hypertension (mkk)

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THE JNC 7 REPORT

HYPERTENSION :Definition, Classification, Diagnosis & Prevention

Canra !i"o#o Nephrology Division, Medical School of Trisakti University Jakarta



Classification of BP for adults aged ! years or older"

The classification is #ased on the $ean of % or $ore properly

$easured seated BP readings on each of % or $ore office visits"

&n contrast 'ith the classification provided in the JNC (& report") ne' category designated pre*hypertension has #een added, and

stages % and + hypertension have #een co$#ined"

Patients 'ith pre*hypertension are at increased risk for progression to hypertension those in +-.!- to +/.!/ $$0g

BP range are at t'ice the risk to develop hypertension as those

'ith lo'er values"

C$%SSIIC%TION O '$OOD PRESS(RE



Categor) S)stolic Diastolic S)stolic Diastolic Categor)

1pti$al 2 %- 2 !- 2 %- 2 !- Nor$al

Nor$al 2 +- 2 !3

0igh*nor$al +- *+/ !3 4 !/ %- * +/ !- *!/ Prehypertension

Borderline hypertens 5- * 5/ /- 4 /5 5- * 3/ /- * // Stage &

6rade & 7$ild8 5- * 3/ /- 4 //

6rade % 7$oderate8 9- * :/ -- 4 -/ ; 9- ; -- Stage &&6rade + 7severe8 ; !- ; -

&solated systolichypertension

<5- 2 /- <5- 2 /- &solated systolichypertension

Su#group #orderline < 5- 2 /-

JNC 6 1997, WHO-ISH 1999, ESH/ESC 2003,

ESH/ESC 2007 JNC 7 2002

CLASSIFICATION OF BOOD PRESSURE

FOR ADUTS AGED 18 RS OR OLDERH)*ertension is efine as "loo *ress+re -./0. 11Hg



0ypertension affects appro=i$ately 3- $illion individuals in the

United States and appro=i$ately #illion individuals 'orld'ide"

>ecent data fro$ the ?ra$ingha$ 0eart Study suggest that

individuals 'ho are nor$otensive at 33 years of age have a /-@

lifeti$e risk for developing hypertension"

The relationship #et'een BP and risk of C(D events is continuous,

consistent, and independent of other risk factors"

The higher the BP, the greater the chance of $yocardial infarction,

0?, stroke, and kidney disease"

?or individuals aged 5- to :- years, each incre$ent of %- $$0g in

systolic BP or - $$0g in diastolic BP dou#les the risk of C(D

across the entire BP range fro$ 3.:3 to !3.3 $$0g"

C%RDIO2%SC($%R RIS3 %CTORS



&n clinical trials, antihypertensive therapy has #een

associated 'ith +3@ to 5-@ $ean reductions in stroke

incidence %-@ to %3@ in $yocardial infarction and $ore

than 3-@ in 0?"&t is esti$ated that in patients 'ith stage hypertension

and additional C(D risk factors, achieving a sustained %

$$0g decrease in systolic BP for - years 'ill prevent

death for every patients treated"

&n the presence of C(D or target*organ da$aged, only /

patients 'ould reAuire this BP reduction to prevent a death"

'ENEITS O $O!ERIN4 'P



0ypertension is the $ost co$$on pri$ary diagnosis in theUnited States 'ith +3 $illion office visits as the pri$ary

diagnosis"

&n the $aority of patients, controlling systolic

hypertension, 'hich is a $ore i$portant C(D risk factor

than diastolic BP e=cept in patients younger than 3- years

and occurs $uch $ore co$$only in older persons"

>ecent clinical trials have de$onstrated that effective BP

control can #e achieved in $ost patients 'ith hypertension,

#ut the $aority 'ill reAuire % or $ore antihypertensive

drugs"

'P CONTRO$ R%TE



Patients should #e seated Auietly for at least 3 $inutes in a

chair rather than on an e=a$ination ta#le, 'ith feet on the

floor and ar$ supported at heart level"

