National High Blood Pressure Education Program

National High Blood Pressure Education Program
NIH Publication No November 1997 This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Heart, Lung, and Blood Institute National High Blood Pressure Education Program Full text of JNC VI may be downloaded from the NHLBI web site.

NIH Publication No November 1997 National 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 Branch Office of Prevention, Education, and Control

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bears no relationship to JNC VI. The slide set is provided for educational purposes. It may be disseminated freely, but may NOT to be used for commercial or product endorsement purposes. MedSlides Board of Directors

NIH Publication No November 1997 The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)

Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Executive Committee: Sheldon G. Sheps, M.D., Chair Mayo Clinic and Mayo Foundation and Mayo Medical School Henry R. Black, M.D., Chair of Chapter 1 Rush-Presbyterian-St. Luke’s Medical Center Jerome D. Cohen, M.D., Chair of Chapter 2 St. Louis University Health Sciences Center Norman M. Kaplan, M.D., Chair of Chapter 3 University of Texas Southwestern Medical School Keith C. Ferdinand, M.D., Chair of Chapter 4 Heartbeats Life Center Aram V. Chobanian, M.D. Boston University Harriet P. Dustan, M.D. University of Vermont College of Medicine Ray W. Gifford, Jr., M.D. Cleveland Clinic Foundation Marvin Moser, M.D. Yale University School of Medicine

National High Blood Pressure Education Program Coordinating Committee
Agency for Health Care Policy and Research American Academy of Family Physicians American Academy of Insurance Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Physician Assistants American Association of Occupational Health Nurses American College of Cardiology American College of Chest Physicians American College of Occupational and Environmental Medicine American College of Physicians American College of Preventive Medicine American Dental Association American Diabetes Association American Dietetic Association American Heart Association American Hospital Association American Medical Association American Nurses’ Association, Inc. 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 Association of Black Cardiologists Citizens for Public Action on High Blood Pressure and Cholesterol, Inc. Council on Geriatric Cardiology Health Care Financing Administration Health Resources and Services Administration International Society on Hypertension in Blacks National Black Nurses’ Association, Inc. National Center for Health Statistics, Centers for Disease Control and Prevention National Heart, Lung, and Blood Institute National Hypertension Association National Institute of Diabetes and Digestive and Kidney Diseases National Kidney Foundation National Medical Association National Optometric Association National Stroke Association NHLBI Ad Hoc Committee on Minority Populations Society for Nutrition Education U.S. Department of Veterans’ Affairs

JNC VI Table of Contents
1. Introduction 2. Blood Pressure Measurement and Clinical Evaluation 3. Prevention and Treatment of High Blood Pressure 4. Special Populations and Situations

Purpose 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.

Progress of the National High Blood Pressure Education Program
Increased awareness, treatment, and control Decreased morbidity and mortality from stroke and coronary heart disease (CHD)

Public Health Challenges for the National High Blood Pressure Education Program
Prevent blood pressure rise with age Decrease prevalence Increase awareness and detection Improve control Reduce cardiovascular risks

Public Health Challenges for the National High Blood Pressure Education Program (continued)
Recognize importance of controlled isolated systolic hypertension Recognize importance of high-normal blood pressure Reduce demographic variations Improve opportunities for treatment

Awareness, Treatment, and Control of High Blood Pressure in Adults*

Percent 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.

Percent 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.

Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995
253* *Provisional data. Adjusted for age, race, and sex.

Prevalence of Heart Failure, by Age, 1976-80 and 1988-91

Summary of Chapter 1 Hypertension 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.

Summary 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.

Blood 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.

Advantages of Self-Measurement
Identifies “white-coat hypertension” Assesses response to medication Improves adherence to treatment Potentially reduces costs Usually provides lower readings than those recorded in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

Ambulatory Measurement
Ambulatory monitoring can provide: readings throughout day during usual activities readings during sleep to assess nocturnal changes measures of SBP and DBP load Ambulatory readings are usually lower than in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

Classification of Blood Pressure for Adults

Recommendations for Followup Based on Initial Measurements

Evaluation Objectives
To identify known causes To assess presence or absence of target organ damage and cardiovascular disease To identify other risk factors or disorders that may guide treatment

Evaluation Components
Medical history Physical examination Routine laboratory tests Optional tests

Medical History Duration and classification of hypertension
Patient history of cardiovascular disease Family history Symptoms suggesting causes of hypertension Lifestyle factors Current and previous medications

