National High Blood Pressure Education Program

JNC 7 Express

The Seventh Report of the Joint National Committee on

Prevention !etection Evaluation and Treatment of High Blood Pressure

" # S # ! E P $ R T % E N T & ' H E $ (T H $ N ! H " % $ N S E R ) * C E S National *nstitutes of Health National Heart (ung and Blood *nstitute

JNC 7 Express

The Seventh Report of the Joint National Committee on

Prevention !etection Evaluation and Treatment of High Blood Pressure

This +or, +as supported entirel- .- the National Heart (ung and Blood *nstitute# The Executive Committee +riting teams and revie+ers served as volunteers +ithout remuneration#

" # S # ! E P$ RT % E N T & ' H E $ (T H $ N ! H " % $ N S E R) * C E S National *nstitutes of Health National Heart (ung and Blood *nstitute National High Blood Pressure Education Program

N*H Pu.lication No# /012300 !ecem.er 3//0

Chair

$ram )# Cho.anian %#!# 4Boston "niversit- %edical Center Boston %$5

Executive Committee

6eorge (# Ba,ris %#!# 4Rush Pres.-terian1St# (u,e7s %edical Center Chicago *(58 Henr- R# Blac, %#!# 4Rush Pres.-terian1St# (u,e7s %edical Center Chicago *(58 9illiam C# Cushman %#!# 4)eterans $ffairs %edical Center %emphis TN58 (ee $# 6reen %#!# %#P#H# 4"niversit- of %ichigan $nn $r.or %*58 Joseph (# *::o Jr# %#!# 4State "niversit- of Ne+ ;or, at Buffalo School of %edicine Buffalo N;58 !aniel 9# Jones %#!# 4"niversitof %ississippi %edical Center Jac,son %S58 Barr- J# %aterson %#!# %#B#$# 4"niversit- of %iami %iami '(58 Su:anne &paril %#!# 4"niversitof $la.ama at Birmingham Birmingham $(58 Jac,son T# 9right Jr# %#!# Ph#!# 4Case 9estern Reserve "niversit- Cleveland &H5

Executive Secretar-

Ed+ard J# Roccella Ph#!# %#P#H# 4National Heart (ung and Blood *nstitute Bethesda %!5
National High Blood Pressure Education Program Coordinating Committee Participants

Claude (enfant %#!# Chair 4National Heart (ung and Blood *nstitute Bethesda %!58 6eorge (# Ba,ris %#!# 4Rush Pres.-terian1St# (u,e7s %edical Center Chicago *(58 Henr- R# Blac, %#!# 4Rush Pres.-terian1 St# (u,e7s %edical Center Chicago *(58 )ic,i Burt Sc#%# R#N# 4National Center for Health Statistics H-attsville %!58 Barr- (# Carter Pharm#!# 4"niversit- of *o+a *o+a Cit- *$58 Jerome !# Cohen %#!# 4Saint (ouis "niversit- School of %edicine St# (ouis %&58 Pamela J# Colman !#P#%# 4$merican Podiatric %edical $ssociation Bethesda %!58 9illiam C# Cushman %#!# 4)eterans $ffairs %edical Center %emphis TN58 %ar, J# C:ira,- Pharm#!# '#$#H#$# 4Health Core *nc# Ne+ar, !E58 John J# !avis P#$#1C# 4$merican $cadem- of Ph-sician $ssistants %emphis TN58 <eith Copelin 'erdinand %#!# '#$#C#C# 4Heart.eats (ife Center Ne+ &rleans ($58 Ra- 9# 6ifford Jr# %#!# %#S# 4Cleveland Clinic 'oundation 'ountain Hills $=58 %ichael 6lic, !#%#!# 4"%!NJ>Ne+ Jerse- !ental School Ne+ar, NJ58 (ee $# 6reen %#!# %#P#H# 4"niversit- of %ichigan $nn $r.or %*58 Stephen Havas %#!# %#P#H# %#S# 4"niversit- of %ar-land School of %edicine Baltimore %!58 Thomas H# Hostetter %#!# 4National *nstitute of !ia.etes and !igestive and <idne- !iseases Bethesda %!58 Joseph (# *::o Jr# %#!# 4State "niversit- of Ne+ ;or, at Buffalo School of %edicine Buffalo N;58 !aniel 9# Jones %#!# 4"niversit- of %ississippi %edical Center Jac,son %S58 (-nn <ir.- R#N# N#P# C#&#H#N#1S# 4Sanofi1 S-nthela.o Research %alvern P$58 <athr-n %# <olasa Ph#!# R#!# (#!#N#

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4Brod- School of %edicine at East Carolina "niversit- 6reenville NC58 Stuart (inas %#!# 4"niversit- of Colorado Health Sciences Center !enver C&58 9illiam %# %anger %#!# Ph#!# 4Ne+ ;or, "niversit- %edical Center Ne+ ;or, N;58 Ed+in C# %arshall &#!# %#S# %#P#H# 4*ndiana "niversit- School of &ptometr- Bloomington *N58 Barr- J# %aterson %#!# %#B#$# 4"niversit- of %iami %iami '(58 Ja- %erchant %#H#$# 4Centers for %edicare ? %edicaid Services 9ashington !C58 Nanc- Houston %iller R#N# B#S#N# 4Stanford "niversit- School of %edicine Palo $lto C$58 %arvin %oser %#!# 4;ale "niversit- School of %edicine Scarsdale N;58 9illiam $# Nic,e- !#&# 4Philadelphia College of &steopathic %edicine Philadelphia P$58 Su:anne &paril %#!# 4"niversit- of $la.ama at Birmingham Birmingham $(58 &telio S# Randall %#!# '#$#C#C# 4Ho+ard "niversit- Hospital 9ashington !C58 James 9# Reed %#!# '#$#C#P# '#$#C#E# 4%orehouse School of %edicine $tlanta 6$58 Ed+ard J# Roccella Ph#!# %#P#H# 4National Heart (ung and Blood *nstitute Bethesda %!58 (ee Shaughness- 4National Stro,e $ssociation Engle+ood C&58 Sheldon 6# Sheps %#!# 4%a-o Clinic Rochester %N58 !avid B# Sn-der R#Ph# !#!#S# 4Health Resources and Services $dministration Roc,ville %!58 James R# So+ers %#!# 4S"N; Health Science Center at Broo,l-n Broo,l-n N;58 (eonard %# Steiner %#S# &#!# 4E-e 6roup &a,hurst NJ58 Ronald Stout %#!# %#P#H# 4Procter and 6am.le %ason &H58 Rita !# Stric,land Ed#!# R#N# 4Ne+ ;or, *nstitute of TechnologSpringfield 6ardens N;58 Carlos )all.ona %#!# 4Ba-lor College of %edicine Houston T@58 Ho+ard S# 9eiss %#!# %#P#H# 46eorgeto+n "niversit- %edical Center 9ashington Hospital Center 9alter Reed $rm%edical Center 9ashington !C58 Jac, P# 9hisnant %#!# 4%a-o Clinic and %a-o %edical School Rochester %N58 (aurie 9illshire %#P#H# R#N# 4$merican Red Cross 'alls Church )$58 6erald J# 9ilson %#$# %#B#$# 4Citi:ens for Pu.lic $ction on High Blood Pressure and Cholesterol *nc# Potomac %!58 %ar- 9inston Ed#!# R#!# 4$merican Heart $ssociation !allas T@58 Jac,son T# 9right Jr# %#!# Ph#!# '# $#C#P# 4Case 9estern Reserve "niversit- Cleveland &H5

