National High Blood Pressure Education Program

1. National High Blood Pressure Education Program NIH Publication No. 98-4080 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.

2. National High Blood Pressure Education Program NIH Publication No. 98-4080 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

3. DISCLAIMER The appearance of rotating Ads on this web site 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

4. National High Blood Pressure Education Program NIH Publication No. 98-4080 November 1997 The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure(JNC VI)

5. 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 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

6. 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 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 National High Blood Pressure Education Program Coordinating Committee 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

7. 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

8. 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.

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

10. 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

11. 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

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

13. Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: United States, 1972-94 The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population.

14. Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States, 1972-94 The decline in age-adjusted mortality for CHD in the total population is 53.2%. *Age-adjusted to the 1940 U.S. census population.

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

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

17. 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.

18. 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.

19. 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.

20. 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)

21. 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)

22. Classification of Blood Pressure for Adults

23. Recommendations for Followup Based on Initial Measurements

24. 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

25. Evaluation Components • Medical history • Physical examination • Routine laboratory tests • Optional tests

26. 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

27. 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

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

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

30. 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 Optional Tests and Procedures

31. Examples of IdentifiableCauses of Hypertension • Renovascular disease • Renal parenchymal disease • Polycystic kidneys • Aortic coarctation • Pheochromocytoma • Primary aldosteronism • Cushing syndrome • Hyperparathyroidism • Exogenous causes

32. 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

33. Clinical Risk Factors forStratification of Patients With Hypertension • Heart diseases • Stroke or transient ischemic attack • Nephropathy • Peripheral arterial disease • Retinopathy

34. Risk Stratification

35. Treatment Strategies andRisk Stratification

36. 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.

37. Summary 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.

38. 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.

39. Goal of HypertensionPrevention 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

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

41. 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 Algorithm for Treatment of Hypertension (continued) Not at Goal Blood Pressure

42. Algorithm for Treatment of Hypertension (continued) 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

43. Algorithm for Treatment of Hypertension(continued) 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

44. Algorithm for Treatment ofHypertension (continued) Initial Drug Choices* • Uncomplicated • Diuretics • -blockers *Based on randomized controlled trials.

45. Algorithm for Treatment of Hypertension(continued) 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 • ACE inhibitors • Isolated systolic hypertension (older persons) • Diuretics preferred • Long-acting dihydropyridine calcium antagonists *Based on randomized controlled trials.

46. Algorithm for Treatment ofHypertension(continued) Initial Drug Choices Specific indications for the following drugs: • ACE inhibitors • Angiotensin II receptor • blockers • -blockers • --blockers • -blockers • Calcium antagonists • Diuretics

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

48. Cyclosporine-induced hypertension Calcium antagonists Diabetes mellitus (1 and 2) with proteinuria ACE inhibitors (preferred) Calcium antagonists Diabetes mellitus (type 2) Low-dose diuretics Dyslipidemia -blockers Prostatism (benign prostatic hyperplasia) -blockers Renal insufficiency (caution in renovascular hypertension and creatinine  3 mg/dL [ 265.2 mol/L]) ACE inhibitors Specific Indications (continued) Some antihypertensive drugs may have favorable effects on comorbid conditions:

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

50. Algorithm for Treatment ofHypertension(continued) 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)