Accurate blood pressure measurement in the office

The Seventh ReportThe Seventh Reportof the Joint National Committee on of the Joint National Committee on

the the

Prevention, Detection, Prevention, Detection, Evaluation, and Treatment Evaluation, and Treatment

of High Blood Pressureof High Blood PressureInternal Medicine/PediatricsInternal Medicine/Pediatrics

Noon conference seriesNoon conference seriesJuly 31, 2006July 31, 2006

Accurate blood pressure measurement in Accurate blood pressure measurement in the officethe office

Patient positionPatient position Patient should be seated in a chair (not on an Patient should be seated in a chair (not on an

examination table) for 5 minutesexamination table) for 5 minutes Feet on floorFeet on floor Arm supported at heart levelArm supported at heart level

Appropriate size cuffAppropriate size cuff Cuff bladder encircling at least 80% of the armCuff bladder encircling at least 80% of the arm

Classification of high blood pressure in Classification of high blood pressure in adultsadults

Classification is based on 2 measurments Classification is based on 2 measurments made at 2 separate office visitsmade at 2 separate office visits

NormalNormal Systolic Systolic 120 AND diastolic 120 AND diastolic 80 80

PrehypertensionPrehypertension Systolic 120-129 OR diastolic 80-89Systolic 120-129 OR diastolic 80-89 Increased risk for progression to hypertensionIncreased risk for progression to hypertension

Stage 1 hypertensionStage 1 hypertension Systolic 140-159 OR diastolic 90-99Systolic 140-159 OR diastolic 90-99

Stage 2 hypertensionStage 2 hypertension Systolic Systolic 160 OR diastolic 160 OR diastolic 100 100

Management of hypetensionManagement of hypetension

Reduction of cardiovascular and renal morbidity Reduction of cardiovascular and renal morbidity and mortalityand mortality

In patients In patients withwith diabetes mellitus diabetes mellitus oror renal renal disease, the target blood pressure is disease, the target blood pressure is 130/80 130/80

In patients In patients withoutwithout diabetes mellitus or renal diabetes mellitus or renal disease, the target blood pressure is disease, the target blood pressure is 140/90 140/90

Primary focus should be directed toward Primary focus should be directed toward achieving the achieving the systolicsystolic blood pressure goal blood pressure goal Most patients will achieve the diastolic pressure goal Most patients will achieve the diastolic pressure goal

once the systolic pressure is at goalonce the systolic pressure is at goal

Goals of pharmacotherapyGoals of pharmacotherapy


Dietary Approaches to Stop Dietary Approaches to Stop Hypertension (DASH) dietHypertension (DASH) diet

Dietary sodium reductionDietary sodium reduction Independent of DASH dietIndependent of DASH diet

Physical activityPhysical activityModeration of alcohol consumptionModeration of alcohol consumption

Lifestyle modificationsLifestyle modifications


For a 2100 kcal/day eating plan:For a 2100 kcal/day eating plan: Total fat: 27% of caloriesTotal fat: 27% of calories

Saturated fat: 6% of caloriesSaturated fat: 6% of caloriesProtein: 18% of caloriesProtein: 18% of caloriesCarbohydrate: 55% of caloriesCarbohydrate: 55% of caloriesCholesterol: 150 mgCholesterol: 150 mgSodium: 2,300 mgSodium: 2,300 mgPotassium: 4,700 mgPotassium: 4,700 mgCalcium: 1,250 mgCalcium: 1,250 mgMagnesium: 500 mgMagnesium: 500 mgFiber: 30 gFiber: 30 g

Dietary Approaches to Stop Hypertension (DASH diet)Dietary Approaches to Stop Hypertension (DASH diet)

Management of hypertensionManagement of hypertension

Thiazide-type diuretics should be used as initial Thiazide-type diuretics should be used as initial therapy for most patientstherapy for most patients Certain comorbidities are “compelling indciations” for the Certain comorbidities are “compelling indciations” for the

use of other drugs as initial monotherapy (see below)use of other drugs as initial monotherapy (see below) Most patients will require Most patients will require drugs to achieve drugs to achieve

target blood pressuretarget blood pressure If blood pressure is If blood pressure is 20/10 mmHg above target, 20/10 mmHg above target,

consider consider initiatinginitiating therapy with 2 drugs (separately therapy with 2 drugs (separately or in combination)or in combination) Consider the risk of orthostatic hypotension in such Consider the risk of orthostatic hypotension in such

patients who also have diabetes mellitus, autonomic patients who also have diabetes mellitus, autonomic neuropathy, etc neuropathy, etc