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Revie+ers

9illiam B# $pplegate %#!# %#P#H# 49a,e 'orest "niversit- School of %edicine 9inston Salem NC58 Jan N# Basile %#!# '#$#C#P# 4)eterans $dministration Hospital Charleston SC58 Ro.ert Care- %#!# 4"niversitof )irginia Health S-stem Charlottesville )$58 )ictor !:au %#!# 4Brigham and 9omen7s Hospital Boston %$58 Brent %# Egan %#!# 4%edical "niversit- of South Carolina Charleston SC58 Bonita 'al,ner %#!# 4Jefferson %edical College Philadelphia P$58 John %# 'lac, %#!# %#P#H# 49a-ne State "niversit- School of %edicine !etroit %*58 Ed+ard !# 'rohlich %#!# 4&chsner Clinic 'oundation Ne+ &rleans ($58 Haralam.os 6avras %#!# 4Boston "niversit- School of %edicine Boston %$58 %artin 6rais %#!# 4'ein.erg School of %edicine North+estern "niversit- Chicago *(58 9illa $# Hsueh %#!# 4!avid 6effen School of %edicine "C($ !epartment of %edicine (os $ngeles C$58 <enneth $# Jamerson %#!# 4"niversit- of %ichigan %edical Center $nn $r.or %*58 Norman %# <aplan %#!# 4"niversit- of Texas South+estern %edical Center !allas T@58 Theodore $# <otchen %#!# 4%edical College of 9isconsin %il+au,ee 9*58 !aniel (ev- %#!# 4National Heart (ung and Blood *nstitute 'ramingham %$58 %ichael $# %oore %#!# 4!an River Region Cardiovascular Health *nitiative Program !anville )$58 Thomas J# %oore %#!# 4Boston "niversit%edical Center Boston %$58 )asilios Papademetriou %#!# '#$#C#P# '#$#C#C# 4)eterans $ffairs %edical Center 9ashington !C58 Carl J# Pepine %#!# 4"niversit- of 'lorida College of %edicine 6ainesville '(58 Ro.ert $# Phillips %#!# Ph#!# 4Ne+ ;or, "niversit- (enox Hill Hospital Ne+ ;or, N;58 Thomas 6# Pic,ering %#!# !#Phil# 4%ount Sinai %edical Center Ne+ ;or, N;58 (# %ichael Prisant %#!# '#$#C#C# '#$#C#P# 4%edical College of 6eorgia $ugusta 6$58 C# )en,ata S# Ram %#!# 4"niversitof Texas South+estern %edical Center and Texas Blood Pressure *nstitute !allas T@58 EliAah Saunders %#!# '#$#C#C# '#$#C#P# 4"niversit- of %ar-land School of %edicine Baltimore %!58 Stephen C# Textor %#!# 4%a-o Clinic Rochester %N58 !onald 6# )idt %#!# 4Cleveland Clinic 'oundation Cleveland &H58 %-ron H# 9ein.erger %#!# 4*ndiana "niversit- School of %edicine *ndianapolis *N58 Paul <# 9helton %#!# %#Sc# 4Tulane "niversit- Health Sciences Center Ne+ &rleans ($5

Staff

Joanne <arim.a,as %#S# R#!# 4Prospect $ssociates (td# no+ part of $merican *nstitutes for Research Health Program Silver Spring %!5 9e appreciate the assistance of Carol Creech %#*#(#S# and 6a.rielle 6essner 4Prospect $ssociates (td# no+ part of $merican *nstitutes for Research Health Program Silver Spring %!5#

The National High Blood Pressure Education Program 4NHBPEP5 Coordinating Committee %em.er &rgani:ations

$merican $cadem- of 'amil- Ph-sicians $merican $cadem- of Neurolog$merican $cadem- of &phthalmolog$merican $cadem- of Ph-sician $ssistants $merican $ssociation of &ccupational Health Nurses $merican College of Cardiolog$merican College of Chest Ph-sicians $merican College of &ccupational and Environmental %edicine $merican College of Ph-sicians1$merican Societ- of *nternal %edicine $merican College of Preventive %edicine $merican !ental $ssociation $merican !ia.etes $ssociation $merican !ietetic $ssociation $merican Heart $ssociation $merican Hospital $ssociation $merican %edical $ssociation $merican Nurses $ssociation $merican &ptometric $ssociation $merican &steopathic $ssociation $merican Pharmaceutical $ssociation $merican Podiatric %edical $ssociation $merican Pu.lic Health $ssociation $merican Red Cross $merican Societ- of Health1S-stem Pharmacists $merican Societ- of H-pertension $merican Societ- of Nephrolog$ssociation of Blac, Cardiologists Citi:ens for Pu.lic $ction on High Blood Pressure and Cholesterol *nc# H-pertension Education 'oundation *nc# *nternational Societ- on H-pertension in Blac,s National Blac, Nurses $ssociation *nc# National H-pertension $ssociation *nc# National <idne- 'oundation *nc# National %edical $ssociation National &ptometric $ssociation National Stro,e $ssociation NH(B* $d Hoc Committee on %inorit- Populations Societ- for Nutrition Education The Societ- of 6eriatric Cardiolog-

