Practice Guidelines

NHLBI Releases New High Blood Pressure Guidelines

Am Fam Physician. 2003 Jul 15;68(2):376-379.

  Related Editorial

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) approved by the National Heart, Lung, and Blood Institute (NHLBI) provides a new guideline for the prevention and management of hypertension. This report is an update of the previous guideline (JNC VI) released in 1997. The complete document is available in the May 21, 2003 issue of JAMA. It also can be accessed on the NHLBI Web site at www.nhlbi.nih.gov.

According to the NHLBI, hypertension affects about 50 million persons in the United States. Even though it is the most common primary diagnosis for office visits, 30 percent of patients are unaware they have hypertension. Antihypertensive therapy has been associated with reductions in stroke, myocardial infarction, and heart failure. According to the JNC 7 report, recent clinical trials have demonstrated that effective blood pressure control can be achieved in patients with hypertension, but the majority will need two or more drugs.

A new category of prehypertension has been added to the updated guidelines, and stages 2 and 3 hypertension have been combined. The accompanying table lists the new classifications. Initially, lifestyle modifications are recommended for patients with prehypertension rather than drug therapy. Patients with prehypertension (120/80 to 139/89 mm Hg) are at increased risk of progression to hypertension; those in the 130/80 to 139/89 mm Hg range have twice the risk to develop hypertension as those with lower values. These modifications include weight reduction, adopting the DASH (Dietary Approaches to Stop Hypertension) diet, lowering sodium intake, getting more physical activity, and consuming alcohol in moderation.

Classification and Management of Blood Pressure in Adults 18 Years or Older

BP classification Systolic BP, mm Hg* Diastolic BP, mm Hg* Lifestyle modification Initial drug therapy without compelling indication Initial drug therapy with compelling indications

Normal

< 120

and

< 80

Encourage

Prehypertension

120 to 139

or

80 to 89

Yes

No antihypertensive drug indicated

Drug(s) for the compelling indications‡

Stage 1 hypertension

140 to 159

or

90 to 99

Yes

Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, beta blocker, CCB, or combination

Drug(s) for the compelling indications, other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed

Stage 2 hypertension

160

or

100

Yes

2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta blocker or CCB)§

Drug(s) for the compelling indications, other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed


BP = blood pressure; ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

*—Treatment determined by highest BP category.

†—Compelling indications include heart failure, postmyocardial infarction, high coronary disease risk, diabetes, chronic kidney disease, and recurrent stroke prevention.

‡—Treat patients with chronic kidney disease or diabetes to a goal of less than 130/80 mm Hg.

§—Initial combined therapy should be used cautiously in those at risk of orthostatic hypotension.

Adapted from National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Available at www.nhlbi.nih.gov/guidelines/hypertension/express.pdf.

Classification and Management of Blood Pressure in Adults 18 Years or Older

View Table

Classification and Management of Blood Pressure in Adults 18 Years or Older

BP classification Systolic BP, mm Hg* Diastolic BP, mm Hg* Lifestyle modification Initial drug therapy without compelling indication Initial drug therapy with compelling indications

Normal

< 120

and

< 80

Encourage

Prehypertension

120 to 139

or

80 to 89

Yes

No antihypertensive drug indicated

Drug(s) for the compelling indications‡

Stage 1 hypertension

140 to 159

or

90 to 99

Yes

Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, beta blocker, CCB, or combination

Drug(s) for the compelling indications, other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed

Stage 2 hypertension

160

or

100

Yes

2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta blocker or CCB)§

Drug(s) for the compelling indications, other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed


BP = blood pressure; ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

*—Treatment determined by highest BP category.

†—Compelling indications include heart failure, postmyocardial infarction, high coronary disease risk, diabetes, chronic kidney disease, and recurrent stroke prevention.

‡—Treat patients with chronic kidney disease or diabetes to a goal of less than 130/80 mm Hg.

§—Initial combined therapy should be used cautiously in those at risk of orthostatic hypotension.

Adapted from National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Available at www.nhlbi.nih.gov/guidelines/hypertension/express.pdf.

The goal of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality. The primary focus should be on achieving the systolic blood pressure goal because most patients with hypertension, especially those 50 years and older, will reach the diastolic goal once the systolic goal has been attained. Maintaining targets less than 140/90 mm Hg is associated with a decrease in complications of cardiovascular disease. For hypertensive patients with renal disease, the goal should be less than 130/80 mm Hg.

Clinical trials have proved that several classes of drugs, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers, beta blockers, calcium channel blockers, and thiazide-type diuretics, will reduce the complications of hypertension. Diuretics enhance the antihypertensive efficacy of multidrug regimens, can be useful in achieving blood pressure control, and are more affordable than other agents. Despite these findings, they remain underused. The JNC 7 report states that thiazide-type diuretics should be used as initial therapy for most patients with hypertension, alone or in combination with another agent, such as an ACE inhibitor or a beta blocker.

Addition of a second drug from a different class should be initiated when use of a single drug in adequate doses fails to achieve the blood pressure goal.

Key aspects of the new guideline include the following:

  • For patients older than 50 years, systolic blood pressure of more than 140 mm Hg is a more important risk factor for cardiovascular disease than diastolic blood pressure;

  • The risk of cardiovascular disease begins at 115/75 mm Hg and doubles with each increment of 20/10 mm Hg;

  • Patients with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications;

  • Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, alone or combined with drugs from other classes;

  • Most patients with hypertension will require two or more medications to achieve goal blood pressure;

  • If blood pressure is more than 20/10 mm Hg above goal, consideration should be given to initiating therapy with two agents, one of which is usually a thiazide-type diuretic;

  • Effective therapy will control hypertension only if the patient is motivated.

The report also covers follow-up and monitoring, comorbidities requiring special attention (e.g., ischemic heart disease, diabetic hypertension, cerebrovascular disease), other special situations (e.g., minority populations, obesity, peripheral arterial disease), and improving hypertension control through adherence to regimens.


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