratory monitoring aimed at its early recognition.308 Most of the poor outcomes are relat- ed to superimposed preeclampsia (table 19). in order to insufficiency.primary hypertension. Preeclampsia.309.307 This relationship was uteroplacental blood flow and fetal hemodynam- independent of type of hypertension. goal of treating chronic hypertension in pregnancy pertensive drugs in stages 1 and 2 hypertension is to reduce maternal risk. as first-line therapy. antihyperten. patients. maternal mortality have been reported in these co must be strongly discouraged. Some clinicians prefer to stop antihyper. Preeclampsia is more common in sive medication should be continued as needed women with chronic hypertension. but the choice of anti- during pregnancy showed a direct linear relation. women with chronic hypertension are with chronic hypertension varies greatly among also at higher risk for adverse neonatal outcomes centers. antihypertensive drug treatment during pregnancy. for pregnant women with target organ treatment options are summarized in table 20. including use of home BP monitoring. loss and acceleration of maternal renal disease vation.

However. Treatment of acute severe hypertension in preeclampsia Hydralazine ■ 5 mg iv bolus.25 ug/kg/min to a maximum of 5 ug/kg/min (rarely. based on reports of avoid the added stress of surgery. Treating hypertension during lactation. Therefore. it does not improve perinatal outcomes tored for potential adverse effects. Treatment of preeclampsia includes 48 hours away. can see precipitous blood pressure drop ■ Short-acting nifedipine is not approved by the Food and Drug Administration for managing hypertension Sodium nitroprusside ■ 0. Propanolol and disturbance. deteriorating renal function. and Treatment of High Blood Pressure . Antihypertensives modest levels (i. and headache or epigastric pain. when others fail) ■ Fetal cyanide poisoning may occur if used for more than 4 hours 52 The Seventh Report of the Joint National Committee on Prevention. Detection. labetalol are preferred if a BB is indicated. adverse fetal and neonatal renal effects. persistent DBPs of 105–110 mmHg or higher. 80 mg every 10 (second-line) minutes for two additional doses to a maximum of 220 mg Nifedipine ■ 10 mg po. it may compromise a fetus of <32 weeks tension who wish to breast-feed for a few months. so acute BP elevations even to tical and effective (table 21). safely. delivery it might be prudent to withhold antihypertensive should be strongly considered when there are signs medication. visual to methyldopa or hydralazine. Hypertension recurs route of administration depends on anticipated in a large proportion (20–50 percent) of subsequent Table 21. oral methyldopa is preferred due hospitalization for bed rest. women with preeclampsia have previously been If delivery is imminent. low adverse effects have been reported from exposure platelet count.e. Treatment does not alter the underlying aiming for levels of 95–105 mmHg. ACEIs Vaginal delivery is preferable to cesarean delivery to and ARBs should be avoided. pathophysiology of the disease. Selection of antihypertensive agents and Recurrence of hypertension. then 40 mg 10 minutes later. with close monitoring of BP. and of fetal distress or intrauterine growth retardation reinstitute antihypertensive therapy following or signs of maternal problems.. including severe discontinuation of nursing. tion. and other BBs and calcium antagonists are eclampsia. Evaluation. parenteral agents are prac- normotensive. but it may slow its progression and provide time for fetal matura. elevated liver enzymes. 150/100 mmHg) may cause are administered before induction of labor for significant symptomatology and require treat. then 10 mg every 20–30 minutes to a maximum of 25 mg. gestation. Oral labetalol is an alterna- prophylaxis in the presence of signs of impending tive. (3) institution of intensive monitoring or delivery timing of delivery. in mothers with stage 1 hyper- the mother. control of BP. and timely delivery. No short-term hypertension. Breast-fed infants of mothers taking therapy should be prescribed only for maternal antihypertensive agents should be closely moni- safety. repeat in several hours as necessary Labetalol ■ 20 mg iv bolus. ment. repeat every 20 minutes to a maximum of 30 mg (controversial) ■ Caution when using nifedipine with magnesium sulfate. If delivery is likely more than when indicated. Diuretics may reduce milk volume and thereby suppress Antihypertensive drug therapy. many also acceptable based on limited data (table 20). and may adversely affect uteroplacental blood flow. Regardless of gestational age. hemolysis. Preeclampsia rarely remits spontaneously Hypertensive mothers can usually breast-feed and in most cases worsens with time. Antihypertensive lactation. Importantly. seizure to its safety record. all antihypertensive drugs that have been studied are excreted into human breast While delivery may be appropriate therapy for milk.

pregnancies. Risk factors for recurrence include Lifestyle interventions should be recommended for
early onset of hypertension in the first pregnancy, a all children with hypertension, with pharmacolog-
history of chronic hypertension, persistent hyper- ic therapy instituted for higher levels of BP or
tension beyond 5 weeks postpartum, and elevated if insufficient response to lifestyle modifications
BP early in pregnancy. Women with preeclampsia occurs. Teenage children with BP below but near
have a greater tendency to develop hypertension the 95th percentile should adopt healthy lifestyles
than those with normotensive pregnancies. similar to adults with prehypertension. Although
the recommendations for choice of drugs are gen-
Hypertension in Children and Adolescents erally similar in children and adults, dosages of
antihypertensive medication for children should
In children and adolescents, hypertension is be smaller and adjusted very carefully. ACEIs and
defined as elevated BP that persists on repeated ARBs should not be used if the patient is preg-
measurement at the 95th percentile or greater for nant. These agents should be used with extreme
age, height, and gender (table 22). As with caution in sexually active teenage girls and only
adults, the fifth Korotkoff sound is used to define when careful counseling and effective pregnancy
DBP.311 precautions are established.

