Presentation on theme: "National High Blood Pressure Education Program"— Presentation transcript:
1National High Blood Pressure Education Program NIH PublicationNoNovember 1997This set of slides is provided by theU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceNational Institutes of HealthNational Heart, Lung, and Blood InstituteNational High Blood Pressure Education ProgramFull text of JNC VI may be downloaded from the NHLBI web site.
2National High Blood Pressure Education Program NIH PublicationNoNovember 1997National Heart, Lung, and Blood Institute (NHLBI) publications fall within the public domain (as do all Government publications). Hence, they are not copyrighted and may be reproduced or reprinted. NHLBI does ask, however, that reprinted material include a credit line acknowledging NHLBI as the source.Communications and Public Information BranchOffice of Prevention, Education, and Control
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4National High Blood Pressure Education Program NIH PublicationNoNovember 1997The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)
5Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood PressureExecutive Committee:Sheldon G. Sheps, M.D., ChairMayo Clinic and Mayo Foundation and Mayo Medical SchoolHenry R. Black, M.D., Chair of Chapter 1Rush-Presbyterian-St. Luke’s Medical CenterJerome D. Cohen, M.D., Chair of Chapter 2St. Louis University Health Sciences CenterNorman M. Kaplan, M.D., Chair of Chapter 3University of Texas Southwestern Medical SchoolKeith C. Ferdinand, M.D., Chair of Chapter 4Heartbeats Life CenterAram V. Chobanian, M.D.Boston UniversityHarriet P. Dustan, M.D.University of Vermont College of MedicineRay W. Gifford, Jr., M.D.Cleveland Clinic FoundationMarvin Moser, M.D.Yale University School of Medicine
6National High Blood Pressure Education Program Coordinating Committee Agency for Health Care Policy and ResearchAmerican Academy of Family PhysiciansAmerican Academy of Insurance MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Physician AssistantsAmerican Association of Occupational Health NursesAmerican College of CardiologyAmerican College of Chest PhysiciansAmerican College of Occupational and Environmental MedicineAmerican College of PhysiciansAmerican College of Preventive MedicineAmerican Dental AssociationAmerican Diabetes AssociationAmerican Dietetic AssociationAmerican Heart AssociationAmerican Hospital AssociationAmerican Medical AssociationAmerican Nurses’ Association, Inc.American Optometric AssociationAmerican Osteopathic AssociationAmerican Pharmaceutical AssociationAmerican Podiatric Medical AssociationAmerican Public Health AssociationAmerican Red CrossAmerican Society of Health-System PharmacistsAmerican Society of HypertensionAssociation of Black CardiologistsCitizens for Public Action on High Blood Pressure and Cholesterol, Inc.Council on Geriatric CardiologyHealth Care Financing AdministrationHealth Resources and Services AdministrationInternational Society on Hypertension in BlacksNational Black Nurses’ Association, Inc.National Center for Health Statistics, Centers for Disease Control and PreventionNational Heart, Lung, and Blood InstituteNational Hypertension AssociationNational Institute of Diabetes and Digestive and Kidney DiseasesNational Kidney FoundationNational Medical AssociationNational Optometric AssociationNational Stroke AssociationNHLBI Ad Hoc Committee on Minority PopulationsSociety for Nutrition EducationU.S. Department of Veterans’ Affairs
7JNC VI Table of Contents 1. Introduction2. Blood Pressure Measurement and Clinical Evaluation3. Prevention and Treatment of High Blood Pressure4. Special Populations and Situations
8Purpose of the JNC VI Report To use evidence-based medicine and consensus to report on contemporary approaches to hypertension prevention and control for use by primary care clinicians.
9Progress of the National High Blood Pressure Education Program Increased awareness, treatment, and controlDecreased morbidity and mortality from stroke and coronary heart disease (CHD)
10Public Health Challenges for the National High Blood Pressure Education Program Prevent blood pressure rise with ageDecrease prevalenceIncrease awareness and detectionImprove controlReduce cardiovascular risks
11Public Health Challenges for the National High Blood Pressure Education Program (continued) Recognize importance of controlled isolated systolic hypertensionRecognize importance of high-normal blood pressureReduce demographic variationsImprove opportunities for treatment
12Awareness, Treatment, and Control of High Blood Pressure in Adults*
13Percent Decline in Age-Adjusted Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: United States,The decline in age-adjusted mortality for stroke in the total population is 59.0%.*Age-adjusted to the 1940 U.S. census population.