Physical Examination Blood pressure readings (2 or more)
Verification in contralateral arm Height, weight, and waist circumference Funduscopic examination Examination of the neck, heart, lungs, abdomen, and extremities Neurological assessment

Laboratory Tests and Other Diagnostic Procedures
Determine presence of target organ damage and other risk factors Seek specific causes of hypertension

Laboratory Tests Recommended Before Initiating Therapy
Urinalysis Complete blood count Blood chemistry (potassium, sodium, creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram

Optional Tests and Procedures
Creatinine clearance Microalbuminuria 24-hour urinary protein Serum calcium Serum uric acid Fasting triglycerides LDL cholesterol Glycosolated hemoglobin Thyroid-stimulating hormone Plasma renin activity/ urinary sodium determination Limited echocardiography Ultrasonography Measurement of ankle/arm index

Examples of Identifiable Causes of Hypertension
Renovascular disease Renal parenchymal disease Polycystic kidneys Aortic coarctation Pheochromocytoma Primary aldosteronism Cushing syndrome Hyperparathyroidism Exogenous causes

Components of Cardiovascular Risk in Patients With Hypertension
Major Risk Factors: Smoking Dyslipidemia Diabetes mellitus Age older than 60 years Sex (men or postmenopausal women) Family history of cardiovascular disease

Clinical Risk Factors for Stratification of Patients With Hypertension
Heart diseases Stroke or transient ischemic attack Nephropathy Peripheral arterial disease Retinopathy

Risk Stratification

Treatment Strategies and Risk Stratification

Summary of Chapter 2 Blood 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.

New sections discuss genetics and clinical clues to identifiable causes of hypertension. New tables list cardiovascular risk factors and describe risk stratification.

Primary Prevention Primary 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.

Goal 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 Hg DBP < 90 mm Hg controlling other cardiovascular risk factors

Algorithm forTreatment of Hypertension
Add agent from different class Inadequate response but well tolerated Algorithm forTreatment of Hypertension Continue adding agents from other classes. Consider referral to a hypertension specialist. Lifestyle Modifications Begin or Continue Not at Goal Blood Pressure Initial Drug Choices Not at Goal Blood Pressure Not at Goal Blood Pressure Substitute drug from different class No response or troublesome side effects

Algorithm for Treatment of Hypertension (continued)
Begin or Continue Lifestyle Modifications Lose weight Limit alcohol Increase physical activity Reduce Sodium Maintain potassium Maintain calcium and magnesium Stop smoking Reduce saturated fat, cholesterol Not at Goal Blood Pressure

Begin or Continue Lifestyle Modifications Not at Goal Blood Pressure (< 140/90 mm Hg) lower goals for patients with diabetes or renal disease Initial Drug Choices

Not at Goal Blood Pressure Initial Drug Choices Uncomplicated Specific Indications Compelling Indications Start at low dose and titrate upward. Low-dose combinations may be appropriate. Not at Goal Blood Pressure

Initial Drug Choices* Uncomplicated Diuretics -blockers *Based on randomized controlled trials.

Initial Drug Choices* Compelling Indications Heart failure ACE inhibitors Diuretics Myocardial infarction -blockers (non-ISA) ACE inhibitors (with systolic dysfunction) Diabetes mellitus (type 1) with proteinuria Isolated systolic hypertension (older persons) Diuretics preferred Long-acting dihydropyridine calcium antagonists *Based on randomized controlled trials.

Initial Drug Choices Specific indications for the following drugs: ACE inhibitors Angiotensin II receptor blockers -blockers --blockers -blockers Calcium antagonists Diuretics

Specific Drug Indications
Some antihypertensive drugs may have favorable effects on comorbid conditions: Angina -blockers Calcium antagonists Atrial tachycardia and fibrillation Nondihydropyridine calcium antagonists Heart failure Carvedilol Losartan Myocardial infarction Diltiazem Verapamil

Specific Indications (continued)
Some antihypertensive drugs may have favorable effects on comorbid conditions: Cyclosporine-induced hypertension Calcium antagonists Diabetes mellitus (1 and 2) with proteinuria ACE inhibitors (preferred) Diabetes mellitus (type 2) Low-dose diuretics Dyslipidemia -blockers Prostatism (benign prostatic hyperplasia) Renal insufficiency (caution in renovascular hypertension and creatinine  3 mg/dL [ mol/L]) ACE inhibitors