Clinicians should be alert to the possibility of The presence of uncomplicated hypertension is
identifiable causes of hypertension in younger not a reason to restrict children from participating
children. Secondary forms of hypertension are in physical activities, particularly because exercise
more common in children and in individuals with may lower BP. Use of anabolic steroid hormones
severe hypertension (>20 mmHg above the 95th for the purpose of bodybuilding should be strong-
percentile). Chronic hypertension is becoming ly discouraged. Efforts should be made to identi-
increasingly common in adolescence and is fy other modifiable risk factors in children (e.g.,
generally associated with obesity, sedentary obesity, lack of physical activity, smoking), and
lifestyle, and a positive family history of hyperten- vigorous interventions should be made when these
sion and other CVDs. As in adults, children and factors are present. Detailed recommendations
adolescents with established hypertension develop regarding hypertension in children and adoles-
target organ damage including LVH. Appropriate cents can be found in the 1996 NHBPEP
assessment for LVH, including echocardiography, Working Group Report on Hypertension Control
should be considered in children who have in Children and Adolescents.311
significant and persistant hypertension.

Table 22. The 95th percentile of blood pressure by selected ages, by the 50th and
75th height percentiles, and by gender in children and adolescents
Girls’ SBP/DBP Boys’ SBP/DBP
50th Percentile 75th Percentile 50th Percentile 75th Percentile
Age for Height for Height for Height for Height

1 104/58 105/59 102/57 104/58

6 111/73 112/73 114/74 115/75

12 123/80 124/81 123/81 125/82

17 129/84 130/85 136/87 138/88

DBP, diastolic blood pressure; SBP, systolic blood pressure

Source: Adapted from the National High Blood Pressure Education Program. Update on the 1987 Task Force Report
on High Blood Pressure in Children and Adolescents: A working group report from the National High Blood Pressure
Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control in
Children and Adolescents. Pediatrics 1996;98(pt 1):649–58.

Special Situations in Hypertension Management 53

Hypertensive Crises: Emergencies and Urgencies aortic dissection who should have their SBP low-
ered to <100 mmHg if tolerated, and patients in
Hypertensive emergencies are characterized by whom BP is lowered to enable the use of throm-
severe elevations in BP (>180/120 mmHg) compli- bolytic agents (see Stroke).
cated by evidence of impending or progressive tar-
get organ dysfunction. They require immediate Some patients with hypertensive urgencies may
BP reduction (not necessarily to normal) to pre- benefit from treatment with an oral, short-acting
vent or limit target organ damage.312,313 Examples agent such as captopril, labetalol, or clonidine fol-
include hypertensive encephalopathy, intracerebral lowed by several hours of observation. However,
hemorrhage, acute MI, acute left ventricular there is no evidence to suggest that failure to
failure with pulmonary edema, unstable angina aggressively lower BP in the ER is associated with
pectoris, dissecting aortic aneurysm, or eclampsia. any increased short-term risk to the patient who
Hypertensive urgencies are those situations associ- presents with severe hypertension. Such a patient
ated with severe elevations in BP without progres- may also benefit from adjustment in their antihy-
sive target organ dysfunction. Examples include pertensive therapy, particularly the use of combi-
upper levels of stage II hypertension associated nation drugs, or reinstitution of medications if
with severe headache, shortness of breath, noncompliance is a problem. Most importantly,
epistaxis, or severe anxiety. The majority of these patients should not leave the ER without a con-
patients present as noncompliant or inadequately firmed followup visit within several days.
treated hypertensive individuals, often with little
or no evidence of target organ damage. Unfortunately, the term “urgency” has led to
overly aggressive management of many patients
Early triage to establish the appropriate therapeu- with severe, uncomplicated hypertension.
tic strategies for these patients is critical to limit- Aggressive dosing with intravenous drugs or even
ing morbidity and mortality.314 Patients present- oral agents, to rapidly lower BP is not without
ing with severe hypertension may represent as risk. Oral loading doses of antihypertensive
much as 25 percent of all patient visits to busy agents can lead to cumulative effects causing
urban emergency rooms (ERs).315 hypotension, sometimes following discharge from
the ER. Patients who continue to be noncompli-
Patients with hypertensive emergencies should be ant will often return to the ER within weeks.
admitted to an intensive care unit for continuous
monitoring of BP and parenteral administration Erectile Dysfunction and Hypertension
of an appropriate agent (table 23). The initial
goal of therapy in hypertensive emergencies is to Erectile dysfunction (ED), defined as the inability
reduce mean arterial BP by no more than 25 per- to have and maintain an erection adequate for
cent (within minutes to 1 hour), then if stable, to intercourse, becomes increasingly common in men
160/100–110 mmHg within the next 2–6 hours. over age 50 and is even more common if they are
Excessive falls in pressure that may precipitate hypertensive.316 In a survey of over 3,000 health
renal, cerebral, or coronary ischemia should be professionals, the frequency of ED was 4 percent
avoided. For this reason, short-acting nifedipine in men under age 50, 26 percent in those 50–59,
is no longer considered acceptable in the initial and 40 percent in those 60–69.316 The frequency
treatment of hypertensive emergencies or urgen- was significantly higher if they were hypertensive,
cies. If this level of BP is well tolerated and the diabetic, obese, smokers, or were taking antide-
patient is clinically stable, further gradual reduc- pressants or BBs.
tions toward a normal BP can be implemented
in the next 24–48 hours. There are exceptions Whereas hypertension per se may be associated
to the above recommendation—patients with an with ED,317 the use of various antihypertensive
ischemic stroke in which there is no clear evidence medications may increase the incidence, in part
from clinical trials to support the use of immedi- because BP lowering itself may cause reduction
ate antihypertensive treatment, patients with of perfusion of genital organs. Available data