14Percent Decline in Age-Adjusted Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States,The decline in age-adjusted mortality for CHD in the total population is 53.2%.*Age-adjusted to the 1940 U.S. census population.
15Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995 253**Provisional data.Adjusted for age, race, and sex.
16Prevalence of Heart Failure, by Age, 1976-80 and 1988-91
17Summary of Chapter 1Hypertension awareness, treatment, and control rates have increased over the past 3 decades. The rates of increase have lessened since JNC V.Age-adjusted mortality for stroke and CHD declined during this time but now appear to be leveling.The incidence of end-stage renal disease and the prevalence of heart failure are increasing.
18Summary of Chapter 1 (continued) Randomized controlled trials provide the best method of estimating benefit of treatment and source of information for clinical policy, but they have limitations.Prevention and treatment of hypertension and target organ disease remain important public health challenges that must be addressed.
19Blood Pressure Measurement Patients should be seated with back supported and arm bared and supported.Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement.Measurement should begin after at least 5 minutes of rest.Appropriate cuff size and calibrated equipment should be used.Both SBP and DBP should be recorded.Two or more readings should be averaged.
20Advantages of Self-Measurement Identifies “white-coat hypertension”Assesses response to medicationImproves adherence to treatmentPotentially reduces costsUsually provides lower readings than those recorded in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)
21Ambulatory Measurement Ambulatory monitoring can provide:readings throughout day during usual activitiesreadings during sleep to assess nocturnal changesmeasures of SBP and DBP loadAmbulatory readings are usually lower than in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)
23Recommendations for Followup Based on Initial Measurements
24Evaluation Objectives To identify known causesTo assess presence or absence of target organ damage and cardiovascular diseaseTo identify other risk factors or disorders that may guide treatment
25Evaluation Components Medical historyPhysical examinationRoutine laboratory testsOptional tests
26Medical History Duration and classification of hypertension Patient history of cardiovascular diseaseFamily historySymptoms suggesting causes of hypertensionLifestyle factorsCurrent and previous medications
27Physical Examination Blood pressure readings (2 or more) Verification in contralateral armHeight, weight, and waist circumferenceFunduscopic examinationExamination of the neck, heart, lungs, abdomen, and extremitiesNeurological assessment
28Laboratory Tests and Other Diagnostic Procedures Determine presence of target organ damage and other risk factorsSeek specific causes of hypertension
29Laboratory Tests Recommended Before Initiating Therapy UrinalysisComplete blood countBlood chemistry (potassium, sodium, creatinine, and fasting glucose)Lipid profile (total cholesterol and HDL cholesterol)12-lead electrocardiogram
30Optional Tests and Procedures Creatinine clearanceMicroalbuminuria24-hour urinary proteinSerum calciumSerum uric acidFasting triglyceridesLDL cholesterolGlycosolated hemoglobinThyroid-stimulating hormonePlasma renin activity/ urinary sodium determinationLimited echocardiographyUltrasonographyMeasurement of ankle/arm index
31Examples of Identifiable Causes of Hypertension Renovascular diseaseRenal parenchymal diseasePolycystic kidneysAortic coarctationPheochromocytomaPrimary aldosteronismCushing syndromeHyperparathyroidismExogenous causes
32Components of Cardiovascular Risk in Patients With Hypertension Major Risk Factors:SmokingDyslipidemiaDiabetes mellitusAge older than 60 yearsSex (men or postmenopausal women)Family history of cardiovascular disease
33Clinical Risk Factors for Stratification of Patients With Hypertension Heart diseasesStroke or transient ischemic attackNephropathyPeripheral arterial diseaseRetinopathy
36Summary of Chapter 2Blood pressure classified as optimal, normal, high-normal, or stages 1, 2, or 3.Recommendations for detection, confirmation, and evaluation remain consistent with those in the JNC V report.In self-monitoring and ambulatory measurement, hypertension is now defined as SBP >135 mm Hg and DBP 85 mm Hg.