Measure$ent of BP in the standing position is indicated

periodically, especially in those at risk for postural

hypotension"

Systolic BP is the point at 'hich the first of % or $ore

sounds is heard 7phase 8 and diastolic BP is the point

#efore the disappearance of sound 7phase 38

%CC(R%TE 'P 5E%S(RE5ENT



Pts should #e seated 'ith their #acks supported, ar$s #ared at heart level >efrain fro$ s$oking or ingesting caffeine +-E preceding the $easure$ent

Start after at least 3E of rest

)ppropriate cuff siFeG the #ladder 'ithin the cuff should encircle at least!-@ of the ar$

Taken prefera#ly 'ith a $ercury sphyg$o$ano$eter or cali#rated aneroid$ano$eter or validated electronic device

The st appearance of sound 7phase 8 is used to define for SBP thedisappearance of sound 7phase 38 is used to define DBP

% or $ore readings separated #y % $in should #e averaged" &f the st readings differ #y $ore than 3 $$ 0g additional readings should #e

o#tained and averaged 1> G st is discarded to ensure that pts is rela=ed, the $ean of %nd 4 +rd

readings is calculated

%CC(R%TE 'P 5E%S(RE5ENT



" Provides infor$ation a#out BP during daily activities and

sleep

%" Harranted for evaluation of hypertension in the a#sence of

target*organ inury

+" 0elpful to assess patients 'ith apparent drug resistance,

hypotensive sy$pto$s 'ith antihypertensive $edications,

episodic hypertension, and autono$ic dysfunction

5" Provides a $easure of the percentage of BP readings that

are elevated, the overall BP load, and the e=tent BP

reduction during sleep

%5'($%TORY 'P 5ONITORIN4



%5'($%TORY 'P 5ONITORIN4

Useful in pts 'ith apparent drug resistance, hypotensive sy$pto$s

'ith antihypertensive drugs, episodic hypertension"

Seldo$ reAuired should not #e used to delay appropriate therapy

BP tends to #e higher in clinic than outside of the office 7'hite*coat hypertension8

)$#ulatory results are an average of -.3 $$ 0g lo'er thanoffice BP

No agree$ent on upper li$it of nor$al ho$e BP #ut reading of+3.!3 or greater should #e considered elevated" Definition 0TN5-./- or greater"

)'ake 2 +3.!3 $$ 0g and asleep %3.:3 $$ 0g" $aority BPfalls -*%-@ during the night



BP self*$easure$ents $ay #enefit patients #y providing

infor$ation on response to antihypertensive $edication,

i$proving patient adherence 'ith therapy, and inevaluating 'hite*coat hypertension"

&ndividuals 'ith a $ean BP of $ore than +3.!3 $$0g

$easured at ho$e are generally considered to #ehypertensive"

SE$65E%S(RE5ENT O 'P



Ivaluation of patients 'ith docu$ented 0ypertension has + o#ectives G

" To assess lifestyle and identify other C( risk factors or conco$itant

disorders that $ay affect prognosis and guide treat$ent 7see C(D risk

factors8

%" To reveal identifia#le causes of high BP 7see &dentifia#le of 0TN8

+" To assess the presence or a#sence of target*organ da$age and C(D

The data needed are acAuired through $edical history, physicale=a$ination, routine la#oratory tests, and other diagnostic procedures"

P%TIENTS E2%$(%TION



0ypertension

Cigarette s$oking

1#esity 7BM& ; +-8Physical inactivity

Dyslipide$ia

DM

Microal#u$inuria or e6?> 2 9-

)ge

7<33 yr for $en, <93 yr for 'o$en8

?a$ily history of pre$ature of C(D

7$en 2 33 yr or 'o$en 2 93 yr8

C%RDIO2%SC($%R RIS3 %CTORS

" Mayor >isk ?actors

0eart

K(0

)ngina or prior M& Prior coronary revasculariFation

0?