54 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Table 23. Parenteral drugs for treatment of hypertensive emergencies*

Drug Dose Onset of Action Duration of Action Adverse Effects† Special Indications

Vasodilators

Sodium nitroprusside 0.25–10 µg/kg/min Immediate 1–2 min Nausea, vomiting, muscle Most hypertensive emergen-
as IV infusion‡ twitching, sweating, thiocynate cies; caution with high
and cyanide intoxication intracranial pressure or
azotemia

Nicardipine hydrochloride 5–15 mg/h IV 5–10 min 15–30 min, may Tachycardia, headache, Most hypertensive emergen-
exceed 4 hrs flushing, local phlebitis cies except acute heart
failure; caution with coronary
ischemia

Fenoldopam mesylate 0.1–0.3 µg/kg per <5 min 30 min Tachycardia, headache, Most hypertensive emergen-
min IV infusion nausea, flushing cies; caution with glaucoma

Nitroglycerin 5–100 µg/min 2–5 min 5–10 min Headache, vomiting, Coronary ischemia
as IV infusion‡ methemoglobinemia, tolerance
with prolonged use

Enalaprilat 1.25–5 mg every 15–30 min 6–12 hrs Precipitous fall in pressure Acute left ventricular failure;
6 hrs IV in high-renin states; variable avoid in acute myocardial
response infarction

Hydralazine hydrochloride 10–20 mg IV 10–20 min IV 1–4 hrs IV Tachycardia, flushing, headache, Eclampsia
10–40 mg IM 20–30 min IM 4–6 hrs IM vomiting, aggravation of angina

Adrenergic Inhibitors

Labetalol hydrochloride 20–80 mg IV 5–10 min 3–6 hrs Vomiting, scalp tingling, Most hypertensive
bolus every 10 min bronchoconstriction, emergencies except acute
0.5–2.0 mg/min IV dizziness, nausea, heart failure
infusion heart block, orthostatic
hypotension

Esmolol hydrochloride 250–500 µg/kg/min 1–2 min 10–30 min Hypotension, nausea, asthma, Aortic dissection,
IV bolus, then 50– first degree heart block, perioperative
100 µg/kg/min by heart failure
infusion; may repeat
bolus after 5 min or
increase infusion to
300 µg/min

Phentolamine 5–15 mg IV bolus 1–2 min 10–30 min Tachycardia, flushing, headache Catecholamine excess

h or hr, hour; IM, intramuscular; IV, intravenous; min, minute(s)

* These doses may vary from those in the Physicians’ Desk Reference (51st ed.)

† Hypotension may occur with all agents

‡ Require special delivery system

regarding individual effects of antihypertensive months of the study, than participants randomized
drug therapy are confounded by age, vascular dis- to placebo. Incidence rates through 48 months
ease, and hormonal status. In the TOHMS study were more similar among treatment groups than
involving antihypertensive drugs from five differ- at 24 months, with nonsignificant differences
ent classes (excluding ARBs) participants random- between chlorthalidone and placebo groups.123
ized to chlorthalidone reported a significantly In the VA Cooperative Trial, no difference on
higher incidence of erection problems, at 24 incidence of sexual dysfunction was noted

Special Situations in Hypertension Management 55

the use of >180/110 mmHg should be controlled prior to epinephrine had a minimal effect. treatment of patients with urinary outflow obstruction includes the use of alpha-1 blockers Dental Issues in Hypertensive Individuals such as terazosin. Symptoms of urinary outflow obstruction or a known history of obstruction should be elicited as Hypertension is very common in the early postop- part of the hypertension work-up. Nitroglycerin is often an agent of choice in patients with coronary ischemia. such as sodium been observed to increase its incidence. A lower risk of ED was reported among men who Surgical candidates with controlled hypertension were physically active. BP levels of patients during dental procedures. and labetalol can be effective. Patients with high volume. When a normal erative period and is related to increased sympa- bladder is distended beyond approximately 300 mL. hypertensive emergencies (see prior section).316 Therefore.103 In other studies cen.321 For elective surgery. Detection. and labetalol. trol can be achieved over several days to weeks trally acting alpha agonists have been associated of outpatient treatment. to correct hypokalemia well in advance ment restarted with another agent. Older patients may particularly bene- other phosphodiesterase-5 inhibitors may be pre. if offending agent should be discontinued and treat. periodic dosing with intravenous enalapri- by keeping the bladder volume below 300 mL and lat or transdermal clonidine hydrochloride may by the use of sympatholytic drugs. as they are concerned with an adverse Uncontrolled hypertension is associated with cardiovascular response. fit from treatment with beta-1 selective BBs before scribed without a significant likelihood of adverse and during the perioperative period.318 nitroprusside. which may require parenteral dosing with spinal cord injuries in particular may exhibit large a loop diuretic such as furosemide. ACEI. this topic325 concluded that. and therapy should be reinstated as encouraged to forestall ED. which indirectly dilate prostatic and urinary sphincter A concern in dental care is the use of epinephrine smooth muscle and also lower BP.317. nicardipine. not obese. needed. A systematic review of wider fluctuations of BP during induction of anes. doxazosin. the sium supplementation should be provided. Nonsurgical be useful. with ED.319 Sudden intraoperative hypertension is managed by many of the same parenteral antihypertensive There are no definitive data on a relation between agents that are utilized in the management of sexual dysfunction and hypertension in women. and CCBs have not rapidly acting parenteral agents. counseling to improve the patient’s quality of life.320 in local anesthetic solutions. thetic tone and vascular resistance. should maintain their medications until the time ers. esmolol. If resumption acute BP increases similar to individuals with auto. Many dental providers do not use catecholamine-containing Patients Undergoing Surgery local anesthetic formulations for any patient with elevated BP. Evaluation. ARBs. effective BP con- BB compared to placebo. Sildenafil or of surgery. lifestyle modifications should be of surgery. In urgent situations. BP should be 56 The Seventh Report of the Joint National Committee on Prevention. and may increase the risk events may occur in uncontrolled hypertensive for perioperative ischemic events. while ACEIs. of oral treatment must be interrupted postopera- nomic dysfunction. to discuss sexual dysfunction problems and offer nicardipine. or surgery. or prazosin. may be of benefit in managing intraoperative tachycardia. between a CCB. clinicians should be willing Intravenous infusions of sodium nitroprusside. while the very Urinary Outflow Obstruction short-acting BB. and Treatment of High Blood Pressure . can be utilized to attain effective control very rapidly.322 reactions in those with concomitant antihyperten- sive therapy so long as nitrates are avoided.324 Contributing sympathetic nervous system stimulation may cause factors include pain and increased intravascular a substantial increase in BP.323 Regardless of gender. hydrochlorothiazide. If ED appears after soon as possible postoperatively. BP control can be improved tively. and nonsmok. although adverse thesia and intubation. Adequate potas- institution of antihypertensive drug therapy.