37Summary of Chapter 2 (continued) New sections discuss genetics and clinical clues to identifiable causes of hypertension.New tables list cardiovascular risk factors and describe risk stratification.
38Primary PreventionPrimary prevention offers an opportunity to interrupt the costly cycle of managing hypertension.A population-wide approach can reduce morbidity and mortality.Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.Blood pressure rise with age is not inevitable.Lifestyle modifications have been shown to lower blood pressure.
39Goal of Hypertension Prevention and Management To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining:SBP < 140 mm HgDBP < 90 mm Hgcontrolling other cardiovascular risk factors
40Algorithm forTreatment of Hypertension Add agent from different classInadequate response but well toleratedAlgorithm forTreatment of HypertensionContinue adding agents from other classes. Consider referral to a hypertension specialist.Lifestyle ModificationsBegin or ContinueNot at Goal Blood PressureInitial Drug ChoicesNot at Goal Blood PressureNot at Goal Blood PressureSubstitute drug from different classNo response or troublesome side effects
41Algorithm for Treatment of Hypertension (continued) Begin or Continue Lifestyle ModificationsLose weightLimit alcoholIncrease physical activityReduce SodiumMaintain potassiumMaintain calcium and magnesiumStop smokingReduce saturated fat, cholesterolNot at Goal Blood Pressure
42Algorithm for Treatment of Hypertension (continued) Begin or Continue Lifestyle ModificationsNot at Goal Blood Pressure (< 140/90 mm Hg)lower goals for patients with diabetes or renal diseaseInitial Drug Choices
43Algorithm for Treatment of Hypertension (continued) Not at Goal Blood PressureInitial Drug ChoicesUncomplicatedSpecific IndicationsCompelling IndicationsStart at low dose and titrate upward.Low-dose combinations may be appropriate.Not at Goal Blood Pressure
44Algorithm for Treatment of Hypertension (continued) Initial Drug Choices*UncomplicatedDiuretics-blockers*Based on randomized controlled trials.
45Algorithm for Treatment of Hypertension (continued) Initial Drug Choices*Compelling IndicationsHeart failureACE inhibitorsDiureticsMyocardial infarction-blockers (non-ISA)ACE inhibitors (with systolic dysfunction)Diabetes mellitus (type 1) with proteinuriaIsolated systolic hypertension (older persons)Diuretics preferredLong-acting dihydropyridine calcium antagonists*Based on randomized controlled trials.
46Algorithm for Treatment of Hypertension (continued) Initial Drug ChoicesSpecific indications for the following drugs:ACE inhibitorsAngiotensin II receptorblockers-blockers--blockers-blockersCalcium antagonistsDiuretics
47Specific Drug Indications Some antihypertensive drugs may have favorable effects on comorbid conditions:Angina-blockersCalcium antagonistsAtrial tachycardia and fibrillationNondihydropyridinecalcium antagonistsHeart failureCarvedilolLosartanMyocardial infarctionDiltiazemVerapamil
48Specific Indications (continued) Some antihypertensive drugs may have favorable effects on comorbid conditions:Cyclosporine-induced hypertensionCalcium antagonistsDiabetes mellitus (1 and 2) with proteinuriaACE inhibitors (preferred)Diabetes mellitus (type 2)Low-dose diureticsDyslipidemia-blockersProstatism (benign prostatic hyperplasia)Renal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL[ mol/L])ACE inhibitors
49Specific Indications (continued) Some antihypertensive drugs may have favorable effects on comorbid conditions:Essential tremorNoncardioselective -blockersHyperthyroidism-blockersMigraineNondihydropyridine calciumantagonistsOsteoporosisThiazidesPerioperative hypertension-blockers
50Algorithm for Treatment of Hypertension (continued) Initial Drug ChoicesNot at Goal Blood Pressure (< 140/90 mm Hg)No response or troublesome side effectsInadequate response but well toleratedSubstitute another drug from different classAdd second agent from different class (diuretic if not already used)Not at Goal Blood Pressure (<140/90 mmHg)
51Algorithm for Treatment of Hypertension (continued) Substitute drug from different classAdd second agent from different classNot at Goal Blood Pressure (< 140/90 mm Hg)Continue adding agents from other classes.Consider referral to a hypertension specialist.