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'ederal $genciesB $genc- for Healthcare Research and CualitCenters for %edicare ? %edicaid Services !epartment of )eterans $ffairs Health Resources and Services $dministration National Center for Health Statistics National Heart (ung and Blood *nstitute National *nstitute of !ia.etes and !igestive and <idne- !iseases

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contents
Preface # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #xi $.stract # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #xiii *ntroduction
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%ethodolog- # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D Classification of Blood Pressure # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #3 Cardiovascular !isease Ris, # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #3 Benefits of (o+ering Blood Pressure # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #0 Blood Pressure Control Rates # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #E $ccurate Blood Pressure %easurement in the &ffice # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #E $m.ulator- Blood Pressure %onitoring Self1%easurement of Blood Pressure
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Patient Evaluation # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #2 (a.orator- Tests and &ther !iagnostic Procedures # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #F Treatment # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #7 6oals of Therap- # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #7 (ifest-le %odifications # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #7 Pharmacologic Treatment # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #7 $chieving Blood Pressure Control in *ndividual Patients # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D0 'ollo+up and %onitoring # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DE

Special Considerations # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DE Compelling *ndications # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DE *schemic Heart !isease # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DE Heart 'ailure # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D2 !ia.etic H-pertension # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D2 Chronic <idne- !isease # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DF Cere.rovascular !isease # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DF

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&ther Special Situations # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DF %inorities # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DF &.esit- and the meta.olic s-ndrome # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DF (eft ventricular h-pertroph- # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D7 Peripheral arterial disease # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D7 H-pertension in older persons # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D7 Postural h-potension # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D7 !ementia # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #D7 H-pertension in +omen # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DG H-pertension in children and adolescents # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DG H-pertensive urgencies and emergencies # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DG $dditional Considerations in $ntih-pertensive !rug Choices # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DH Potential favora.le effects # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DH Potential unfavora.le effects # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DH

*mproving H-pertension Control # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DH $dherence to Regimens # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #DH Resistant H-pertension # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #3/

Pu.lic Health Challenges and Communit- Programs # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #3D Evidence Classification # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #30 Stud- $..reviations
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Reference (ist # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #37

p r e fac e
Since the ISixth Report of the Joint National Committee on the Prevention !etection Evaluation and Treatment of High Blood Pressure 4JNC F5J +as released in DHH7 ne+ ,no+ledge has come to light from a variet- of sources# The National High Blood Pressure Education Program Coordinating Committee 4NHBPEP CC5 +hich represents EF professional voluntar- and 'ederal organi:ations has periodicall- revie+ed the emerging findings during its .iannual meetings# Eventuall- a critical mass of information accumulated that generated much demand for a seventh report# %- decision to appoint a JNC 7 Committee +as predicated on four reasonsB 4D5 pu.lication of man- ne+ h-per1 tension o.servational studies and clinical trials8 435 need for a ne+ clear and concise guideline that +ould .e useful for clinicians8 405 need to simplif- the classification of .lood pressure8 and 4E5 clear recognition that the JNC reports +ere not .eing used to their maximum .enefit#

!r# $ram Cho.anian +as selected as the JNC 7 chair .ecause li,e his predeces1 sors he is +ell versed in h-pertension -et independent of these maAor studies# The JNC 7 Executive Committee and +riting teams +ere selected entirel- from the NHBPEP CC .ecause the- are recogni:ed as experts in their disciplines .their peers# !r# Cho.anian and his colleagues set>and met>a goal of complet1 ing and pu.lishing this +or, in 2 months .ecause of the urgenc- of appl-ing the ne+ information to improve h-pertension prevention and treatment#

This has .een a remar,a.le accomplishment .ut the tas, of NHBPEP CC num.ers is far from over# The- and man- others are no+ charged +ith dissemi1 nating the JNC 7 report .ecause none of this>neither the research studies nor the recommendations>+ill matter unless the JNC 7 is applied# To facilitate its application the JNC 7 +ill .e produced in t+o versions# $ IJNC 7 ExpressJ has .een developed for .us- clinicians# $ longer version to .e pu.lished later +ill provide for a .roader and more detailed revie+ of the recommendations# $dditional professional and patient education tools +ill support implementation of the JNC 7 recommendations#

!r# Cho.anian has our deep appreciation for leading the JNC 7 Executive and Coordinating Committee mem.ers in developing this ne+ report# * feel confi1 dent that this represents a landmar, document and that its application +ill greatl- improve our a.ilit- to address a ver- important pu.lic health pro.lem#

Claude (enfant %#!#

!irector National Heart (ung and Blood *nstitute Chair National High Blood Pressure Education Program
xi

a.stract
The ISeventh Report of the Joint National Committee on Prevention !etection Evaluation and Treatment of High Blood PressureJ provides a ne+ guideline for h-pertension prevention and management# The follo+ing are the report7s ,e- messagesB

*n persons older than 2/ -ears s-stolic .lood pressure greater than DE/ mmHg is a much more important cardiovascular disease 4C)!5 ris, factor than diastolic .lood pressure# The ris, of C)! .eginning at DD2L72 mmHg dou.les +ith each increment of 3/LD/ mmHg8 individuals +ho are normotensive at age 22 have a H/ percent lifetime ris, for developing h-pertension# *ndividuals +ith a s-stolic .lood pressure of D3/MD0H mmHg or a diastolic .lood pressure of G/MGH mmHg should .e considered as preh-pertensive and reNuire health1promoting lifest-le modifications to prevent C)!#

Thia:ide1t-pe diuretics should .e used in drug treatment for most patients +ith uncomplicated h-pertension either alone or com.ined +ith drugs from other classes# Certain high1ris, conditions are compelling indications for the initial use of other antih-pertensive drug classes 4angiotensin converting en:-me inhi.itors angiotensin receptor .loc,ers .eta1.loc,ers calcium channel .loc,ers5#

