The 7th Report of JNC on Hypertension Dr. Mohammed Othman Al-Rukban, ABFM,SBFM. Assistant Professor Department of Family And Community Medicine

Contents  Methodology  Classification  CVD risk  Benefits of lowering BP  BP control rates  Measurements of BP  Patients evaluation  Treatments  Special considerations  Improving Hypertension control  Public health challenges & Community programs

Methodology I. Publication of many hypertension observational studies and clinical trials. II. Need for a new, clear, and concise guideline that would be useful for clinicians. III. Need to simplify the classification of blood pressure. IV. Clear recognition that the JNC reports were not being used to their maximum benefit. Dr. Mohammed Al Rukban

Methodology  NHLBI  NHBPEP CC –46 Professional, Voluntary, and Federal Organizations –Biannual meetings –Dr. Aram Chobanian –5 months work  Medline searches  English Language  Jan1997—April 2003  >80 Papers  Revised by 33 Hypertension leaders Dr. Mohammed Al Rukban

DBPmmHgSBPmmHgBpclassification And<80<120Normal Or Prehypertention Or90-99Or> >160Stage1Hypertension Stage 2 Hypertension Classification

Dr. Mohammed Al Rukban Initial Drug Therapy LifestyleModifi-cationDBPmmHgSBPmmHgBpclassification With compelling Indications Without Compelling Indication Drugs for compelling indications No antihypertensive drug indicated EncourageAnd<80<120Normal YesOr Prehypertention Drug(s) for the compelling indications. other antihyperte nsive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Thiazide-type diuretics for most. may consider ACEI, ARB, CCB, or combination YesYesOr90-99Or> >160Stage1Hypertension Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) Stage 2 Hypertension Classification

CVD 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 The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg Dr. Mohammed Al Rukban

BENEFITS OF LOWERING BP # In clinical trials, antihypertensive therapy has been associated with reductions in incidence of: # In clinical trials, antihypertensive therapy has been associated with reductions in incidence of: – Stroke (35-40%) – Myocardial infarction (20-25%) – Heart failure (>50%) # In patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated. # In the presence of CVD or target organ damage, only 9 patients would require such BP reduction to prevent a death. Dr. Mohammed Al Rukban

BLOOD PRESSURE CONTROL RATES BLOOD PRESSURE CONTROL RATES Dr. Mohammed Al Rukban National Health and Nutrition Examination Survey, percent III phase 2 ( ) III PHASE 1 PHASE 1( )II( ) Awareness Treatment Control

Measurements of BP  ACCURATE BLOOD PRESSURE MEASUREMENT IN THE OFFICE (Clinicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals) (Clinicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals)  AMBULATORY BLOOD PRESSURE MONITORING  SELF-MEASUREMENT OF BLOOD PRESSURE Dr. Mohammed Al Rukban

PATIENT EVALUATION PATIENT EVALUATION OBJECTIVES: 1. To access lifestyle 2. Identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment 3. To reveal identifiable causes of high BP 4. To assess the presence or absence of target organ damage and CVD. Dr. Mohammed Al Rukban

PATIENT EVALUATION 1. Medical history 2. Physical examination - Appropriate measurement of BP - Auscultation for carotid, abdominal, and femoral bruits - Palpation of the thyroid gland - Palpation of the thyroid gland - Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation - Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation - Palpation of the lower extremities for edema and pulses - Palpation of the lower extremities for edema and pulses - Neurological assessment - Neurological assessment Dr. Mohammed Al Rukban

PATIENT EVALUATION 3- LABORATORY TESTS AND OTHER DIAGNOSTIC PROCEDURES  Electrocardiogram  Urinalysis  Blood glucose and hematocrit  Serum potassium, creatinine & calcium  Lipid profile  Optional tests include; measurement of urinary albumin excretion or albumin/creatinine ratio. Dr. Mohammed Al Rukban

TREATMENT Goals of Reduction of cardiovascular and renal morbidity and Treating SBP and DBP to targets that are <140/90 In patients with Hypertension and diabetes or renal disease, the BP goal is < 130/80 mmHg. Dr. Mohammed Al Rukban

Lifestyle Modification Approximate SBP Reduction (RANGE) RecommendationModification 5-20 mmHg/10 kg weight loss Maintain normal body weight (body mass index ). Weight Reduction 8-14 mmHg Consume a diet rich in fruits,vegetables, and low fat diary products with a reduced content of saturated and total fat. Adopt DASH eating plan 2-8 mmHg Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). Dietary sodium reduction Dr. Mohammed Al Rukban

4-9 mmHg Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week Physical Activity 2-4 mmHg Limit consumption to no more than 2 drinks (1 oz or 30 mL ethanol; e.g 24 oz beer, 10 oz wine or 3 oz 80- proof whisky) per day in women and lighter weight persons. Moderation of Alcohol consumption Dr. Mohammed Al Rukban Lifestyle Modification

Usual Dose Range in MG/ DAY Drug (Trade Name) Class Chlorothiazed (Diuril) Chlorthalidone (generic) Hydroclorothiazide (Microzide, Hydro DIURIL) Polythiazide (Renese) Indapamide (Lozol) Metalozol (Mykrox) Metalazone (zaroxolyn) Thiazide diuretics Bumetanide (bumex) Furosemide (Lasix) Torsemide (Demadex) Loop diuretics Amiloride (Midamor) Triamtrene (Dyrenium) Potassium- sparing diuretics Eplernone ( Inspra) Spironolactone (Aldactone) Aldosterone receptor blockers Pharmacological Treatment Dr. Mohammed Al Rukban

Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (zebeta) Metoprolol (lopressor) Metoprolol extended release (Toprol XL) Nadolol (Corgard) Propranolol (Inderal) Propranolol long- acting (Inderal LA) Timolol (Blocadren) Beta-Blockers Acebutolol (Sectral) Penbutolol (Levatol) Pindolol (generic) Beta-Blockers with intrinsic sypathomimetic activity Carvedilol (Coreg) Labetalol (Normodyne) Combined Alpha – and beta-blockers Pharmacological Treatment Dr. Mohammed Al Rukban

Pharmacological Treatment Benazepril (Lotensin) captopril (capoten) Enalapril (vasotec) Fosinopril (monopril) Lisinopril (prinivil, zestril) Moexipril (Univasc) Perindopril (Accupril) Quinapril (Accupril) Ramipril (Altace) Trandolapril(Mavik) ACE Inhibitors Candesartan (Atacand) Eprosartan (Teveltan) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan) Angiotensin II Antagonists Dr. Mohammed Al Rukban

Pharmacological Treatment Diltiazem extended release (cardizem CD, Dilacor XR, Tiazac) Diltiazem extended release (Cardizem LA) Verapamil immediate release (calan, isoptin) Verapamil long acting (calan SR, Isoptin SR) Verapamil – Coer (Covera HS, Verelan PM) Calcium channel blockers- non Dihydropyridines Amlodipine ( Norvasc ) Felodipine (plendil) Isradipine (Dynaciric CR) Nicardipine sustained release (Cardene SR) Nifedipine long-acting (Adalat CC, procardia XL) Nisoldipine (Sular) Calcium Channel Blockers - Dihydropyridines Dr. Mohammed Al Rukban

Pharmacological Treatment Doxazosin ( Cardura) Prazosin (minipress) Terazosin (Hytrin) Alpha- Blockers Clonidine (Catapres) Clonidine patch (catapres-TTS) Methyldopa (Aldomet) Resrpine (generic) Guanfacine (generic) Central alpha- agonists and other centrally acting drugs Hydralazine (Apresoline) Minoxidil (Loniten) Direct Vasodilators Dr. Mohammed Al Rukban

Algorithm for treatment of hypertension LIFESTYLE MODIFICATION INITIAL DRUG CHOICES INITIAL DRUG CHOICES Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for patients with diabetes or chronic kidney disease) Without Compelling Indications With Compelling Indications Stage1Hypertension Thiazide –type diuretics for most. May consider May considerACEI,ARB,BB,CCB, Or combination Stage2Hypertension Two drug combination for most (usually thiazide type diuretic and ACEI, or ARB or BB,or CCB) Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Dr. Mohammed Al Rukban

NOT AT GOAL BLOOD PRESSURE Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Dr. Mohammed Al Rukban

SPECIAL CONSIDERATION CLINICAL TRIAL BASIS RECOMMENDED DRUGS Compelling Indication ALDO ANT CCBARBACEIBBDiuretic ACC/AHA heart failure guideline MERIT HF, COPERNICUS, CIBIS,SOLVD, AIRE, TRACE, VALHEFT,RALES Heart failure ACC/AHA POST MI GUIDELINE,BHAT,SAVE Capricom, EPHISUS --- Post myocardial infarction ALLHAT,HOPE,ANBP2,LIFE,CONVINCE---- High coronary disease risk NKF-ADA guideline, UKPDS,ALLHAT -----Diabetes NKF Guild line Captoprill Trial RENAAL IDNT,REIN,AASK-- Chronic Kidney Disease PROGRESS-- Recurrent stroke Prevention

OTHER SPECIAL SITUATION Minorities Minorities Obesity and the metabolic syndrome Obesity and the metabolic syndrome Left Ventricular hypertrophy Left Ventricular hypertrophy Peripheral arterial disease Peripheral arterial disease Hypertension in older persons Hypertension in older persons Postural hypotension Postural hypotension Dementia Dementia Hypertension in Women Hypertension in Women Hypertension in children and adolescents Hypertension in children and adolescents Hypertensive urgencies and emergencies Hypertensive urgencies and emergencies Dr. Mohammed Al Rukban

Antihypertensive Drugs Potential Favorable effects Thiazide-Type diuretics are useful in slowing demineralization in Osteoporosis. BBs useful in the treatment of arterial tachyarrhythmias/fibrillation, Migraine, thyrotoxicosis, essential tremor, or preoperative hypertension. CCBs may be useful in Raynaud’s syndrome and certain arrhythmias alpha-blockers may be useful in prostatism. Dr. Mohammed Al Rukban

Antihypertensive Drugs POTENTIAL UNFAVOURABLE EFFECTS Thiazide diuretics should be used cautiously in patients who have gout or who have a history of significant hyponatremia. BBs should generally be avoided in individuals who have asthma, reactive airways diseases, or heart block. ACEIs and ARBs Should not be given to women likely to become pregnant and contraindicated in those who are. ACEIs should not be used in individuals with a history of angioedema. Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia and should generally be avoided In patients who have serum potassium values more than 5.0 mEq/L while not taking medications. Dr. Mohammed Al Rukban

Improving Hypertension control Public health challenges & Community programs

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 Dr. Mohammed Al Rukban

The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg. Dr. Mohammed Al Rukban

Individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension Dr. Mohammed Al Rukban

Individuals with a systolic blood pressure of mmHg or a diastolic blood pressure of mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD. Dr. Mohammed Al Rukban

Thiazide -type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drug from other classes. Dr. Mohammed Al Rukban

Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotension converting enzyme inhibitors, angiotension receptor blockers, beta-blockers, calcium channel blockers). Dr. Mohammed Al Rukban

Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure pressure (<140/90 mmHg,or <130/80 mmHg for patients with diabetes or chronic kidney disease). Dr. Mohammed Al Rukban

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. Dr. Mohammed Al Rukban

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 Dr. Mohammed Al Rukban