U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) National Heart, Lung, and Blood Institute National High Blood Pressure Education Program

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS National Heart, Lung, and Blood Institute National High Blood Pressure Education Program

Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure George L. Bakris, M.D. Department of Preventive Medicine Rush-Presbyterian-St. Lukes Medical Center Henry R. Black, M.D. Department of Preventive Medicine Rush-Presbyterian-St. Lukes Medical Center William C. Cushman, M.D. Preventive Medicine Section Veterans Affairs Medical Center Lee A. Green, M.D. Department of Family Medicine University of Michigan Joseph L. Izzo, Jr., M.D. Department of Medicine and Pharmacology SUNY at Buffalo School of Medicine Daniel W. Jones, M.D. Department of Medicine and Center for Excellence in Cardiovascular-Renal Research University of Mississippi Medical Center Barry J. Materson, M.D. Department of Medicine University of Miami School of Medicine Suzanne Oparil, M.D. Department of Medicine, Physiology & Biophysics Division of Cardiovascular Disease University of Alabama Jackson T. Wright, Jr., M.D. University Hospitals of Cleveland Case Western Reserve University Executive Secretary Edward J. Roccella, Ph.D, M.P.H. National Heart, Lung, and Blood Institute Executive Committee Aram Chobanian, M.D., Chair Deans Office and Department of Medicine Boston University School of Medicine

National High Blood Pressure Education Program Coordinating Committee American Academy of Family Physicians American Academy of Neurology American Academy of Ophthalmology American Academy of Physician Assistants American Association of Occupational Health Nurses American College of Cardiology American College of Chest Physicians American College of Occupational and Environmental Medicine American College of Physicians American Society of Internal Medicine American College of Preventive Medicine American Dental Association American Diabetes Association American Dietetic Association American Heart Association American Hospital Association American Medical Association American Nurses Association American Optometric Association American Osteopathic Association American Pharmaceutical Association American Podiatric Medical Association American Public Health Association American Red Cross American Society of Health-System Pharmacists American Society of Hypertension American Society of Nephrology Association of Black Cardiologists Citizens for Public Action on High Blood Pressure and Cholesterol, Inc. Hypertension Education Foundation, Inc. International Society on Hypertension in Blacks National Black Nurses Association, Inc. National Hypertension Association, Inc. National Kidney Foundation, Inc. National Medical Association National Optometric Association National Stroke Association NHLBI Ad Hoc Committee on Minority Populations Society for Nutrition Education The Society of Geriatric Cardiology Federal Agencies: Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services Department of Veterans Affairs Health Resources and Services Administration National Center for Health Statistics National Heart, Lung, and Blood Institute National Institute of Diabetes and Digestive and Kidney Diseases

JNC 7 ExpressSuccinct evidence-based recommendations. Published in JAMA May 21, 2003, and as a Government Printing Office publication. Full Reportcomprehensive justification and rationale (coming soon).

Purpose Why JNC 7? Publication of many new studies. Need for a new, clear, and concise guideline useful for clinicians. Need to simplify the classification of BP.

For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD. New Features and Key Messages

New Features and Key Messages (Continued) Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. Certain high-risk conditions are compelling indications for other drug classes. Most patients will require two or more antihypertensive drugs to achieve goal BP. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

New Features and Key Messages (Continued) The most effective therapy prescribed by the careful clinician will control HTN 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. The responsible physicians judgment remains paramount.

BP Measurement and Clinical Evaluation Classification of BP CVD Risk Benefits of Lowering BP BP Control Rates BP Measurement Techniques In-office Ambulatory BP Monitoring Self-measurement Patient Evaluation Laboratory Tests and Other Diagnostic Procedures

Blood Pressure Classification Normal<120and<80 Prehypertension120–139or80–89 Stage 1 Hypertension140–159or90–99 Stage 2 Hypertension>160or>100 BP ClassificationSBP mmHgDBP mmHg

CVD Risk HTN prevalence ~ 50 million people in the United States. The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors. Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg. Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.

Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure50%

Benefits of Lowering BP In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.

BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991–941999–2000 Awareness Treatment Control Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

BP Measurement Techniques MethodBrief Description In-officeTwo readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Ambulatory BP monitoringIndicated for evaluation of white-coat HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk. Self-measurementProvides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.

Office BP Measurement Use auscultatory method with a properly calibrated and validated instrument. Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. Appropriate-sized cuff should be used to ensure accuracy. At least two measurements should be made. Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

Ambulatory BP Monitoring ABPM is warranted for evaluation of white-coat HTN in the absence of target organ injury. Ambulatory BP values are usually lower than clinic readings. Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg. BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.

Self-Measurement of BP Provides information on: 1.Response to antihypertensive therapy 2.Improving adherence with therapy 3.Evaluating white-coat HTN Home measurement of >135/85 mmHg is generally considered to be hypertensive. Home measurement devices should be checked regularly.

Patient Evaluation Evaluation of patients with documented HTN has three objectives: 1.Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. 2.Reveal identifiable causes of high BP. 3.Assess the presence or absence of target organ damage and CVD.

CVD Risk Factors Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m 2 ) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome.