%ost patients +ith h-pertension +ill reNuire t+o or more antih-pertensive medications to achieve goal .lood pressure 4ODE/LH/ mmHg or OD0/LG/ mmHg for patients +ith dia.etes or chronic ,idne- disease5# *f .lood pressure is P3/LD/ mmHg a.ove goal .lood pressure consideration should .e given to initiating therap- +ith t+o agents one of +hich usuallshould .e a thia:ide1t-pe diuretic# The most effective therap- prescri.ed .- the most careful clinician +ill control h-pertension onl- if patients are motivated# %otivation improves +hen patients have positive experiences +ith and trust in the clinician# Empath- .uilds trust and is a potent motivator#

*n presenting these guidelines the committee recogni:es that the responsi.le ph-sician7s Audgment remains paramount#
xiii

introduction
'or more than three decades the National Heart (ung and Blood *nstitute 4NH(B*5 has coordinated the National High Blood Pressure Education Program 4NHBPEP5 a coalition of 0H maAor professional pu.lic and voluntar- organi1 :ations and seven 'ederal $gencies# &ne important function is to issue guide1 lines and advisories designed to increase a+areness prevention treatment and control of h-pertension 4high .lood pressure 4BP55# Since the pu.lication of the ISixth Report of the Joint National Committee on the Prevention !etection Evaluation and Treatment of High Blood Pressure 4JNC F5J released in DHH7 D man- large1scale clinical trials have .een pu.lished# The decision to appoint a JNC 7 committee +as .ased on four factorsB 4D5 pu.lication of man- ne+ h-pertension o.servational studies and clinical trials8 435 need for a ne+ clear and concise guideline that +ould .e useful for clinicians8 405 need to simplif- the classification of .lood pressure8 and 4E5 clear recognition that the JNC reports +ere not .eing used to their maximum .enefit# This JNC report is presented in t+o separate pu.licationsB a current succinct practical guide and a more com1 prehensive report to .e pu.lished separatel- +hich +ill provide a .roader dis1 cussion and Austification for the current recommendations# *n presenting these guidelines the committee recogni:es that the responsi.le ph-sician7s Audgment is paramount in managing patients#

m et h o d o lo g Since the pu.lication of the JNC F report the NHBPEP Coordinating Committee 4CC5 chaired .- the director of the NH(B* has regularl- revie+ed and discussed the h-pertension clinical trials at its .iannual meetings# *n maninstances the principal investigator of the larger studies has presented the information directl- to the CC# The committee7s presentations and revie+s are summari:ed and posted on the NH(B* 9e. site#3 *n agreeing to commission a ne+ report the !irector reNuested that the CC mem.ers provide in +riting a detailed rationale explaining the necessit- to update the guidelines and to descri.e the critical issues and concepts to .e considered for a ne+ report# The JNC 7 chair +as selected plus a nine1mem.er Executive Committee appointed entirel- from the NHBPEP CC mem.ership# The NHBPEP CC served as mem.ers of five +riting teams each of +hich +as cochaired .- t+o Executive Committee mem.ers# The concepts identified .- the NHBPEP CC mem.ership +ere used to develop the report outline# $ timeline +as devel1 oped to complete and pu.lish the +or, in 2 months# Based on the identified critical issues and concepts the Executive Committee identified relevant %edical Su.Aect Headings 4%eSH5 terms and ,e-+ords to further revie+ the

scientific literature# These %eSH terms +ere used to generate %E!(*NE searches that focused on English language peer1revie+ed scientific literature from Januar- DHH7 through $pril 3//0# )arious s-stems of grading the evi1 dence +ere considered and the classification scheme used in the JNC F report and other NHBPEP clinical guidelines +as selected0 E +hich classifies studies in a process adapted from (ast and $.ramson#2 The Executive Committee met on six occasions t+o of +hich included meetings +ith the entire NHBPEP CC# The +riting teams also met .- teleconference and used electronic com1 munications to develop the report# T+ent-1four drafts +ere created and revie+ed in a reiterative fashion# $t its meetings the Executive Committee used a modified nominal group process to identif- and resolve issues# The NHBPEP CC revie+ed the penultimate draft and provided +ritten comments to the Executive Committee# *n addition 00 national h-pertension leaders revie+ed and commented on the document# The NHBPEP CC approved the JNC 7 report#

c l a s s i f i c at i o n o f . loo d p r e s s u r e
Ta.le D provides a classification of BP for adults ages DG and older# The classi1 fication is .ased on the average of t+o or more properl- measured seated BP readings on each of t+o or more office visits# *n contrast to the classification provided in the JNC F report a ne+ categor- designated preh-pertension has .een added and stages 3 and 0 h-pertension have .een com.ined# Patients +ith preh-pertension are at increased ris, for progression to h-pertension8 those in the D0/MD0HLG/MGH mmHg BP range are at t+ice the ris, to develop h-pertension as those +ith lo+er values#F

cardiovascular disease ris,

H-pertension affects approximatel- 2/ million individuals in the "nited States and approximatel- D .illion +orld+ide# $s the population ages the prevalence of h-pertension +ill increase even further unless .road and effective preventive measures are implemented# Recent data from the 'ramingham Heart Studsuggest that individuals +ho are normotensive at age 22 have a H/ percent life1 time ris, for developing h-pertension#7

The relationship .et+een BP and ris, of C)! events is continuous consistent and independent of other ris, factors# The higher the BP the greater is the chance of heart attac, heart failure stro,e and ,idne- disease# 'or individu1
3

Ta.le D# Classification and management of .lood pressure for adults Q

*nitial drug therap9ith Compelling BP Classification Normal Preh-pertension Stage D H-pertension SBPQ mmHg !BPQ mmHg (ifest-le %odification 9ithout Compelling *ndication *ndications 4See Ta.le G5

OD3/ D3/MD0H DE/MD2H

and OG/ or G/MGH or H/MHH

Encourage ;es ;es No antih-pertensive !rug4s5 for compelling drug indicated# indications#S Thia:ide1t-pe diuretics !rug4s5 for the com1 for most# %a- consider pelling indications#S $CE* $RB BB CCB &ther antih-pertensive or com.ination# drugs 4diuretics $CE* $RB BB CCB5 T+o1drug com.ination as needed# for mostR 4usuallthia:ide1t-pe diuretic and $CE* or $RB or BB or CCB5#

