Accurate blood pressure measurement in the office

1. The Seventh Reportof the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood PressureInternal Medicine/PediatricsNoon conference seriesJuly 31, 2006

2. Patient position Patient should be seated in a chair (not on an examination table) for 5 minutes Feet on floor Arm supported at heart level Appropriate size cuff Cuff bladder encircling at least 80% of the arm Accurate blood pressure measurement in the office

3. Classification is based on 2 measurments made at 2 separate office visits Normal Systolic  120 AND diastolic  80 Prehypertension Systolic 120-129 OR diastolic 80-89 Increased risk for progression to hypertension Stage 1 hypertension Systolic 140-159 OR diastolic 90-99 Stage 2 hypertension Systolic  160 OR diastolic  100 Classification of high blood pressure in adults

5. Reduction of cardiovascular and renal morbidity and mortality In patients with diabetes mellitus or renal disease, the target blood pressure is  130/80 In patients without diabetes mellitus or renal disease, the target blood pressure is  140/90 Primary focus should be directed toward achieving the systolic blood pressure goal Most patients will achieve the diastolic pressure goal once the systolic pressure is at goal Goals of pharmacotherapy Management of hypetension

6. Dietary Approaches to Stop Hypertension (DASH) diet Dietary sodium reduction Independent of DASH diet Physical activity Moderation of alcohol consumption Lifestyle modifications Management of hypetension

7. For a 2100 kcal/day eating plan: Total fat: 27% of caloriesSaturated fat: 6% of caloriesProtein: 18% of caloriesCarbohydrate: 55% of caloriesCholesterol: 150 mgSodium: 2,300 mg Potassium: 4,700 mgCalcium: 1,250 mgMagnesium: 500 mgFiber: 30 g Dietary Approaches to Stop Hypertension (DASH diet) Management of hypetension

9. Thiazide-type diuretics should be used as initial therapy for most patients Certain comorbidities are “compelling indciations” for the use of other drugs as initial monotherapy (see below) Most patients will require  drugs to achieve target blood pressure If blood pressure is  20/10 mmHg above target, consider initiating therapy with 2 drugs (separately or in combination) Consider the risk of orthostatic hypotension in such patients who also have diabetes mellitus, autonomic neuropathy, etc Pharmacotherapy Management of hypertension

11. Patients should return at approximately monthy intervals until target blood pressure is reached After blood pressure is stable at target, monitoring can usually be done at 3-6 month intervals Serum potassium and creatinine should be monitored at least 1-2 times per year Cormorbidities (diabetes mellitus, congestive heart failure, etc) may influence the monitoring schedule Monitoring Management of hypertension

12. Target blood pressure  130/80 mmHg Combinations of  2 medications are usually necessary ACE and ARBS slow the progression of non-diabetic (as well as diabetic) kidney disease Limited creatine elevation ( 35% above baseline) is acceptable (unless hyperkalemia develops) …with diabetes mellitus Management of hypertension

13. Target blood pressure  130/80 mmHg Combinations of  3 medications are usually necessary ACE and ARBS slow the progression of diabetic nephropathy with chronic kidney disease Management of hypertension

14. Stable angina pectoris Beta blockers are first-line therapy Calcium-channel blockers are an alternative to beta blockers Acute coronary syndrome (unstable angina or myocardial infarction) Beta blocker ACE inhibitors Post-myocardial infarction Beta blocker ACE inhibitor Aldosterone antagonists (lipid management and aspirin therapy) with ischemic heart disease Management of hypertension

15. Asymptomatic ventricular dysfunction ACE inhibitors Beta blockes Symptomatic ventricular dysfunction ACE inhibitors and ARBs Beta blockers Aldosterone blockers (loop diurectics) …with congestive heart failure Management of hypertension

16. Have a reduced response to monotherapy with… Beta blockers ACE inhibitors ARBS …compared with Diuretics Calcium channel blockers Combinations that include a diuretic largely eliminate these differences Incidence of angioedema 2-4 times greater than in other ethnic groups In African Americans Management of hypertension

18. In persons older than 50 years, systolic blood pressure greater than 140 mmHg is a much more important cardiovascular disease (CVD) risk factor than diastolic blood pressure. The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg; individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension. Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD. Key messages

19. Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers). Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease). Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers). Key messages (continued)

20. Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers). Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease). If blood pressure is >20/10 mmHg above goal blood pressure, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic. Key messages (continued)

21. • The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator. • In presenting these guidelines, the committee recognizes that the responsible physician’s judgment remains paramount. Key messages

22. • The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator. • In presenting these guidelines, the committee recognizes that the responsible physician’s judgment remains paramount. Key messages

23. The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator. In presenting these guidelines, the committee recognizes that the responsible physician’s judgment remains paramount. Key messages

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