Brain

Stroke or T&)

CLD

P)D

>etinopathy

%" Target 1rgan Da$age



Sleep apnea

Drug induce or drug related

CLDPri$ary aldosteronis$

>enovascular Disease

Chronic steroid therapy and CushingEs syndro$e

Pheochro$ocyto$a

Coarctatio of the aorta

Thyroid or parathyroid disease

IDENTII%'$E C%(SE O HTN



>outine la#oratory tests reco$$ended #efore initiating

therapy include an electrocardiogra$ urinalysis #lood

glucose and he$atocrit seru$ potassiu$, creatinine, andcalciu$, and a lipid profile that includes high*density

lipoprotein cholesterol, lo'*density lipoprotein

cholesterol, and triglycerides"

1ptional tests include $easure$ent of urinary al#u$in

e=cretion or al#u$in.creatinine ratio"

$%' TEST & OTHER DI%4 TEST



1. Goals of Therapy The ulti$ate pu#lic health goal of antihypertensive therapy is the

reduction of C( and renal $or#idity and $ortality"

Because $ost patients 'ith hypertension 'ill reach the diastolicBP goal once systolic BP is at goal, the pri$ary focus should #e

on achieving the systolic BP goal 7?igure8

Treating systolic BP and diastolic BP to targets than are less than

5-./- $$0g is associated 'ith a decrease in C(Dco$plications"

&n patients 'ith hypertension 'ith dia#etes or renal disease, the

BP goal is less than +-.!- $$0g"

TRE%T5ENT



TREAT!ENT OF HPERTENSION

L"#$ %&'($ )*+"#"&"*.

N*& & G*( BP10/90 ))H #* &4*%$ 5"&4 D! * CD

I."&"( + 4*"$%

H'$&$.%"*. 5"&4*&

*)$((". ".+"&"*.%

H'$&$.%"*. 5"&4

*)$((". ".+"&"*.%

S&$ 1

T4":"+$ &'$ +"$&"%

C*.%"+$ ACE-I, ARB,BB, CCB * *);".&"*.

S&$ 2

2 +% *);".&"*.

#* )*%&

D% #* *)$((".

".+"&"*.

N*& & G*( BP

O&")":$ +*%$% *

++ ++"&"*.( +%



2. Lifestyle Modications

Maor lifestyle $odifications sho'n to lo'er BP include

'eight reduction those individuals 'ho are over'eight

adoption of Dietary )pproaches to Stop 0ypertension

eating plan, 'hich is rich in potassiu$ and calciu$

dietary sodiu$ reduction physical activity and

$oderation of alcohol consu$ption 7Ta#le +8



5oification Reco11enation %**ro8i1ate s)stolicre+ction, range

!eig9t re+ction 5aintain nor1al "o) #eig9t '5I;<6=-0>

<6=. 11Hg/. ?g #eig9tloss

%o*t D%SH eating *lanDietar) %**roac9es toSto* H)*ertension>

Cons+1e a iet ric9 in fr+its,

vegeta"les & lo# fat air) *ro+cts#it9 a re+ce content of sat+rate &

total fat

;6- 11Hg

Dietar) soi+1 re+ction Re+ce ietar) soi+1 inta?e to no

1ore t9an .. 1E@/$ =- g soi+1 orA g soi+1 c9lorie>

=6; 11Hg

P9)sical activit) Engage in reg+lar aero"ic *9)sical

activit) s+c9 as "ris? #al?ing at leastB. 1in *er a), 1ost a)s of t9e #ee?>

-60 11Hg

5oeration of alco9olcons+1*tion

$i1it cons+1*tion to no 1ore t9an =rin?s *er a) o or B. 1l et9anol,

eg, =- o "eer, . o #ine or B o ;.*roof #9is?e)> in 1ost 1en an no

1ore t9an rin? *er a) in #o1en

an lig9ter #eig9t *ersons

=6- 11Hg

LIFESTLE !ODIFICATIONS TO !ANAGE HPERTENSION

JNC VII, 2002



3. Pharmacologic Treatment

I=cellent clinical trial outco$e data prove that lo'ering BP

'ith several classes of drugs, including )ngiotensin*Converting InFy$ 7)CI8 inhi#itors, )ngiotensin*>eceptor