Stage 3 H-pertension

TDF/

or TD//

;es

!BP diastolic .lood pressure8 SBP s-stolic .lood pressure# !rug a..reviationsB $CE* angiotensin converting en:-me inhi.itor8 $RB angiotensin receptor .loc,er8 BB .eta1.loc,er8 CCB calcium channel .loc,er# Treatment determined .- highest BP categor-# Q R *nitial com.ined therap- should .e used cautiousl- in those at ris, for orthostatic h-potension# S Treat patients +ith chronic ,idne- disease or dia.etes to BP goal of OD0/LG/ mmHg#

als E/M7/ -ears of age each increment of 3/ mmHg in s-stolic BP 4SBP5 or D/ mmHg in diastolic BP 4!BP5 dou.les the ris, of C)! across the entire BP range from DD2L72 to DG2LDD2 mmHg#G The classification Ipreh-pertension J introduced in this report 4ta.le D5 recog1 ni:es this relationship and signals the need for increased education of health care professionals and the pu.lic to reduce BP levels and prevent the development of h-pertension in the general population#H H-pertension prevention strategies are availa.le to achieve this goal# 4See I(ifest-le %odificationsJ section#5

. e n e f i t s o f lo+ e r i n g . loo d p r e s s u r e
*n clinical trials antih-pertensive therap- has .een associated +ith reductions in stro,e incidence averaging 02ME/ percent8 m-ocardial infarction 3/M32 percent8 and heart failure more than 2/ percent#D/ *t is estimated that in patients +ith stage D h-pertension 4SBP DE/MD2H mmHg andLor !BP H/MHH mmHg5 and additional cardiovascular ris, factors achieving a sus1 tained D3 mmHg reduction in SBP over D/ -ears +ill prevent D death for ever- DD patients treated# *n the presence of C)! or target organ damage onl- H patients +ould reNuire such BP reduction to prevent a death#DD

Ta.le 3# Trends in a+areness treatment and control of high .lood pressure in adults ages DGM7EQ
National Health and Nutrition Examination Surve- Percent ** 4DH7FMG/5 *** 4Phase D DHGGMHD5 *** 4Phase 3 DHHDMHE5 DHHHM3///

$+areness Treatment ControlR

2D 0D D/

70 22 3H

FG 2E 37

7/ 2H 0E

High .lood pressure is s-stolic .lood pressure 4SBP5 TDE/ mmHg or diastolic .lood Q pressure 4!BP5 TH/ mmHg or ta,ing antih-pertensive medication#
R SBP ODE/ mmHg and !BP OH/ mmHg#

SourcesB "npu.lished data for DHHHM3/// computed .- %# 9ol: National Heart (ung and Blood *nstitute8 JNC F#D

. lo o d p r e s s u r e c o n t r o l r at e s
H-pertension is the most common primar- diagnosis in $merica 402 million office visits as the primar- diagnosis5#D3 Current control rates 4SBP ODE/ mmHg and !BP OH/ mmHg5 though improved are still far .elo+ the Health- People 3/D/ goal of 2/ percent8 0/ percent are still una+are thehave h-pertension# 4See ta.le 3#5 *n the maAorit- of patients controlling s-stolic h-pertension +hich is a more important C)! ris, factor than !BP except in patients -ounger than age 2/D0 and occurs much more commonl- in older persons has .een considera.l- more difficult than controlling diastolic h-pertension# Recent clinical trials have demonstrated that effective BP control can .e achieved in most patients +ho are h-pertensive .ut the maAorit- +ill reNuire t+o or more antih-pertensive drugs#DE D2 9hen clinicians fail to pre1 scri.e lifest-le modifications adeNuate antih-pertensive drug doses or appropriate drug com.inations inadeNuate BP control ma- result#

accurate .lood pressure measurement in the office

The auscultator- method of BP measurement +ith a properl- cali.rated and validated instrument should .e used#DF Persons should .e seated Nuietl- for at least 2 minutes in a chair 4rather than on an exam ta.le5 +ith feet on the floor and arm supported at heart level# %easurement of BP in the standing position is indicated periodicall- especiall- in those at ris, for postural h-poten1 sion# $n appropriate1si:ed cuff 4cuff .ladder encircling at least G/ percent of the arm5 should .e used to ensure accurac-# $t least t+o measurements should .e made# SBP is the point at +hich the first of t+o or more sounds is heard

4phase D5 and !BP is the point .efore the disappearance of sounds 4phase 25# Clinicians should provide to patients ver.all- and in +riting their specific BP num.ers and BP goals#

am.ulator- .lood pressure monitoring

$m.ulator- .lood pressure monitoring 4$BP%5D7 provides information a.out BP during dail- activities and sleep# $BP% is +arranted for evaluation of I+hite1coatJ h-pertension in the a.sence of target organ inAur-# *t is also helpful to assess patients +ith apparent drug resistance h-potensive s-mptoms +ith antih-pertensive medications episodic h-pertension and autonomic d-sfunction# The am.ulator- BP values are usuall- lo+er than clinic readings# $+a,e indi1 viduals +ith h-pertension have an average BP of more than D02LG2 mmHg and during sleep more than D3/L72 mmHg# The level of BP measurement .- using $BP% correlates .etter than office measurements +ith target organ inAur-# DG $BP% also provides a measure of the percentage of BP readings that are elevat1 ed the overall BP load and the extent of BP reduction during sleep# *n most individuals BP decreases .- D/ to 3/ percent during the night8 those in +hom such reductions are not present are at increased ris, for cardiovascular events#

s e l f 1 m e a s u r e m e n t o f . lo o d p r e s s u r e
BP self measurements ma- .enefit patients .- providing information on response to antih-pertensive medication improving patient adherence +ith therap- DH and in evaluating +hite1coat h-pertension# Persons +ith an average BP more than D02LG2 mmHg measured at home are generall- considered to .e h-pertensive# Home measurement devices should .e chec,ed regularl- for accurac-#

pat i e n t e v a l u at i o n
Evaluation of patients +ith documented h-pertension has three o.AectivesB 4D5 to assess lifest-le and identif- other cardiovascular ris, factors or con1 comitant disorders that ma- affect prognosis and guide treatment 4ta.le 058 435 to reveal identifia.le causes of high BP 4ta.le E58 and 405 to assess the pres1 ence or a.sence of target organ damage and C)!# The data needed are acNuired through medical histor- ph-sical examination routine la.oratortests and other diagnostic procedures# The ph-sical examination should
2

