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

2. 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

3. 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

4. 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

5. DBPmmHgSBPmmHgBpclassification And<80<120Normal Or80-89120-139Prehypertention Or90-99Or>100140-159>160Stage1Hypertension Stage 2 Hypertension Classification

6. 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 YesOr80-89 120- 139 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>100 140- 159 >160Stage1Hypertension Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) Stage 2 Hypertension Classification

7. CVD risk @ 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 Dr. Mohammed Al Rukban

8. 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

9. BLOOD PRESSURE CONTROL RATES BLOOD PRESSURE CONTROL RATES Dr. Mohammed Al Rukban National Health and Nutrition Examination Survey, percent 1999-2000III phase 2 (1991-94) III PHASE 1 PHASE 1(1988-91)II(1976-80) 70687351Awareness 59545531Treatment 34272910Control

10. 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

11. 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

12. 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

13. 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

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

15. Lifestyle Modification Approximate SBP Reduction (RANGE) RecommendationModification 5-20 mmHg/10 kg weight loss Maintain normal body weight (body mass index 18.5-24.9 ). 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

16. 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

17. Usual Dose Range in MG/ DAY Drug (Trade Name) Class 125-50012.5-2512.5-502-41.25-2.50.5-1.02.5-5 Chlorothiazed (Diuril) Chlorthalidone (generic) Hydroclorothiazide (Microzide, Hydro DIURIL) Polythiazide (Renese) Indapamide (Lozol) Metalozol (Mykrox) Metalazone (zaroxolyn) Thiazide diuretics 0.5-220-802.5-10 Bumetanide (bumex) Furosemide (Lasix) Torsemide (Demadex) Loop diuretics 5-1050-100 Amiloride (Midamor) Triamtrene (Dyrenium) Potassium- sparing diuretics 50-10025-50 Eplernone ( Inspra) Spironolactone (Aldactone) Aldosterone receptor blockers Pharmacological Treatment Dr. Mohammed Al Rukban

18. 25-1005-202.5-1050-10050-10040-12040-16060-18020-40 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 200-80010-4010-40 Acebutolol (Sectral) Penbutolol (Levatol) Pindolol (generic) Beta-Blockers with intrinsic sypathomimetic activity 12.5-50200-800 Carvedilol (Coreg) Labetalol (Normodyne) Combined Alpha – and beta-blockers Pharmacological Treatment Dr. Mohammed Al Rukban

19. Pharmacological Treatment 10-40 25-100 2.5-40 10-40 7.5-30 4-8 10-40 2.5-20 1-4 Benazepril (Lotensin) captopril (capoten) Enalapril (vasotec) Fosinopril (monopril) Lisinopril (prinivil, zestril) Moexipril (Univasc) Perindopril (Accupril) Quinapril (Accupril) Ramipril (Altace) Trandolapril(Mavik) ACE Inhibitors 8-32 400-800 150-300 25-100 20-40 20-80 80-320 Candesartan (Atacand) Eprosartan (Teveltan) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan) Angiotensin II Antagonists Dr. Mohammed Al Rukban

20. Pharmacological Treatment 180-420120-54080-320120-360120-360 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 2.5-102.5-202.5-1060-12030-6010-40 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

21. Pharmacological Treatment 1-162-201-20 Doxazosin ( Cardura) Prazosin (minipress) Terazosin (Hytrin) Alpha- Blockers 0.1-0.80.1-0.3250-10000.05-0.250.5-2 Clonidine (Catapres) Clonidine patch (catapres-TTS) Methyldopa (Aldomet) Resrpine (generic) Guanfacine (generic) Central alpha- agonists and other centrally acting drugs 25-1002.5-80 Hydralazine (Apresoline) Minoxidil (Loniten) Direct Vasodilators Dr. Mohammed Al Rukban

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Improving Hypertension control Public health challenges & Community programs

30. 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

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

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

33. 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. Dr. Mohammed Al Rukban

34. 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

35. 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

36. 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

37. 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

38. 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