Blockers 7)>Bs8, *#lockers, Calciu$ Channel Blockers

7CCBs8, and thiaFide*type diuretics, 'ill all reduce the

co$plications of hypertension"

Ta#le 5 and Ta#le 3 provide a list of co$$only used

antihypertensive agents"

The list of co$pelling indications reAuiring the use of otherantihypertensive drugs as initial therapy are list in Ta#le 9"

&f a drug isnEt tolerated or is contraindicated, then of the other

classes proven to reduce C( events should #e used instead"



K/DOQI – NKF, 2002

ANTIHPERTENSI<E DRUGS USED ON

SE<ERAL CLINICAL CONDITIONS

%CE In9, %R',

CC' i+retics>

$o# salt iet B./;<!it9o+t *rotein+ria

g/l>

%CE In9, %R',

CC' i+retics>

$o# salt iet =</7<!it9 *rotein+ria

g/l>

RRT

%ll agents, e8ce*ti+retics

$o# salt &#ater iet, (

-./0.!it9 PD

%ll agents, e8ce*t

i+retics

$o# salt &

#ater iet, (

-./0.!it9 HDESRD

%CE In9, %R'

i+retics>

%CE In9, %R'

i+retics>

$o# salt iet

$o# salt iet

B./;.

B./;<

!it9 *rotein+ria

g/l>

!it9o+t *rotein+ria

%CE In9, %R'

i+retics>

$o# salt iet =</7<!it9 *rotein+ria

g/l>

C3D

incl+ing

ia"etic

ne*9ro*at9)>

'eta "loc?ers

Di+retics

$o# salt iet,

e8ercise

-./0.4eneral

P9ar1acologic

treat1ent

Non6

*9ar1acologic

Target

11Hg>

Po*+lation



INTER2ENTION $E2E$ I $E2E$ II $E2E$ III

Control BP

)CI*& . )&& >B therapy

Control glucose 7DM8

Protein intake intervention

Salt intake intervention

?luid intake intervention

Control lipid

No cigarette)void regular NS)&D

Control ho$ocystein

Control hyperinsuline$ia

Use antio=idant

Correct ane$ia

)void hypokale$ia

Control hyperphosphate$ia

Ko' dose aspirin

Istrogen replace$ent

Renal benefit General/CV benefit Hebert, et al, Kidney Int. 200

! U L T I P L E R I S 6 S

F A C T O R S I N

T E R < E N T I O N

S T R A T E G

T O S L O W T

H E

P R O G R E S S I O N O F R E N A L D I S E A S E



4. Achieving P !ontrol in "ndivid#als

PatientsMost patients 'ith hypertension 'ill reAuire % or $ore

antihypertensive $edications to achieve their Bp goals"

)ddition of %nd

drug fro$ a different class should #einitiated 'hen use of a single drug in adeAuate doses

fails to achieve the BP goal"

Hhen Bp is $ore than %-.- $$0g a#ove goal,consideration should #e given to initiating therapy 'ith

% drugs, either as separate prescriptions or in fi=ed*close

co$#inations 7?igure8"



A<ERAGE NU!BER OF ANTIHPERTENSI<E AGENTS

NEEDED FOR PTS TO ACHIE<E TARGET BP

UPDS DBP 8=

ABCD DBP 7=

!DRT !AP 92

HOT DBP 80

AAS !AP 92

1 2 3

N*> A.&"4'$&$.%"*. $.&%

C("."( T"( T$& BP))H



$. %ollo&'#p and Monitoring

1nce antihypertensive drug therapy is initiated, $ost patientsshould return for follo'*up and adust$ent of $edications at

appro=i$ately $onthly intervals until the BP goal is reached"

