Hypertension JNC 7 Guidelines The Seventh Report of the Joint National Committee on Prevention nhlbi.nih

1. Hypertension JNC 7 GuidelinesThe Seventh Report of the Joint National Committee on Preventionwww.nhlbi.nih.gov/guidelines/hypertension Jeffrey Beal, M.D. Clinical Director, Florida/Caribbean AIDS Education and Training Center AAHIVMS Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions.Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions.

2. Disclosure of Financial Relationships Speakers Bureau: Bristol-Myers Squibb, Glaxo Use this slide if you have no significant financial relationships with any commercial entities. If you use this slide, please delete slide 3.Use this slide if you have no significant financial relationships with any commercial entities. If you use this slide, please delete slide 3.

3. All of the following are key messages from JNC 7 except: Systolic BP > 140 mmHG is a much more important CVD risk factor than diastolic BP in persons >50 y/o The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg Thiazide-type diuretics are rarely indicated in the treatment of hypertension Goal blood pressure for hypertensive patients is <140/90 mmHg, or <130/80 mmHg for pts with Diabetes or CKD Wrong answer is 3. Thiazide diuretics tx. Of choice for uncomplicated hypertension alone or in combination with other drugs.Wrong answer is 3. Thiazide diuretics tx. Of choice for uncomplicated hypertension alone or in combination with other drugs.

4. Which of the following is incorrect for the proper measurement of BP in the office setting? Persons should be seated for at least 5 minutes resting before taking the BP BP should be taken with the patient sitting on exam table with the arm relaxed in their lap At least 2 measurements should be made SBP is the point at which the first of two or more sounds is heard DBP is the point before the disappearance of sound (phase 5) Answer 2 Patients should be seated in a chair rather than an exam table, with feet on the floor, and arm supported at heart level.Answer 2 Patients should be seated in a chair rather than an exam table, with feet on the floor, and arm supported at heart level.

5. Normal blood pressure is defined in JNC 7 as: <120/<70 <120/<80 120-139/80-89 140-159/90-99 =160/ =100 Answer = 2Answer = 2

6. JNC 7 Classification of BP Normal BP = < 120/80 Prehypertension = 120-139/80-89 Stage 1 HTN = 140-159/90-99 Stage 2 HTN = = 160/100 Answer =Answer =

7. Of the following lifestyle modifications, which has the greatest potential reduction in SBP? Weight loss to normal body weight (BMI 18.5-24.9 kg/m2) Adopting the DASH eating plan Dietary sodium restriction Physical activity Moderation of alcohol intake Answer 1 DASH = dietary approach to stop hypertensionAnswer 1 DASH = dietary approach to stop hypertension

9. Management of Hypertension 60 y/o HIV positive Black female has initial and 3 subsequent office visits with elevated BP by nurse Blood pressure 140/96, repeated 5 minutes later 142/92 Patient assessed as Stage 1 HTN 20% of patients with mircroalbuminuria develop nephropathy within 5 years on standard Diabetic care.20% of patients with mircroalbuminuria develop nephropathy within 5 years on standard Diabetic care.

10. CV Risk Factors HTN Cigarette Smoking Obesity: Weight 220lbs, height 5�6� = BMI 35.5 Physically Inactive Dyslipidemia: ?Chol, ? HDL, Nl LDL/Trig. Diabetes mellitus

11. CV Risk Factors Microalb. or Estimated GFR<60 mL/min Age > 55 for ?, > 65 ? FH premature CV disease (<55 ?, < 65 ?)

12. Physical Exam BP equivalent in both arms Grade II KW changes on funduscopic Waist circumference >40 ?, >35 ? (pt.42) No carotid, abdominal, femoral bruit Nl thyroid palpation, heart, lung and abdomen exam, lower ext. pulses, and neurologic exam

13. Lab/other diagnostic ECG mild LVH UA, Glucose, Hct., serum K+, Creatinine, Ca++, Triglycerides normal Chol. 230 mg/dL, HDL 30 mg/dL, LDL 88 mg/dL

14. Identifiable Causes of HTN Sleep apnea CKD Primary aldosteronism (?K+, fails HTN tx.) Renovascular ds. Chronic steroids/Cushing�s syndrome Pheochromocytoma Coarctation of aorta Thyroid/Parathyroid disease

15. Medications Causing HTN NSAID, especially Cox-2 inhibitors Cocaine, amphetamine, other illicit drugs Sympathomimetics (decongestants, anorectics) Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) OTC (ephedra, ma haung, bitter orange) Cox-2 inhibitors = celecoxib (Celebrex), rofecoxib (Vioxx), Valdecoxib (Bextra)Cox-2 inhibitors = celecoxib (Celebrex), rofecoxib (Vioxx), Valdecoxib (Bextra)

16. Lifestyle Modification Lifestyle modification education done Weight loss and exercise Low Na++, DASH diet Low fat diet Patient never drinks more than 4 oz. wine, 2-3 meals per week

17. Patient Concomitant Medication Atazanavir 300 mg + Ritonavir 100 mg + Truvada

19. What medication(s) would you start? Diuretic therapy ACE Inhibitor Angiotensin receptor blocker Beta-blocker Calcium channel blocker Diuretic plus one of the above Answer 1. Answer 1.

20. Generalizations for HTN/HIV No clinical studies to date with ARV therapy and pharmacologic effect on antihypertensive medications Best to start with one drug and add using lowest starting dose and increasing on at least monthly visits if patient clinically stable

21. Antihypertensive Drugs Diuretics: no drug interactions Beta Blockers: Monitor prolonged PR interval ATV Ritonavir can increase BB levels NNRTI can ?? BB levels ACE inhibitors and ARB Varied effect Calcium Channel Blockers In general levels increased