Management of Hypertension according to JNC 7

1. Management of Hypertension according to JNC 7 BY SANDAR KYI, MD

2. Introduction • Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge. • In the US: Forty-three million people are estimated to have hypertension

3. Introduction • Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population

4. Introduction • Generally, the higher the blood pressure, the greater the risk. Untreated hypertension affects all organ systems and can shorten one's life expectancy by 10 to 20 years.

5. Introduction • The question is, what are the barriers to the management of hypertension according to JNC 7?.

6. Hypothesis • It is a hypothesis that barriers to the effective management of patient with uncontrolled hypertension include • patient management time constraints, • physician practice patterns, • drug adverse effects, and • patient specific factors such as lack of adherence to therapy, limited access to care, financial barriers related to the cost of medications & lack of knowledge about the seriousness of uncontrolled hypertension.

7. Methods • Random chart reviews of 200 patients out of 500 charts those are following in FCC of RCRMC for hypertension from 2000-2006. • Sex – F:M 157:43 • Race – Hispanic : Non-Hispanic 115 : 85 Smoker : Non Smoker - 58:142 • Inclusion Criteria : pt with pre-hypertension, HTN stage 1,stage 2 according to JNC 7.

8. Methods • All charts were reviewed following factors: - Demographic factor: age, sex, culture background, first language -co-morbidity: hypercholesterolemia, IHD, diabetes • outcome of BP treatment: • acute coronary event (CP,angina, MI,CHF, bypass surgery) • stroke (TIA, CVA both ischemic and hemorrhagic) • BP whether reached goal BP or not

9. JNC VII report recommendations • Initial therapy based on the JNC VII report recommendations is as follows: • Prehypertension (systolic 120-139, diastolic 80-89): No antihypertensive drug is indicated. (f/up BP measure within 1 yr). • Stage 1 hypertension (systolic 140-159, diastolic 90-99): Thiazide-type diuretics are recommended for most. ACE inhibitor, angiotensin II receptor blocker (ARB), beta-blocker, calcium channel blocker, or combination may be considered. • Stage 2 hypertension (systolic more than 160, diastolic more than 100): Two-drug combination (usually thiazide-type diuretic and ACE inhibitor or ARB or beta-blocker or calcium channel blocker) is recommended for most. • For the compelling indications, other antihypertensive drugs (eg, diuretics, ACE inhibitor, ARB, beta-blocker, calcium channel blocker) may be considered as needed.

10. JNC 7 Reference Card

11. JNC 7 Reference Card

12. Number of patients with HTN who f/up in FCC

13. Number of patients with HTN who did not reach goal BP

14. Complication in non-compliant patients

15. Complication in patient whose Dr not following JNC 7

16. Complication in patients who did not take med: due to SE

17. Complication in patients who reached goal BP

18. % of Acute Coronary Event Complication

19. Numbers of patients with co-morbidity • In pts who reached goal BP - 18 (25%) • In pts who were non-compliant – 34 (52%) • In pts who didn’t take med: due to SE – 10 (32%) • In pts whose Dr not following JNC 7- 15 (47%)

20. Numbers of patients with co-morbidity

21. Discussion • Thus, according to this study, patient non-compliant had been identified as one of the main reasons that BP therapy fails. • Drug adverse effects have also been identified as a factor related to physician prescribing pattern of hypertensive medications.

22. Discussion • Other findings seem to suggest that physicians are familiar with the JNC 7 guidelines for treating HTN but do not implement this knowledge into their everyday practice. • BP is one of the contributing factor to get complication but other co-morbidities (high cholesterol, DM ) can also contribute to complications.

23. Conclusion • This study clearly demonstrates that positive association between uncontrolled HTN & complication (such as cardiovascular disease , CVA,). • The finding of this study provide useful information for designing effective physician interventions for the management of patients with uncontrolled HTN.

24. Limitations of Research Study • Small sample sizes with 6yrs duration. • Didn’t review patient cultural background, educational status, BMI, smoking history details, control of diabetic, & control of hypercholesterolemia. • Also not mentioned Duration of Physician time spent with pt. Usage of language interpreter if pt doesn’t speak English as first language.

25. Recommendation • Further extensive study to include following factors: • patient cultural background, educational status, BMI, smoking history details, control of diabetic & control of hypercholesterolemia. • Duration of Physician time spent with pt. Usage of language interpreter if pt doesn’t speak English as first language.

26. References • Barriers to Blood Pressure ControlG. Divakara Murthy Archives of Internal Medicine • E-medicine HTNSat Sharma, MD, FRCPC, FACP, FCCP, DABSM, Program Director, Associate Professor, Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Manitoba; Site Director of Respiratory Medicine, St Boniface General Hospital • The National High Blood Pressure Education Program

27. Thank you!