Ta.le 0# Cardiovascular ris, factors

%aAor Ris, 'actors

Ta.le E# *dentifia.le causes of h-pertension

Sleep apnea !rug1induced or related causes 4see ta.le H5 Chronic ,idne- disease Primar- aldosteronism Renovascular disease Chronic steroid therap- and Cushing7s s-ndrome Pheochromoc-toma Coarctation of the aorta Th-roid or parath-roid disease

H-pertensionQ Cigarette smo,ing &.esit-Q 4.od- mass index T0/ ,gLm35 Ph-sical inactivit!-slipidemiaQ !ia.etes mellitusQ %icroal.uminuria or estimated 6'R OF/ m(Lmin $ge 4older than 22 for men F2 for +omen5 'amil- histor- of premature cardiovascular disease 4men under age 22 or +omen under age F25

Target &rgan !amage

Heart K (eft ventricular h-pertrophK $ngina or prior m-ocardial infarction K Prior coronar- revasculari:ation K Heart failure Brain K Stro,e or transient ischemic attac, Chronic ,idne- disease Peripheral arterial disease Retinopath6'R glomerular filtration rate# Q Components of the meta.olic s-ndrome#

include an appropriate measurement of BP +ith verification in the contralat1 eral arm8 examination of the optic fundi8 calculation of .od- mass index 4B%*5 4measurement of +aist circumference also ma- .e useful58 auscultation for carotid a.dominal and femoral .ruits8 palpation of the th-roid gland8 thorough examination of the heart and lungs8 examination of the a.domen for enlarged ,idne-s masses and a.normal aortic pulsation8 palpation of the lo+er extremities for edema and pulses8 and neurological assessment#

(a.orator- Tests and &ther !iagnostic Procedures

Routine la.orator- tests recommended .efore initiating therap- include an electrocardiogram8 urinal-sis8 .lood glucose and hematocrit8 serum potassium creatinine 4or the corresponding estimated glomerular filtration rate U6'RV5 and calcium83/ and a lipid profile after H1 to D31hour fast that includes high1 densit- lipoprotein cholesterol and lo+1densit- lipoprotein cholesterol and trigl-cerides# &ptional tests include measurement of urinar- al.umin excre1 tion or al.uminLcreatinine ratio# %ore extensive testing for identifia.le causes is not indicated generall- unless BP control is not achieved#

treatment
6oals of Therap-

The ultimate pu.lic health goal of antih-pertensive therap- is the reduction of cardiovascular and renal mor.idit- and mortalit-# Since most persons +ith h-pertension especiall- those age P2/ -ears +ill reach the !BP goal once SBP is at goal the primar- focus should .e on achieving the SBP goal# Treating SBP and !BP to targets that are ODE/LH/ mmHg is associated +ith a decrease in C)! complications# *n patients +ith h-pertension and dia.etes or renal disease the BP goal is OD0/LG/ mmHg#3D 33

(ifest-le %odifications

$doption of health- lifest-les .- all persons is critical for the prevention of high BP and is an indispensa.le part of the management of those +ith h-per1 tension# %aAor lifest-le modifications sho+n to lo+er BP include +eight reduction in those individuals +ho are over+eight or o.ese 30 3E adoption of the !ietar- $pproaches to Stop H-pertension 4!$SH5 eating plan32 +hich is rich in potassium and calcium 3F dietar- sodium reduction 32M37 ph-sical activi1 t- 3G 3H and moderation of alcohol consumption# 4See ta.le 2#50/ (ifest-le modifi1 cations reduce BP enhance antih-pertensive drug efficac- and decrease cardio1 vascular ris,# 'or example a D F// mg sodium !$SH eating plan has effects similar to single drug therap-#32 Com.inations of t+o 4or more5 lifest-le modi1 fications can achieve even .etter results#

Pharmacologic Treatment

There are excellent clinical outcome trial data proving that lo+ering BP +ith several classes of drugs including angiotensin converting en:-me inhi.itors 4$CE*s5 angiotensin receptor .loc,ers 4$RBs5 .eta1.loc,ers 4BBs5 calcium channel .loc,ers 4CCBs5 and thia:ide1t-pe diuretics +ill all reduce the com1 plications of h-pertension#D/ 0DM07 Ta.les F and 7 provide a list of commonlused antih-pertensive agents#

Thia:ide1t-pe diuretics have .een the .asis of antih-pertensive therap- in most outcome trials#07 *n these trials including the recentl- pu.lished $ntih-pertensive and (ipid (o+ering Treatment to Prevent Heart $ttac, Trial 4$((H$T5 00 diuretics have .een virtuall- unsurpassed in preventing the car1 diovascular complications of h-pertension# The exception is the Second $ustralian National Blood Pressure trial +hich reported slightl- .etter out1 comes in 9hite men +ith a regimen that .egan +ith an $CE* compared to one starting +ith a diuretic#0F !iuretics enhance the antih-pertensive efficac-

Ta.le 2# (ifest-le modifications to manage h-pertension QR

$pproximate SBP %odification Recommendation Reduction 4Range5

9eight reduction

%aintain normal .od- +eight 4.od- mass index DG#2M3E#H ,gLm35#

2M3/ mmHgLD/ ,g +eight loss30 3E

$dopt !$SH eating plan

Consume a diet rich in fruits vegeta.les and lo+fat dairproducts +ith a reduced content of saturated and total fat#

GMDE mmHg 32 3F

!ietar- sodium reduction

Reduce dietar- sodium inta,e to no more than D// mmol per da43#E g sodium or F g sodium chloride5#

3MG mmHg 32M37

Ph-sical activit-

Engage in regular aero.ic ph-sical activit- such as .ris, +al,ing 4at least 0/ min per da- most da-s of the +ee,5#

EMH mmHg 3G 3H

%oderation of alcohol consumption

(imit consumption to no more than 3 drin,s 4D o: or 0/ m( ethanol8 e#g# 3E o: .eer D/ o: +ine or 0 o: G/1proof +his,e-5 per da- in most men and to no more than D drin, per da- in +omen and lighter +eight persons#