Identifiable Causes of Hypertension Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushings syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Laboratory Tests Routine Tests Electrocardiogram Urinalysis Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Treatment Overview Goals of therapy Lifestyle modification Pharmacologic treatment Algorithm for treatment of hypertension Classification and management of BP for adults Followup and monitoring

Goals of Therapy Reduce CVD and renal morbidity and mortality. Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years of age.

Lifestyle Modification ModificationApproximate SBP reduction (range) Weight reduction5–20 mmHg/10 kg weight loss Adopt DASH eating plan8–14 mmHg Dietary sodium reduction2–8 mmHg Physical activity4–9 mmHg Moderation of alcohol consumption 2–4 mmHg

Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

Classification and Management of BP for adults BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal<120and <80Encourage Prehypertension120–139or 80–89YesNo antihypertensive drug indicated. Drug(s) for compelling indications. Stage 1 Hypertension 140–159or 90–99YesThiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension >160or >100YesTwo-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). *Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Followup and Monitoring Patients should return for followup and adjustment of medications until the BP goal is reached. More frequent visits for stage 2 HTN or with complicating comorbid conditions. Serum potassium and creatinine monitored 1–2 times per year.

Followup and Monitoring (continued) After BP at goal and stable, followup visits at 3- to 6-month intervals. Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

Special Considerations Compelling Indications Other Special Situations Minority populations Obesity and the metabolic syndrome Left ventricular hypertrophy Peripheral arterial disease Hypertension in older persons Postural hypotension Dementia Hypertension in women Hypertension in children and adolescents Hypertension urgencies and emergencies

Compelling Indications for Individual Drug Classes Compelling IndicationInitial Therapy OptionsClinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE THIAZ, BB, ACEI, ARB, ALDO ANT BB, ACEI, ALDO ANT THIAZ, BB, ACE, CCB Heart failure Postmyocardial infarction High CAD risk

Diabetes Chronic kidney disease Recurrent stroke prevention Compelling Indications for Individual Drug Classes Compelling IndicationInitial Therapy OptionsClinical Trial Basis NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK PROGRESS THIAZ, BB, ACE, ARB, CCB ACEI, ARB THIAZ, ACEI

Minority Populations In general, treatment similar for all demographic groups. Socioeconomic factors and lifestyle important barriers to BP control. Prevalence, severity of HTN increased in African Americans. African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. These differences usually eliminated by adding adequate doses of a diuretic.

Left Ventricular Hypertrophy LVH is an independent risk factor that increases the risk of CVD. Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.

Peripheral Arterial Disease (PAD) PAD is equivalent in risk to ischemic heart disease. Any class of drugs can be used in most PAD patients. Other risk factors should be managed aggressively. Aspirin should be used.

Hypertension in Older Persons More than two-thirds of people over 65 have HTN. This population has the lowest rates of BP control. Treatment, including those who with isolated systolic HTN, should follow same principles outlined for general care of HTN. Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.

Postural Hypotension Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs. BP in these individuals should be monitored in the upright position. Avoid volume depletion and excessively rapid dose titration of drugs.

Dementia Dementia and cognitive impairment occur more commonly in people with HTN. Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.

Hypertension in Women Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP. Development of HTNconsider other forms of contraception. Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.

Children and Adolescents HTN defined as BP95th percentile or greater, adjusted for age, height, and gender. Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications. Drug choices similar in children and adults, but effective doses are often smaller. Uncomplicated HTN not a reason to restrict physical activity.

Hypertensive Urgencies and Emergencies Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy. Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.

Additional Considerations in Antihypertensive Drug Choices Potential favorable effects Thiazide-type diuretics useful in slowing demineralization in osteoporosis. BBs useful in the treatment of atrial tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN. CCBs useful in Raynauds syndrome and certain arrhythmias. Alpha-blockers useful in prostatism.

Additional Considerations in Antihypertensive Drug Choices Potential unfavorable effects Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia. BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or third-degree heart block. ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant. ACEIs should not be used in individuals with a history of angioedema. Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.

Improving Hypertension Control Adherence to regimens Resistant hypertension

Strategies for Improving Adherence to Regimens Clinician empathy increases patient trust, motivation, and adherence to therapy. Physicians should consider their patients cultural beliefs and individual attitudes in formulating therapy.

Causes of Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN

Public Health Challenges and Community Programs Public health approaches (e.g. reducing calories, saturated fat, and salt in processed foods and increasing community/school opportunities for physical activity) can achieve a downward shift in the distribution of a populations BP, thus potentially reducing morbidity, mortality, and the lifetime risk of an individuals becoming hypertensive. These public health approaches can provide an attractive opportunity to interrupt and prevent the continuing costly cycle of managing HTN and its complications.

Population-Based Strategy SBP Distributions Before Intervention After Intervention Reduction in SBP mmHg Reduction in BP % Reduction in Mortality StrokeCHDTotal –6–4–3 –8–5–4 –14 –9–7

Supporting Materials Web site For patients and the general public Facts About the DASH Eating Plan (Revised May 2003) Your Guide to Lowering Blood Pressure For health professionals Reference Card Slide Show

Web site

DASH Fact Sheet

Your Guide to Lowering Blood Pressure

Reference Card