Seru$ potassiu$ and creatinine should #e $onitored at least

to % ti$es per year" )fter BP is at goal and sta#le, follo'*up

visits can usually #e at +* to 9* $onth intervals"

1ther C( risk factors should #e treated to their respective goals,

and to#acco avoidance should #e pro$oted vigorously"

Ko'*dose aspirin therapy should #e considered only 'hen BP

is controlled, #ecause the risk of he$orrhagic stroke is

increased in patients 'ith uncontrolled hypertension"



Special Considerations

The patient 'ith hypertension and certain co$or#idities

reAuires special attention and follo'*up #y the clinician"

1. !ompelling "ndications

Ta#le 9 descri#es co$pelling indications that reAuirecertain antihypertensive drug classes for high*risk

conditions"

The drug selections for these co$pelling indications are

#ased on favora#le outco$e data fro$ clinical trials"

1ther $anage$ent considerations include $edications

already in use, tolera#ility, and desired BP targets"



2. "schemic (eart )isease *"()+

&0D is the $ost co$$on for$ of target*organ da$age

associated 'ith hypertension"

&n patients 'ith hypertension and sta#le angina pectoris, the

st drug of choice is usually a *#locker alternatively, long*

acting CCBs can #e used"&n patients 'ith )cute coronary syndro$es, hypertension

should #e treated initially 'ith *#locker and )CI

inhi#itors, 'ith addition of other drugs as needed for BP

control"

&n patients 'ith post$yocardial infarction, )CI inhi#itors,

*#locker, and aldosterone antagonists have proven to #e

$ost #eneficial"



3. (eart %ail#re

&n the for$ of systolic or daistolic ventricular dysfunction,

result pri$arily fro$ systolic hypertension and &0D"

?astidious BP and cholesterol control are the pri$ary

preventive $easures for those at high risk for 0?"

&n asy$pto$atic individuals 'ith de$onstra#le ventricular

dysfunction, )CI inhi#itors and *#locker are

reco$$ended"

?or those 'ith sy$pto$atic ventricular dysfunction or end*

stage heart disease, )CI inhi#itors, *#locker, )>Bs, and

aldosterone #lockers are reco$$ended along 'ith loop

diuretics"



4. )ia,etic (ypertension

Co$#inations of % or $ore drugs are usually needed toachieve the target BP goal of less than +-.!- $$0g"

ThiaFide diuretics, *#locker, )CI inhi#itors, )>Bs,

and CCBs are #eneficial in reducing C(D and strokeincidence in patients 'ith dia#etes"

The )CI inhi#itors* or )>B*#ased treat$ents

favora#ly affect the progression of dai#eticnephropathy and reduce al#u$inuria, and )>Bs have

#een sho'n to reduce progression to

$akroal#u$inuria"



$. !hronic -idney )isease *!-)+

&n patients 'ith CLD, defined #y either

a" >educed e=cretory function 'ith an esti$ated

glo$erular filtration rate of less than 9-$K.$in per

":+ $%

#" The presence of al#u$inuria, therapeutic goals are toslo' deterioration of renal function and prevent C(D

. !ere,rovasc#lar )isease

The risks and #enefits of acute lo'ering of BP during an

acute stroke are still unclear control of BP at

inter$ediate levels is appropriate until the condition has

sta#iliFed or i$proved"