3ME mmHg 0/

!$SH !ietar- $pproaches to Stop H-pertension# Q 'or overall cardiovascular ris, reduction stop smo,ing# R The effects of implementing these modifications are dose and time dependent and could .e greater for some individuals#

of multidrug regimens can .e useful in achieving BP control and are more afforda.le than other antih-pertensive agents# !espite these findings diuretics remain underutili:ed#0H Thia:ide1t-pe diuretics should .e used as initial therap- for most patients +ith h-pertension either alone or in com.ination +ith one of the other classes 4$CE*s $RBs BBs CCBs5 demonstrated to .e .eneficial in randomi:ed con1 trolled outcome trials# The list of compelling indications reNuiring the use of other antih-pertensive drugs as initial therap- are listed in ta.le G# *f a drug is not tolerated or is contraindicated then one of the other classes proven to reduce cardiovascular events should .e used instead#
G

Ta.le F# &ral antih-pertensive drugsQ

"sual dose range Class !rug 4Trade Name5 in mgLda-

"sual !ail'reNuencD13 D D D D D D 3 3 D

Thia:ide diuretics

Chlorothia:ide 4!iuril5 chlorthalidone 4generic5 h-drochlorothia:ide 4%icro:ide H-dro!*"R*( R5 pol-thia:ide 4Renese5 indapamide 4(o:olR5 metola:one 4%-,rox5 metola:one 4=aroxol-n5

D3212// D3#2132 D3#212/ 31E D#3213#2 /#21D#/ 3#212 /#213 3/1G/ 3#21D/

(oop diuretics

.umetanide 4BumexR5 furosemide 4(asixR5 torsemide 4!emadexR5

Potassium1sparing diuretics

amiloride 4%idamorR5 triamterene 4!-renium5

21D/ 2/1D//

D13 D13

$ldosterone receptor .loc,ers

eplerenone 4*nspra5 spironolactone 4$ldactoneR5

2/1D// 3212/

D D

BBs

atenolol 4TenorminR5 .etaxolol 4<erloneR5 .isoprolol 4=e.etaR5 metoprolol 4(opressorR5 metoprolol extended release 4Toprol @(5

321D// 213/ 3#21D/ 2/1D// 2/1D//

D D D D13 D

nadolol 4CorgardR5 propranolol 4*nderalR5 propranolol long1acting 4*nderal ($R5 timolol 4BlocadrenR5 BBs +ith intrinsic s-mpathomimetic activitace.utolol 4SectralR5 pen.utolol 4(evatol5 pindolol 4generic5 Com.ined alpha1 and BBs carvedilol 4Coreg5 la.etalol 4Normod-ne TrandateR5

E/1D3/ E/1DF/ F/1DG/ 3/1E/

D 3 D 3

3//1G// D/1E/ D/1E/ D3#212/ 3//1G//

3 D 3 3 3

Ta.le F# &ral antih-pertensive drugsQ 4continued5

"sual dose range Class !rug 4Trade Name5 in mgLda-

"sual !ail'reNuencD 3 D13 D D D D D D D

$CE*s

.ena:epril 4(otensinR5 captopril 4CapotenR5 enalapril 4)asotecR5 fosinopril 4%onopril5 lisinopril 4Prinivil =estrilR5 moexipril 4"nivasc5 perindopril 4$ceon5 Nuinapril 4$ccupril5 ramipril 4$ltace5 trandolapril 4%avi,5

D/1E/ 321D// 21E/ D/1E/ D/1E/ 7#210/ E1G D/1G/ 3#213/ D1E

$ngiotensin ** antagonists

candesartan 4$tacand5 eprosartan 4Teveten5 ir.esartan 4$vapro5 losartan 4Co:aar5 olmesartan 4Benicar5 telmisartan 4%icardis5 valsartan 4!iovan5

G103 E//1G// D2/10// 321D// 3/1E/ 3/1G/ G/103/

D D13 D D13 D D D13

CCBs>non1!ih-drop-ridines

!iltia:em extended release 4Cardi:em C! !ilacor @R Tia:acR5 diltia:em extended release 4Cardi:em ($5 verapamil immediate release 4Calan *soptinR5 verapamil long acting 4Calan SR *soptin SRR5 verapamil>Coer Covera HS )erelan P%5

DG/1E3/ D3/12E/ G/103/ D3/1EG/ D3/10F/

D D 3 D13 D

CCBs>!ih-drop-ridines

amlodipine 4Norvasc5 felodipine 4Plendil5 isradipine 4!-nacirc CR5 nicardipine sustained release 4Cardene SR5 nifedipine long1acting 4$dalat CC Procardia @(5 nisoldipine 4Sular5

3#21D/ 3#213/ 3#21D/ F/1D3/ 0/1F/ D/1E/

D D 3 3 D D

D/

Ta.le F# &ral antih-pertensive drugsQ 4continued5

"sual dose range Class !rug 4Trade Name5 in mgLda-

"sual !ail'reNuencD 310 D13

$lpha1D .loc,ers

doxa:osin 4Cardura5 pra:osin 4%inipressR5 tera:osin 4H-trin5

D1DF 313/ D13/

Central alpha13 agonists and other centrall- acting drugs

clonidine 4CatapresR5 clonidine patch 4Catapres1TTS5 meth-ldopa 4$ldometR5 reserpine 4generic5 guanfacine 4TenexR5

/#D1/#G /#D1/#0 32/1D /// /#D1/#32 /#213

3 D +,l3 D D

!irect vasodilators

h-drala:ine 4$presolineR5 minoxidil 4(onitenR5

321D// 3#21G/

3 D13

*n some patients treated once dail- the antih-pertensive effect ma- diminish to+ard the end of the dosing interval 4trough effect5# BP should .e measured Aust prior to dosing to determine if satisfactor- BP control is o.tained# $ccordingl- an increase in dosage or freNuenc- ma- need to .e considered# These dosages ma- var- from those listed in the IPh-sicians !es, Reference 27th ed#J $vaila.le no+ or soon to .ecome availa.le in generic preparations#