monitored closely in the dental office if general may play a reinforcing role in the fatigue and day-
anesthesia is administered to hypertensive individ- time somnolence. Sleep deprivation alone may
uals because of potential wide fluctuations in BP raise BP351 and impair glucose tolerance.352 There
and the risk of hypotension in those receiving is also a direct relationship between the severity of
antihypertensive drugs. CCBs and other vasodila- sleep apnea and the level of BP. Finally, sustained
tors may cause hypertrophy of the gums. and effective treatment of OSA with continuous
positive airway pressure (CPAP) has been reported
Obstructive Sleep Apnea to lower nighttime and daytime BP in hyperten-
sive individuals with OSA.353–355
Obstructive sleep apnea (OSA) occurs in 2–4 per-
cent of the adult population, and >50 percent of In addition to weight loss, improvements in the
individuals with OSA have hypertension.263,326–333 quality of sleep in OSA patients can occur as
Obesity is so common in OSA that the index of a result of a variety of positioning measures
suspicion for OSA should be high in any hyperten- during sleep, particularly sleeping on one’s side.
sive patient whose BMI is above 27 kg/m2.331 Treatment with CPAP can be useful in overall
These individuals should be questioned thoroughly BP lowering and may also improve cardiac
for symptoms of OSA, including snoring, wit- ischemia356,357 and HF symptoms.331,332 The role
nessed apnea, irregular breathing during sleep, of oral prostheses and surgical approaches
restless sleeping, and chronic morning fatigue. remains to be fully defined.354 No specific class of
Frequently it is the sleep partner who provides the antihypertensive drugs has yet been demonstrated
most reliable history, especially regarding snoring, to be superior for BP lowering in OSA patients.354
because the affected individual may deny or be
unaware of the problem. If the diagnosis is sus- Hypertension and the Eye
pected clinically, confirmation by a formal sleep
study is indicated. The impact of sleep apnea on Hypertension can affect the retina, choroid, and
CVD is probably related in large part to its associ- optic nerve of the eye, particularly with stage 2
ation with elevated BP. However, OSA may act hypertension. These changes can be appreciated
through a number of mechanisms to elicit myocar- with inspection of the retinal vessels by direct
dial and vascular damage, including an increase in ophthalmoscopy, photography, or angiography.
catecholamine release,333,334 activation of inflam- Hypertensive retinopathy is most commonly man-
matory mechanisms,335 insulin resistance,336,337 and ifested by generalized or focal narrowing of reti-
endothelial dysfunction.338 Other cardiovascular nal arterioles. In acute or advanced hypertension,
conditions associated with OSA include arrhyth- the retinal vasculature may be injured sufficiently
mias, HF, MI, and stroke.331,332,339–344 to cause occlusion or leakage. These changes may
be manifested as nerve fiber layer infarcts (“soft”
Previous debate about whether OSA is an etiologic exudates or cotton-wool patches), extravascular
factor in hypertension has focused largely around edema (“hard” exudates), intraretinal hemor-
the strong association of OSA with obesity. While rhages, and retinal arterial macroaneurysms.
obesity is known to contribute in large part to
OSA,345-348 patients with OSA may also be at Hypertensive choroidopathy is most frequently seen
increased risk for weight gain,349 and treatment of in young patients with acute hypertension, including
OSA may reduce visceral fat.350 It now appears cases of eclampsia or pheochromocytoma. Findings
that the potential causal association between OSA include Elschnig spots (nonperfused areas of the
and hypertension involves both the obesity-hyper- choriocapillaris) and Siegrist streaks (linear
tension link and an independent role of OSA in hyperpigmentation over choroidal arteries).
chronic BP elevation. Episodes of apnea with Hypertensive optic neuropathy occurring with
repeated oxygen desaturation in OSA have been severe hypertension may present with flame
shown to stimulate strong sympathetic nervous hemorrhages, optic disc edema, venous conges-
system discharges that directly elevate BP.333,334 tion, and macular exudates.358–360
Poorer quality of sleep and shorter sleep periods