/. 0ther pecial it#ations

Minority Populations. BP control rates vary in $inority

populations and are lo'est in Me=icans )$ericans and Native )$ericans" &n general, the treat$ent of hypertension

is si$ilar for all de$ographic groups, #ut socioecono$ics

factors and lifestyle $ay #e i$portant #arriers to BP control

in so$e $inority patients"Obesity and the Metabolic Syndrome. 1#esity is an

increasingly prevalent risk factor for the develop$entof

hypertension and C(D" The )dult Treat$ent Panel &&&

guideline for cholesterol $anage$ent defines the $eta#olicsyndro$e as the presence of + or $ore of the follo'ing

conditions G a#do$inal o#esity, glucose intolerance, BP of at

least +-.!3 $$0g, high triglyserids, or lo' high density

lipoprotein cholesterol"



Left Ventricular Hypertrophy is an independent risk factor

that increases the risk of su#seAuent C(D"

Peripheral Arterial Disease is eAuivalent in risk to &0D"

Hypertension in Older Individuals. 0ypertension occurs in

$ore than t'o thirds of individuals after age 93 years"

Postural Hypotension. BP in these individuals should also

#e $onitored in the upright position" Caution should #e used

to avoid volu$e depletion and a=cessively rapid dose

titration of antihypertensive drugs" Dementia and cognitive i$pair$ent occur $ore co$$only

in patients 'ith hypertension"



Hypertension in omen! 'ho #eco$e pregnant should #e

follo'ed carefully #ecause of increased risk to $other and

fetus" Preecla$psia, 'hich occurs after the %- th gestation

'eek of pregnancy, is characteriFed #y ne'*onset or'orsening hypertension, al#u$inuria, and hyperurice$ia,

so$eti$es 'ith coagulation a#nor$alities"

"hildren and Adolescents! hypertension is defined as BP

that is, on repeated $easure$ent"

Hypertensive #r$encies and %mer$encies. Patients 'ith

$arked BP elevations and acute target*organ da$age

reAuired hospitaliFation and parenteral drug therapy" Patients'ith $arkedly elevated BP #ut 'ithout acute target*organ

da$age usually donEt reAuired hospitaliFation, #ut they

should receive i$$ediate co$#ination oral antihypertensive

therapy"



. Additional !onsiderations in

Antihypertensive )r#g !hoices

)ntihypertensive drugs can have favora#le or

unfavora#le effects on other co$or#idities"

Potential &avorable %ffects. ThiaFide type diuretics are

useful in slo'ing de$ineraliFation in osteoporosis"

Potential #nfavorable %ffects. ThiaFide diuretics

should #e used cautiously in patients 'ho have gout or

'ho have a history of significant hyponatre$ia"



Improving Hypertension Control

Adherence to 'e$imens. Behavioral $ode suggest that the

$ost effective therapy prescri#ed #y the $ost carefulclinician 'ill control hypertension only if the patients is

$otivated to take the prescri#ed $edication and to

esta#lish and $aintain a health*pro$oting lifestyle"

Motivation i$proves 'hen patients have positivee=periences 'ith and trust in their cilinicians"

'esistant Hypertension is the failure to reach goal BP in

patients 'ho are adhering to full doses of an appropriate+*drug regi$en that includes a diuretic" )fter e=cluding

potential identifia#le hypertension, clinicians should

carefully e=plore reasons 'hy the patients is not at goal

BP"



Public Health Challenges and Community Programs

Pu#lic health approaches, such as reducing calories, saturated fat,

and salt in processed foods and increasing co$$unity and schoolopportunities for physical activity, can achieve a do'n*'ard shift in

the distri#ution of a populationEs BP, thus potentially reducing

$or#idity, $ortality, and the lifeti$e risk of an individual #eco$ing

hypertensive"

Currently, %% $illion adults are over'eight, 'hich contri#utes to

the rise in BP and related conditions"

The JNC : endorses the )$erican Pu#lic 0ealth )ssociation

resolution that the food $anufacturers and restaurant reduce sodiu$in the food suply #y 3-@ during the ne=t decade"

These pu#lics health approaches can provide an attractive

opportunity to interrupt and prevent the continuing costly cycle of

i h t i d it li ti

hypertension (mkk)

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