Specific Indications (continued)
Some antihypertensive drugs may have favorable effects on comorbid conditions: Essential tremor Noncardioselective -blockers Hyperthyroidism -blockers Migraine Nondihydropyridine calcium antagonists Osteoporosis Thiazides Perioperative hypertension -blockers

Initial Drug Choices Not at Goal Blood Pressure (< 140/90 mm Hg) No response or troublesome side effects Inadequate response but well tolerated Substitute another drug from different class Add second agent from different class (diuretic if not already used) Not at Goal Blood Pressure (<140/90 mmHg)

Substitute drug from different class Add second agent from different class Not at Goal Blood Pressure (< 140/90 mm Hg) Continue adding agents from other classes. Consider referral to a hypertension specialist.

Algorithm for Treatment of Hypertension
Add agent from different class Inadequate response but well tolerated Algorithm for Treatment of Hypertension Continue adding agents from other classes. Consider referral to a hypertension specialist. Lifestyle Modifications Begin or Continue Not at Goal Blood Pressure Initial Drug Choices Not at Goal Blood Pressure Not at Goal Blood Pressure Substitute drug from different class No response or troublesome side effects

Lifestyle Modifications
For Prevention and Management Lose weight if overweight. Limit alcohol intake. Increase aerobic physical activity. Reduce sodium intake. Maintain adequate intake of potassium. For Overall and Cardiovascular Health Maintain adequate intake of calcium and magnesium. Stop smoking. Reduce dietary saturated fat and cholesterol.

Pharmacologic 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.

Special Considerations in Selecting Drug Therapy
Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions Economic considerations

Drug Therapy A 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.

Classes of Antihypertensive Drugs
ACE inhibitors Adrenergic inhibitors Angiotensin II receptor blockers Calcium antagonists Direct vasodilators Diuretics

Combination Therapies
-adrenergic blockers and diuretics ACE inhibitors and diuretics Angiotensin II receptor antagonists and diuretics Calcium antagonists and ACE inhibitors Other combinations

Followup 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 after 1 year at or below goal.

Causes for Inadequate Response to Drug Therapy
Pseudoresistance Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension

Guidelines 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.

Guidelines 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.

Hypertensive 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.

Drugs Available for Hypertensive Emergencies
Vasodilators Nitroprusside Nicardipine Fenoldopam Nitroglycerin Enalaprilat Hydralazine Adrenergic Inhibitors Labetalol Esmolol Phentolamine

Summary of Chapter 3 Modifying 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.

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.

Special Populations Racial and ethnic groups Children and adolescents
Women Older persons

Racial and Ethnic Groups

Children 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.

95th Percentile of Blood Pressure by Selected Ages and Height in Girls

95th Percentile of Blood Pressure by Selected Ages and Height in Boys

Women Clinical 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.

Pregnant Women Chronic 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.

Antihypertensive Drugs Used in Pregnancy

Antihypertensive Drugs Used in Pregnancy (continued)

Older 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.

Older 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.

Special Situations Cardiovascular diseases Sleep apnea
Renal disease Diabetes mellitus Dyslipidemia Sleep apnea Bronchial asthma Gout Surgery Various chemical agents

Cardiovascular Diseases
Cerebrovascular disease Indication for treatment, except immediately after ischemic cerebral infarction Coronary artery disease Benefits of therapy well established Left ventricular hypertrophy Antihypertensive agents (except direct vasodilators) indicated Reduced weight and decreased sodium intake beneficial

Cardiovascular Diseases (continued)
Cardiac failure ACE inhibitors, especially with digoxin or diuretics, shown to prevent subsequent heart failure Peripheral arterial disease Limited or no data available

Renal Disease Hypertension 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.

Diabetes Mellitus Drug 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.

Dyslipidemia Coexistence 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.

Sleep Apnea Obstructive 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.

Bronchial 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.

Gout 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.

Patients 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.

Cocaine 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.

Immunosuppressive Agents
Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations. Treatment is based on vasodilation including dihydropyridine calcium antagonists.

Erythropoietin Erythropoietin 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.

Other Chemical Agents That May Induce Hypertension
Mineralocorticoids and derivatives Anabolic steroids Monoamine oxidase inhibitors Lead Cadmium Bromocriptine

Summary of Chapter 4 Racial 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.

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.

A 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.

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