Special Situations in Hypertension Management 57

Renal Transplantation are the individuals in whom special evaluation for
the problem is carried out. If present bilaterally,
Hypertension is a relatively common occurrence renal artery stenosis can lead to reduced kidney
in patients receiving organ transplants; in those function (ischemic nephropathy).363
receiving kidney allografts, the prevalence of
hypertension probably exceeds 65 percent.361 Clinical clues to renovascular disease include (1)
Nocturnal hypertension, a reversal of diurnal BP onset of hypertension before age 30 (especially
rhythm, may be present in these individuals, who without a family history) or recent onset of signif-
may need ABPM to evaluate overall BP control. icant hypertension after age 55; (2) an abdominal
bruit, particularly if it continues into diastole and
Hypertension is less common in other forms of is lateralized; (3) accelerated or resistant hyperten-
transplantation. The mechanisms of hypertension sion; (4) recurrent (flash) pulmonary edema; (5)
in transplant patients are multifactorial, but renal failure of uncertain etiology, especially with
vasoconstriction and long-term vascular structural a normal urinary sediment; (6) coexisting diffuse
changes caused by chronic immunosuppressive atherosclerotic vascular disease, especially in
drugs, which are calcineurin inhibitors heavy smokers; or (7) acute renal failure precipi-
(cyclosporin and tacrolimus) and corticosteroids, tated by antihypertensive therapy, particularly
are among the most important.362 Impaired renal ACEIs or ARBs.78,79,81
function is another exacerbating factor; despite
successful renal transplantation, most patients In patients with indications of renovascular dis-
have enough impairment in renal function to cause ease, captopril-enhanced radionuclide renal scan,
relative salt and water retention. Transplant renal duplex Doppler flow studies, and magnetic reso-
artery stenosis may also be a factor. nance angiography may be used as noninvasive
screening tests. Three-dimensional images can
Observational studies suggest that hypertension be obtained by spiral computed tomography, a
correlates with deterioration in graft function. technique that necessitates the use of intravenous
Large-scale, controlled, clinical trials on the contrast.81 Definitive diagnosis of renovascular
effects of BP control on decline in GFR or on disease requires renal angiography, which carries
CVD incidence are lacking in this population. some risk, particularly of radiocontrast-induced
The high risk of graft occlusion and cardiovascu- acute renal failure or atheroembolism.364
lar events has suggested that BP should be low-
ered to 130/80 mmHg or less. Because of the In patients, usually women, with fibromuscular
absence of compelling data, no particular class of dysplasia, results of percutaneous transluminal
antihypertensives can be considered superior to renal angioplasty (PTRA) have been excellent
any other. The difficulty of lowering BP in this and comparable to surgical revascularization.365
group makes combination drugs necessary in Patients with normal renal function and athero-
almost all patients. As with other renal diseases, sclerotic renal artery stenosis that is focal,
serum creatinine and potassium should be moni- unilateral, and nonostial also may be managed
tored 1–2 weeks following initiation or escalation by angioplasty.365 Renal artery stenting has
in therapy with ACEIs or ARBs. A >1 mg/dL become an important adjunct to PTRA, being
increase in serum creatinine should raise the used to counteract elastic recoil and to abolish the
question of renal artery stenosis. residual stenosis often observed after PTRA.366

Patients With Renovascular Disease Even though many patients with high-grade
renal artery stenosis remain stable for prolonged
Hemodynamically significant renal artery stenosis periods if BP is well controlled,367 surgical revas-
may be associated with all stages of hypertension, cularization or PTRA with renal artery stenting
but it is more commonly recognized in patients may be needed to preserve renal function.81
with stage 2 or resistant hypertension, since these

58 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Drugs and Other Agents Affecting
B lo o d P r e s s u r e

Many prescription drugs and some over-the- of intercurrent drug usage (such as an increase in
counter agents and herbal supplements may affect serum potassium or creatinine concentrations with
BP and complicate BP control in treated hyperten- nonsteroidal anti-inflammatory drugs); and (4)
sive individuals. Consequently, searching for the atypical hypertension (such as severe but transient
presence of these agents in a person’s medical hypertension in a young patient presenting with
history can identify a “secondary” component chest pain and ECG changes accompanying possi-
contributing to BP elevation. Such recognition ble cocaine usage).
may negate the need to employ unnecessary and
potentially hazardous testing. Table 24 provides a list of agents that may alter
BP. They may affect BP in several ways, such as
Use of agents that can affect BP in a given patient affecting sodium balance; increasing adrenergic
should be suspected in the following situations: or suppressing parasympathetic neural activity;
(1) loss of control of previously well-controlled altering the production, release, or effectiveness
hypertension; (2) presence of comorbidities (par- of vasoactive hormones; or exerting direct effects
ticularly osteoarthritis); (3) biochemical evidence on the endothelium or vascular smooth muscle.