52Algorithm for Treatment of Hypertension Add agent from different classInadequate response but well toleratedAlgorithm for Treatment of HypertensionContinue adding agents from other classes. Consider referral to a hypertension specialist.Lifestyle ModificationsBegin or ContinueNot at Goal Blood PressureInitial Drug ChoicesNot at Goal Blood PressureNot at Goal Blood PressureSubstitute drug from different classNo response or troublesome side effects
53Lifestyle Modifications For Prevention and ManagementLose weight if overweight.Limit alcohol intake.Increase aerobic physical activity.Reduce sodium intake.Maintain adequate intake of potassium.For Overall and Cardiovascular HealthMaintain adequate intake of calcium and magnesium.Stop smoking.Reduce dietary saturated fat and cholesterol.
54Pharmacologic Treatment Decreases cardiovascular morbidity and mortality based on randomized controlled trials.Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.
55Special Considerations in Selecting Drug Therapy DemographicsCoexisting diseases and therapiesQuality of lifePhysiological and biochemical measurementsDrug interactionsEconomic considerations
56Drug TherapyA low dose of initial drug should be used, slowly titrating upward.Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours.Combination therapies may provide additional efficacy with fewer adverse effects.
57Classes of Antihypertensive Drugs ACE inhibitorsAdrenergic inhibitorsAngiotensin II receptor blockersCalcium antagonistsDirect vasodilatorsDiuretics
58Combination Therapies -adrenergic blockers and diureticsACE inhibitors and diureticsAngiotensin II receptor antagonists and diureticsCalcium antagonists and ACE inhibitorsOther combinations
59Followup Follow up within 1-2 months after initiating therapy. Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications.Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose.Consider reducing dose and number of agents after1 year at or below goal.
60Causes for Inadequate Response to Drug Therapy PseudoresistanceNonadherence to therapyVolume overloadDrug-related causesAssociated conditionsIdentifiable causes of hypertension
61Guidelines for Improving Adherence to Therapy Be aware of signs of nonadherence.Establish goal of therapy.Encourage a positive attitude about achieving goals.Educate patients about the disease and therapy.Maintain contact with patients.Encourage lifestyle modifications.Keep care inexpensive and simple.
62Guidelines for Improving Adherence to Therapy (continued) Integrate therapy into daily routine.Prescribe long-acting drugs.Adjust therapy to minimize adverse affects.Continue to add drugs systematically to meet goal.Consider using nurse case management.Utilize other health professionals.Try a new approach if current regime is inadequate.
63Hypertensive Emergencies and Urgencies Emergencies require immediate blood pressure reduction to prevent or limit target organ damage.Urgencies benefit from reducing blood pressure within a few hours.Elevated blood pressure alone rarely requires emergency therapy.Fast-acting drugs are available.
64Drugs Available for Hypertensive Emergencies VasodilatorsNitroprussideNicardipineFenoldopamNitroglycerinEnalaprilatHydralazineAdrenergic InhibitorsLabetalolEsmololPhentolamine
65Summary of Chapter 3Modifying lifestyles in populations can have a major protective effect against high blood pressure and cardiovascular disease.Lowering blood pressure decreases death from stroke, coronary events, and heart failure; slows progression of renal failure; prevents progression to more severe hypertension; and reduces all-cause mortality.A diuretic and/or a -blocker should be chosen as initial therapy unless there are compelling or specific indications for another drug.
66Summary of Chapter 3 (continued) Management strategies can improve adherence through the use of multidisciplinary teams.The reductions in cardiovascular events demonstrated in randomized controlled trials have important implications for managed care organizations.Management of hypertensive emergencies requires immediate action whereas urgencies benefit from reducing blood pressure within a few hours.
67Special Populations Racial and ethnic groups Children and adolescents WomenOlder persons
69Children and Adolescents Blood pressure at 95th or higher percentile is considered elevated.Lifestyle modifications should be recommended.Drug therapy should be prescribed for higher levels of blood pressure.Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.
