JNC 7 blood pressure classification in adults aged 18 years

1
JNC 7 blood pressure classification in adults
aged 18 years
National Heart, Lung, and Blood Institute. JNC 7
Express. The Seventh Report of the Joint National
Committee on the Prevention, Detection,
Evaluation and Treatment of High Blood Pressure.
2003.
2
JNC 7 hypertension treatment algorithm
Lifestyle modifications
Not at goal blood pressure (lt140/90 mm HG)
(lt130/80 mm HG for those with diabetes or
chronic kidney disease)
Initial drug choices
With compelling indications
Without compelling indications
Drug(s) for compelling indications Other
antihypertensivedrugs (diuretics, ACEI,ARB, BB,
CCB) as needed.
Stage 2 Hypertension (SBP gt160 or DBP gt100 mm HG)
2-drug combination for most (usually
thiazide-type diuretic and ACEI, or ARB, or BB,
or CCB).
Stage 1 Hypertension (SBP 140159 or DBP 9099 mm
HG) Thiazide-type diuretics for most. May
consider ACEI, ARB, BB, CCB, or combination.0
Not at goal blood pressure
Optimize dosages or add additional drugs until
goal blood pressure is achieved.Consider
consultation with hypertension specialist.
National Heart, Lung, and Blood Institute. JNC 7
Express. The Seventh Report of the Joint National
Committee on the Prevention, Detection,
Evaluation and Treatment of High Blood Pressure.
2003.
3
Definition of hypertension subtypes
True Hypertension Definition1 gt140/90 mm HG by
clinic measurement gt130/80 mm HG by home or
ambulatory measurement
Masked Hypertension Synonyms White-coat
normotension reverse white-coat hypertension
undetected ambulatory hypertension2 Definition
Normotensive by clinic measurement and
hypertensive by home and ambulatory measurement1
White-Coat Hypertension Synonym Isolated office
hypertension2 Definition Hypertensive by clinic
(office) measurement and normotensive by home and
ambulatory measurement3

• National Heart, Lung, and Blood Institute. JNC 7
  Express. The Seventh Report of the Joint National
  Committee on Prevention, Detection, Evaluation
  and Treatment of High Blood Pressure. 2003.
• Pickering TG, et al. Hypertension.
  200240795-796.
• Staessen JA, et al. Blood Press Monit.
  20016355-370.

4
Recommendations for clinical use of ambulatory
blood pressure monitoring US guidelines

• Suspected white-coat hypertension
• Drug-resistant hypertension
• Hypotensive symptoms with medications
• Episodic hypertension
• Autonomic dysfunction

National Heart, Lung, and Blood Institute. JNC 7
Express. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. 2003.
5
Use of ambulatory blood pressure in hypertension
management
Adapted from White WB. N Engl J Med.
20033482377-2378.
6
Clinical conclusions The usefulness of ABPM

• Accounts for BP variations over time
• Diagnosis of white-coat hypertension and masked
  hypertension
• Allows for evaluation of consistency of drug
  effect over dosing periods ?24 hours
• More reproducible than clinic BP

Mancia G, et al. J Hypertens. 199715(Suppl
2)S43-S50.
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Potential targets for therapeutic intervention on
kidney function
Angiotensin I
Angiotensin II
Renin
Impaired release of renin due to NSAIDs,
beta-blockers, cyclosporine, tacrolimus,
diabetes, or advanced age
ACE inhibitors1
Angiotensin receptor
Adrenal gland
Distal convoluted tubule
  Impaired aldosterone metabolism due to
adrenal disease, heparin, or ketoconazole
Afferent arteriole
Collecting duct
Collecting duct
Juxtaglomerular cells
Aldosterone
Glomerular capsule
Aldosterone-receptor blockers spironolactone
and eplerenone4
Apical membrane
Proximal tubule
Aldosterone
K-
K
Aldosterone-receptor
Na
Lumen
Na-
Collecting duct(principal cell)
Sodium-channel blockers amiloride, triamterene,
trimethoprim, and pentamidine
1. Palmer BF. N Engl J Med. 2004351585-592. 2.
Maibaum J, et al. Expert Opin Ther Patients.
200313589-603. 3. Ooi S-YS, et al.
Prescriber. 2004533-46. 4. Givertz MM.
Circulation. 20051111012-1018.
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Angiotensin receptor blockers (ARBs) Mechanism
of action
ACE-independent ANG II Formation
Angiotensinogen
Renin
Bradykinin
ANG I
ACE
ACE
Frag
ments
ANG II
AT1 Receptor
AT2 Receptor
ARB
ARB
Vascular Endothelium
Unger T. Am J Cardiol. 200289(suppl)3A-10A.
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Studies investigating effects of RAAS
manipulation on CV disease outcomes
ACE inhibition
Angiotensin receptor blockade
GISSI-3 ISIS-4
Adapted from Dzau V, et al. Am Heart J.
19911211244-1263.