Table 24. Common substances associated with hypertension in humans
Prescription Drugs Street Drugs and Other “Natural Products”
Cortisone and other steroids Cocaine and cocaine withdrawal
(both cortico- and mineralo-), ACTH Ma Huang, “herbal ecstasy,” and other phenyl
Estrogens (usually just oral contraceptive propanolamine analogues
agents with high estrogenic activity) Nicotine and withdrawal
Nonsteroidal anti-inflammatory drugs Anabolic steroids
Phenylpropanolamines and analogues Narcotic withdrawal
Cyclosporine and Tacrolimus Methylphenidate
Erythropoietin Phencyclidine
Sibutramine Ketamine
Ketamine Ergotamine and other ergot-containing
Desflurane herbal preparations
Carbamazepine St. John’s Wort
Bromocryptine Food Substances
Metoclopramide
Antidepressants (especially venlafaxine) Sodium chloride
Buspirone Ethanol
Clonidine, BB combination Licorice
Pheochromocytoma: BB without alpha Tyramine-containing foods (with MAO-I)
blocker first; glucagon Chemical Elements and Other Industrial
Chemicals
Clozapine
Lead
Mercury
Thallium and other heavy metals
Lithium salts, especially the chloride

ACTH, adrenocorticotropic hormone; BB, beta blocker

Note: Bold-faced items within the list represent the substances of more current clinical importance.

Drugs and Other Agents Affecting Blood Pressure 59

Detection. and both obesity and aging predispose to medication classes consumed by hypertensive osteoarthritis as well as diabetes. celecoxib or naproxen) induced a significant although changes in cortisol and cellular calcium increase in average 24-hour SBP in type 2 diabetic concentrations also may play a role. Cyclooxygenase-2 (COX-2) inhibitors also grams) may lower BP in the first 4 hours after may cause elevation in BP. BP responses vary within the class of the of ethanol a day or approximately two “drinks” NANSAIDs. often accompanied by peripheral edema and Larger amounts of alcohol ingestion have a dose.10 The use of ABPM has high. At equally effect on BP. rofecoxib. older agents like Indomethacin are the most extensively stud- Modest consumption of alcohol (e. This accounts for some of the discrep. however. a ingestion. natriuretic prostaglandins such as PGE2. treatment with rofecoxib (but not to result from sympathetic neural activation. 60 The Seventh Report of the Joint National Committee on Prevention. supporting a salt-retention mecha- related effect on BP.g. Alcohol patients. This is a major concern Nonaspirin nonsteroidal anti-inflammatory drugs because diabetic patients are often older and (NANSAIDs) represent one of the most common obese. increases in pressure are daily) is not generally associated with BP increases. double-blind randomized trial was conducted haps at the time a patient is seen for an office visit evaluating the effects of celecoxib. nism of hypertension associated with the loss of motensive subjects. A large intake of alcohol (>30 nism.373 Thus. Reduction in the well-described vasodilatory underscoring the importance of the timing of BP effects of some prostaglandins are another mecha- measurement. weight gain. <30 grams ied.368. or in the ER during withdrawal). The mechanism(s) of alcohol’s effect efficacious doses for the management of on BP are unclear but appear predominantly osteoarthritis. and Treatment of High Blood Pressure . Approximately 10–15 hours later (per. both in hypertensive and nor.. patients receiving ACEIs or angiotensin-II receptor blockers.369 lighted the biphasic effects of alcohol on BP. patients with osteoarthritis whose hypertension ancies reported in the literature about alcohol’s was treated with ACEIs or ARBs. current data suggest that cer- Nonaspirin Nonsteroidal Anti-Inflammatory tain NSAIDs and COX-2 inhibitors may have Drugs destabilizing effects on BP control in diabetic hypertensive patients. Evaluation. Among the NANSAIDs. BP increase may and naproxen on 24-hour BP in type 2 diabetic be noted.370–372 Recently.

whether prescription. goals but to alert clinicians to missed patient empathetic environment. and to rule out iatrogenic causes of elevated blood pressure. and improved clinician to advance therapy when a goal has not health status. This may be due in positive experiences with.or personal digital assistant- their clinical skills. and trust in. and a posi. satisfaction.377 in their own care. or over-the-counter. ■ Schedule more frequent appointments and health care personnel ■ Ask what the patient takes for pain. necessary prescription refills. their clini. ease of access. contact with patients who are not achieving goal blood pressure. represents clinical inertia lifestyle. Feedback reminders from any source tive regard from the office staff.Improving Hypertension Control Issues Dealing With Adherence to Regimens Clinical Inertia Behavioral models suggest that the most effective There is a broad range of clinician commitment to therapy prescribed by the most careful clinician optimal hypertension therapy (table 26). Clinician awareness and monitoring Table 25. all are known to (computer-based. despite knowing that the to establish and maintain a health-promoting patient is not at goal BP. ■ Recognize depression and other psychiatric illnesses. Better communication improves outcomes. • Sudden loss of control.374 Table 26. Provide empathetic reinforcement ■ Anticipate adherence problems for young men. ■ Adopt an attitude of concern coupled with hope and interest in the ■ Consider nonadherence as a cause of: patient’s future. Failure will control hypertension only if the patient is to titrate or combine medications and to reinforce motivated to take the medication as directed and lifestyle modifications. Patients often evaluate a clinician’s been achieved (table 27). One of the most effective is patient correlate with positive outcomes of care. interactive. Such systems can be competence by their customer service skills. part to clinician focus on relieving symptoms. lack of familiarity with clinical guidelines. not electronic (computer. • Failure to reach goal blood pressure ■ Provide positive feedback for blood pressure and behavioral • Resistant hypertension improvement. ■ If blood pressure is not at goal. respect.376 (table 25). a cians. ask about behaviors to achieve ■ Encourage patients to bring in all medications from all blood pressure control. including panic attacks. physicians and other sources. ■ Hold exit interviews to clarify regimen. Motivation improves when patients have which must be overcome. guidelines). Improving Hypertension Control 61 . to use decision support systems that prompt the- such as adherence. A patient may tell you that complementary. Clinician-patient partnerships that are based on A number of approaches are available to over- trust. minimal waiting time.375 Customer service includes based) or paper-based (flow charts. automated telephone-based. influence provider satisfaction and patient adher. outside auditors) can be ence. nurse care managers. Clinicians are the role model and should very effective in not only helping to achieve BP train staff by providing a positive. or dis- empathy builds trust and is a potent motivator comfort in titrating to a goal. ■ Be willing to change unsuccessful regimens and search for What Can the Clinician Do? those more likely to succeed. to each visit for review they understand but tell the exit interviewer that they do not. algorithms. and a holistic knowledge of the come clinical inertia. and manage appropriately. and patients’ comfort and willingness to participate laboratory abnormalities. This will increase appointments.