7095th Percentile of Blood Pressure by Selected Ages and Height in Girls
7195th Percentile of Blood Pressure by Selected Ages and Height in Boys
72WomenClinical trials have not demonstrated significant differences between men and women in treatment response and outcomes.Some women using oral contraceptives may have significant increases in blood pressure.High blood pressure in not a contraindication to hormone replacement therapy.
73Pregnant WomenChronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation.Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both.ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women.Methyldopa is recommended for women diagnosed during pregnancy.
75Antihypertensive Drugs Used in Pregnancy (continued)
76Older Persons Hypertension is common. SBP is better predictor of events than DBP.Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office.Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.
77Older Persons (continued) Therapy should begin with lifestyle modifications.Starting doses for drug therapy should be lower than those used in younger adults.Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.
79Cardiovascular Diseases Cerebrovascular diseaseIndication for treatment, except immediately after ischemic cerebral infarctionCoronary artery diseaseBenefits of therapy well establishedLeft ventricular hypertrophyAntihypertensive agents (except direct vasodilators) indicatedReduced weight and decreased sodium intake beneficial
80Cardiovascular Diseases (continued) Cardiac failureACE inhibitors, especially with digoxin or diuretics, shown to prevent subsequent heart failurePeripheral arterial diseaseLimited or no data available
81Renal DiseaseHypertension may result from renal disease that reduces functioning nephrons.Evidence shows a clear relationship between high blood pressure and end-stage renal disease.Blood pressure should be controlled to < 130/85 mm Hg or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours.ACE inhibitors work well to control blood pressure and slow progression of renal failure.
82Diabetes MellitusDrug therapy should begin along with lifestyle modifications to reduce blood pressure to< 130/85 mm Hg.ACE inhibitors, -blockers, calcium antagonists, and low dose-diuretics are preferred.Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering agents.
83DyslipidemiaCoexistence of hypertension and dyslipidemia requires aggressive management.Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity.Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals.
84Sleep ApneaObstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences.Improved hypertension control has been reported following treatment of sleep apnea.
85Bronchial Asthma or Chronic Airway Disease Elevated blood pressure is common in acute asthma and is possibly related to treatment with systemic corticosteroids or -agonists.-blockers and--blockers may exacerbate asthma.ACE inhibitors only rarely induce bronchospasm.Over-the-counter medications are generally safe in limited doses for patients on drug therapy.
86Gout Diuretics can increase serum uric acid levels. Diuretics should be avoided in patients with gout.Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.
87Patients Undergoing Surgery When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg.Those not on prior drug therapy may be best treated with cardioselective-blockers before and after surgery.Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.
88Cocaine and Amphetamines Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems.Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction.Acute amphetamine toxicity is similar to that of cocaine but longer in duration.Ongoing cocaine abuse does not appear to cause chronic hypertension.
89Immunosuppressive Agents Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations.Treatment is based on vasodilation including dihydropyridine calcium antagonists.
90ErythropoietinErythropoietin often increases blood pressure in treatment of patients with end-stage renal disease.Management includes optimal volume control, antihypertensive agents, and reducing erythopoietin dose or changing method of administration.
91Other Chemical Agents That May Induce Hypertension Mineralocorticoids and derivativesAnabolic steroidsMonoamine oxidase inhibitorsLeadCadmiumBromocriptine
92Summary of Chapter 4Racial and ethnic groups are growing segments of our society. The prevalence of hypertension and control rates differ across groups. Clinicians should be aware of social and cultural factors when managing hypertension.Guidelines are provided for management of children and women with hypertension.In older persons, diuretics are preferred and long-acting dihydropyridine calcium antagonists may be considered.
93Summary of Chapter 4 (continued) Specific therapy for patients with left ventricular hypertrophy, coronary artery disease, and heart failure are outlined.Patients with renal insufficiency with greater than g/day of proteinuria should be treated to a goal of 125/75 mm Hg; those with less proteinuria should be treated to 130/85 mm Hg. ACE inhibitors have additional renoprotective effects.Patients with diabetes should be treated to a therapy goal of below 130/85 mm Hg.
94A Population-Wide Strategy A population-wide strategy to reduce overall blood pressure by only a few mm Hg could affect overall cardiovascular morbidity and mortality as much as or more than treatment alone.