PharmacotherapyPharmacotherapy


Patients should return at approximately monthy Patients should return at approximately monthy intervals until target blood pressure is reachedintervals until target blood pressure is reached

After blood pressure is stable at target, After blood pressure is stable at target, monitoring can usually be done at 3-6 month monitoring can usually be done at 3-6 month intervalsintervals

Serum potassium and creatinine should be Serum potassium and creatinine should be monitored at least 1-2 times per yearmonitored at least 1-2 times per year

Cormorbidities (diabetes mellitus, congestive Cormorbidities (diabetes mellitus, congestive heart failure, etc) may influence the monitoring heart failure, etc) may influence the monitoring scheduleschedule

MonitoringMonitoring


Target blood pressure Target blood pressure 130/80 mmHg 130/80 mmHg Combinations of Combinations of 2 medications are usually 2 medications are usually

necessarynecessary ACE and ARBS slow the progression of non-ACE and ARBS slow the progression of non-

diabetic (as well as diabetic) kidney diseasediabetic (as well as diabetic) kidney disease Limited creatine elevation (Limited creatine elevation ( 35% above baseline) is 35% above baseline) is

acceptable (unless hyperkalemia develops)acceptable (unless hyperkalemia develops)

……with diabetes mellituswith diabetes mellitus


Target blood pressure Target blood pressure 130/80 mmHg 130/80 mmHg Combinations of Combinations of 3 medications are usually 3 medications are usually

necessarynecessary ACE and ARBS slow the progression of diabetic ACE and ARBS slow the progression of diabetic

nephropathynephropathy

with chronic kidney diseasewith chronic kidney disease


Stable angina pectorisStable angina pectoris Beta blockers are first-line therapyBeta blockers are first-line therapy

Calcium-channel blockers are an alternative to beta blockersCalcium-channel blockers are an alternative to beta blockers Acute coronary syndrome (unstable angina or Acute coronary syndrome (unstable angina or

myocardial infarction)myocardial infarction) Beta blockerBeta blocker ACE inhibitorsACE inhibitors

Post-myocardial infarctionPost-myocardial infarction Beta blockerBeta blocker ACE inhibitorACE inhibitor Aldosterone antagonistsAldosterone antagonists (lipid management and aspirin therapy)(lipid management and aspirin therapy)

with ischemic heart diseasewith ischemic heart disease


Asymptomatic ventricular dysfunctionAsymptomatic ventricular dysfunction ACE inhibitorsACE inhibitors Beta blockesBeta blockes

Symptomatic ventricular dysfunctionSymptomatic ventricular dysfunction ACE inhibitors and ARBsACE inhibitors and ARBs Beta blockersBeta blockers Aldosterone blockersAldosterone blockers (loop diurectics)(loop diurectics)

……with congestive heart failurewith congestive heart failure


Have a reduced response to monotherapy with…Have a reduced response to monotherapy with… Beta blockersBeta blockers ACE inhibitorsACE inhibitors ARBSARBS

……compared withcompared with DiureticsDiuretics Calcium channel blockersCalcium channel blockers

Combinations that include a diuretic largely Combinations that include a diuretic largely eliminate these differenceseliminate these differences

Incidence of angioedema 2-4 times greater than Incidence of angioedema 2-4 times greater than in other ethnic groupsin other ethnic groups

In African AmericansIn African Americans

Key messagesKey messages 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 (continued)Key messages (continued) 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)Key messages (continued) 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 messagesKey messages • 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 messagesKey messages • 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 messagesKey messages 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.

QuestionQuestionCategoryCategory SystolicSystolic

pressurepressureDiastolic Diastolic pressurepressure

NormalNormal

PrehypertensiPrehypertensiononStage 1 Stage 1 hypertensionhypertensionStage 2 Stage 2 hypertensionhypertension

QuestionQuestionIndicationIndication((assume no comorbidity)assume no comorbidity)

Recommended initial Recommended initial therapytherapy

PrehypertensionPrehypertension

HypertensionHypertension

Stage 1 hypertensionStage 1 hypertension

Stage 2 hypertensionStage 2 hypertension

QuestionQuestionComorbidityComorbidity Recommended initial Recommended initial

therapytherapyDiabetes mellitusDiabetes mellitus

HypertensionHypertension

Ischemic heart Ischemic heart diseasediseaseCongestive heart Congestive heart failurefailure

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Accurate blood pressure measurement in the office