blood pressure must be measured. Collaborate with other health professionals The National Committee for Quality Assurance ■ Use complementary skills and knowledge of nurses. Organize care delivery systems have the information they need to reliably ■ Schedule next appointment before patient leaves office. Detection. All health care profession- the patient to state specific behaviors to carry out treatment als must be committed to enhancing BP control recommendations. educate staff to provide patient encourage. dentists. pharmaco- or symptoms”. dietary supple. occupational health departments. identi- available. ■ Inform the patient about recommended treatment. pharmacists. Table 29. Evaluation. fy cases.g.381 BP con- trol rates by monitored physicians have increased Patient-centered behavioral interventions. pharmacists.ncqa. Employer Data and Information Set (HEDIS). preferably computer-based. Patient education about treatment nurses. and podiatrists) ■ Discuss patient’s concerns.. Patients should be told counseling. patients who have suffered an MI. pharmacists. dentists. ■ Assess the patient’s understanding and acceptance of the registered dietitians.380 Clinicians should periodically audit their own patient files to assess their degree of Role of Other Health Care Professionals compliance and success with established goals and treatment interventions. improve BP control (table 28).378 their BP on each visit and encouraged not only to Nurse clinicians and pharmacists have proven ask for those numbers but to also inquire as to their effectiveness in helping to achieve goal BP. and provide a patient lifestyles and BP control (table 29). ■ Elicit concerns and questions. physician assistants. Public health nurses and community lifestyle including diet. and provide opportunities for and educate patients. and lay community staying on treatment. Enforcement of HEDIS guidelines by managed ■ Follow up with patients who missed appointments. patients whose BP is <140/90 mmHg. and contact patients to confirm appointments. care organizations has successfully increased the ■ Use an office-based system approach for monitoring and appropriate use of ACEIs in HF and of BBs in followup (e. and alcohol intake. nutri- diagnosis of hypertension. such as to as high as 59 percent. if that is the case. and adherence to treatment. a set of standardized performance measures ■ Refer selected patients for more intensive counseling. written copy.g. and workers have all contributed to better hyperten- provide specific written information about the role of sion control. to influence or reinforce instructions to improve ■ Tell the patient the blood pressure reading.org/Programs/HEDIS). (http://www. education • One cannot tell if blood pressure is elevated by “feeling about effective lifestyle interventions. Clinicians must work with other health care professionals (e. assess quality of health care ■ Use appointment reminders. through reinforcing messages about the risks of ■ Emphasize: • Need to continue treatment hypertension. the importance of managing both • Control does not mean cure SBP and DBP and achieving goal BP. BP control. tion educators. and clarify misunderstandings. outreach workers in high-risk communities are ments. logic therapies. worksite ■ Come to agreement with the patient on goal blood pressure. registered dietitians. licensed nutritionists. and podiatrists. Table 27. computer or chart reminders. managed care ■ Ask the patient to rate from 1 to 10 his or her chance of organizations. (NCQA) has established the Health Plan physician assistants. Nurse-managed hypertension clinics. physical activity. designed to ensure that purchasers and consumers 62 The Seventh Report of the Joint National Committee on Prevention.379 why BP is above the goal. optometrists. nurse case managers and other Table 28. disease management monitors physician records for the percent of aids). NCQA now ment. They Commercial health plans may provide resources also should be given a written record to keep as for chart auditing or other assistance to improve their part of this commitment.. use standard brochures when also helpful through their efforts to screen. refer and track followup appointments. optometrists. and Treatment of High Blood Pressure .

beverages. ■ Suggest common interest group activities (e.g. by allied health care personnel. action. often forgot to take their medica- explain to patients that the terms “hypertension” tion.385 Improving Hypertension Control 63 . Characterization of Patients Leading to Tailored Goal Setting and Behavioral Change Therapy The clinician and patient must agree upon BP There is a broad range of patient involvement in. ■ Minimize the cost of therapy. along with motivational hypertensive patients found that the individuals interviewing. and were most likely to consume ■ Simplify the regimen to once-daily dosing. abuse tobacco.. and small incremental goal setting modification plan. Clinicians should tobacco abuse). This last take medications just before or after brushing teeth.. family members or other social supports also may ■ Encourage self-monitoring with validated blood pressure be useful (table 31). The take medications as prescribed to feel better and patients in the last group (23 percent) were more to reduce risks. a walking ■ Encourage gradual sustained weight loss. information on the hazards related to lack for specific components of the medication and lifestyle of BP control. Behavioral changes are more successfully facilitat- sumption.g. and smoking. and took their medication. rather than assigning the same inter- fell into 4 categories. and maintenance). Optimal management strategies ing that making behavioral changes is ultimately are likely to differ for patient types.g. healthy weight. hypertension therapy. Individualize the regimen quences of hypertension or failure to take their ■ Include patient in decision making. group will probably require persistent reinforce- ■ Agree with the patient on realistic short-term objectives ment. the patient’s goals when providing advice and encour. likely to be male and young.382 These attitudes must be The third group (22 percent) had the highest BMI. goals and an estimated achievement time. if possible. and had a lower BP control rate. Healthy his or her responsibility. patient must be empowered with the understand- aging adherence. salt and alcohol con. were least afraid of the conse- Table 30. The Patient attitudes are greatly influenced by cultural second group (16 percent) tended to rely on med- differences. contemplation. without informing their physician. behaviors including food. recognize financial issues and Table 31. and stop medication ■ Incorporate treatment into patient’s daily lifestyle. group) to enhance mutual support and motivation. those goals should be clearly recorded in the Management strategies need to be focused on the chart. beliefs. knew less about hypertension. e. Involvement of ■ Encourage discussion of adverse drug effects and concerns. medication. informed about hypertension. the health system.Patient Factors (39 percent) was health-oriented. physical preparation. involve caring family affording medications. A cluster analysis of 727 ed using this approach. patients need specific education they will likely require more frequent office visits designed to help them modify their lifestyle and to or contact with nurses or other providers. and and commitment to. Promote social support systems enlist local community and national programs to assist in ■ With full permission of the patient. members or other social support (e. and previous experiences with ication rather than lifestyle to control their BP. devices. These and “high BP” are used interchangeably and that patients may benefit most from clinical counseling neither indicates an anxiety state. alcohol. they progress through a series well as a patient’s beliefs and involvement with of stages (precontemplation.383 The largest group vention to every patient.384. discussion at each visit. With the support of the clinician.. As people make behav- lifestyles influence adherence to medication as ioral changes. In addition to and help with achieving lifestyle modifications. faith-based or ■ Indicate that adherence to the regimen will be a subject of community organizations) in the treatment process. understood and respected if the clinician is to did not practice health-promoting lifestyles build trust and increase communication with (except for low rates of alcohol consumption and patients and families (table 30). activity. ■ Encourage discussion of diet and physical activity. motivation.

Further. lifestyle modifications may be cost-free or may Clinicians must calibrate these devices (see Self. The price of medication is the Patient satisfaction with health care providers amount of money needed for purchase. and worksites on food bud- indicate how likely they are to follow the plan. Detection. therapy by registered dietitians improves the At visits where BP is above goal. Patients goal. and the predicts compliance with treatment. Evaluation. lower than office BP. Most pharma- ceutical companies have special needs programs Economic Barriers that are often handled through their marketing departments.nhlbi. budgets. Patients can be asked to use a 1–10 ranking to schools. Home. while the evidence for insurance concerns and social services may be structured training or self-monitoring is less clear. have been shown tion of persons who can assist the patient with to improve BP control. However. and Treatment of High Blood Pressure . smoking cessation and Measurement). obesity. and this information should A patient adhering to the DASH eating plan may be considered when assessing progress toward the require less medication and save money.nih..gov/. Patients often perceive that Additional Sources of Information lifestyle modifications such as following the DASH eating plan are expensive. communities. office BP should still be used to need to understand the important difference determine whether a patient is at goal. All clinicians cost is the outcome or consequences of not adher- need to provide positive. geting and meal planning. the clinician can use motivational their patients to these classes. and even premature death. patient-centered care ing to this treatment advice. important to overall adherence. or other chronic disease risk fac- accordingly. like counseling. which may include to satisfy and enable their patients to follow impaired quality of life. Home BP devices can be very useful tors. kidney failure.g. Nutrition educators offer classes in 64 The Seventh Report of the Joint National Committee on Prevention. This should be done. reduction of alcohol consumption). even save money (e. alterations in the health of patients who have high cholesterol. the by having the patient determine their BP with beneficial effects of lifestyle modification may the device in the presence of the clinician. Some patient-centered behavioral stroke. Medical nutrition interviewing to identify the barriers to adherence. include reduction in the amount and cost of determined BP tends to be approximately 5 mmHg prescribed medications and the cost of insurance. between the price of a medication and the cost of nonadherence. Clinicians should refer If not likely. The cost of medications may be a barrier to effec- tive treatment. The identifica- interventions.386 Patients should be advised that most in involving many patients in their own care. CVD. but following Additional information is available at the NHLBI these plans can be accomplished even on modest Web site http://www. treatment. in part. dia- treatment plan should be made and documented betes.

also known as case-control studies F Prospective studies. also known as cohort studies. use of statistical methods to combine the results from clinical trials RA Randomized controlled trials.3. The classification scheme is from the JNC 6 report and other NHBPEP Working Group Reports.9 Scheme Used for Classification of the Evidence 65 .S c h e m e U s e d f o r C l a s s i f i c at i o n o f t h e E v i d e n c e M Meta-analysis. also known as experimental studies RE Retrospective analyses. including historical or prospective followup studies X Cross-sectional surveys.4. also known as prevalence studies PR Previous review or position statements C Clinical interventions (nonrandomized) These symbols are appended to the citations in the reference list. The studies that provided evidence supporting the recommendations of this report were classified and reviewed by the staff and the Executive Committee.6.

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