R SourceB

Ph-siciansW !es, Reference# 27 ed# %ontvale NJB Thomson P!R 3//0

DD

Ta.le 7# Com.ination drugs for h-pertension

Com.ination T-pe Q

'ixed1!ose Com.ination mgR

Trade Name

$CE*s and CCBs

$mlodipine1.ena:epril h-drochloride 43#2LD/ 2LD/ 2L3/ D/L3/5 Enalapril1felodipine 42L25 Trandolapril1verapamil 43LDG/ DL3E/ 3L3E/ EL3E/5

(otrel (exxel Tar,a

$CE*s and diuretics

Bena:epril1h-drochlorothia:ide 42LF#32 D/LD3#2 3/LD3#2 3/L325 Captopril1h-drochlorothia:ide 432LD2 32L32 2/LD2 2/L325 Enalapril1h-drochlorothia:ide 42LD3#2 D/L325 'osinopril1h-drochlorothia:ide 4D/LD3#2 3/LD3#25 (isinopril1h-drochlorothia:ide 4D/LD3#2 3/LD3#2 3/L325 %oexipril1h-drochlorothia:ide 47#2LD3#2 D2L325 Cuinapril1h-drochlorothia:ide 4D/LD3#2 3/LD3#2 3/L325

(otensin HCT Capo:ide )aseretic %onoprilLHCT Prin:ide =estoretic "niretic $ccuretic $tacand HCT Teveten1HCT $valide H-:aar

$RBs and diuretics

Candesartan1h-drochlorothia:ide 4DFLD3#2 03LD3#25 Eprosartan1h-drochlorothia:ide 4F//LD3#2 F//L325 *r.esartan1h-drochlorothia:ide 4D2/LD3#2 0//LD3#25 (osartan1h-drochlorothia:ide 42/LD3#2 D//L325

&lmesartan medoxomil1h-drochlorothia:ide 43/LD3#2 E/LD3#2 E/L325 Benicar HCT Telmisartan1h-drochlorothia:ide 4E/LD3#2 G/LD3#25%icardis1HCT )alsartan1h-drochlorothia:ide 4G/LD3#2 DF/LD3#2 DF/L325!iovan1HCT

BBs and diuretics

$tenolol1chlorthalidone 42/L32 D//L325 Bisoprolol1h-drochlorothia:ide 43#2LF#32 2LF#32 D/LF#325 %etoprolol1h-drochlorothia:ide 42/L32 D//L325 Nadolol1.endroflumethia:ide 4E/L2 G/L25 Propranolol ($1h-drochlorothia:ide 4E/L32 G/L325 Timolol1h-drochlorothia:ide 4D/L325

Tenoretic =iac (opressor HCT Cor:ide *nderide ($ Timolide

Centrall- acting drug %eth-ldopa1h-drochlorothia:ide 432/LD2 32/L32 2//L0/ 2//L2/5 and diuretic Reserpine1chlothalidone 4/#D32L32 /#32L2/5 Reserpine1chlorothia:ide 4/#D32L32/ /#32L2//5 Reserpine1h-drochlorothia:ide 4/#D32L32 /#D32L2/5 !iuretic and diuretic $miloride1h-drochlorothia:ide 42L2/5 Spironolactone1h-drochlorothia:ide 432L32 2/L2/5 Triamterene1h-drochlorothia:ide 407#2L32 72L2/5

$ldoril !emi1Regroton Regroton !iupres H-dropres %oduretic $ldacta:ide !-a:ide %ax:ide

Q !rug a..reviationsB BB .eta1.loc,er8 $CE* angiotensin converting en:-me inhi.itor8 $RB angiotensin receptor .loc,er8

CCB calcium channel .loc,er#

R

Some drug com.inations are availa.le in multiple fixed doses# Each drug dose is reported in milligrams#

D3

$chieving Blood Pressure Control in *ndividual Patients

%ost patients +ho are h-pertensive +ill reNuire t+o or more antih-pertensive medications to achieve their BP goals#DE D2 $ddition of a second drug from a different class should .e initiated +hen use of a single drug in adeNuate doses fails to achieve the BP goal# 9hen BP is more than 3/LD/ mmHg a.ove goal consideration should .e given to initiating therap- +ith t+o drugs either as separate prescriptions or in fixed1dose com.inations# 4See figure D#5 The initia1 tion of drug therap- +ith more than one agent ma- increase the li,elihood of achieving the BP goal in a more timel- fashion .ut particular caution is advised in those at ris, for orthostatic h-potension such as patients +ith dia1 .etes autonomic d-sfunction and some older persons# "se of generic drugs or com.ination drugs should .e considered to reduce prescription costs#

'igure D# $lgorithm for treatment of h-pertension

(ifest-le %odifications

Not at 6oal Blood Pressure 4ODE/LH/ mmHg5 4OD0/LG/ mmHg for patients +ith dia.etes or chronic ,idne- disease5

*nitial !rug Choices

9ithout Compelling *ndications

9ith Compelling *ndications

Stage D H-pertension 4SBP DE/MD2H or !BP H/MHH mmHg5

Thia:ide1t-pe diuretics for most# %a- consider $CE* $RB BB CCB or com.ination#

Stage 3 H-pertension 4SBP TDF/ or !BP TD// mmHg5

T+o1drug com.ination for most 4usuall- thia:ide1 t-pe diuretic and $CE* or $RB or BB or CCB5#

!rug4s5 for the compelling indications 4See ta.le G5 &ther antih-pertensive drugs 4diuretics $CE* $RB BB CCB5 as needed#

Not at 6oal Blood Pressure

&ptimi:e dosages or add additional drugs until goal .lood pressure is achieved# Consider consultation +ith h-pertension specialist#
!BP diastolic .lood pressure8 SBP s-stolic .lood pressure# !rug a..reviationsB $CE* angiotensin converting en:-me inhi.itor8 $RB angiotensin receptor .loc,er8 BB .eta1.loc,er8 CCB calcium channel .loc,er# D0

'ollo+up and %onitoring

&nce antih-pertensive drug therap- is initiated most patients should return for follo+up and adAustment of medications at approximatel- monthl- intervals until the BP goal is reached# %ore freNuent visits +ill .e necessar- for patients +ith stage 3 h-pertension or +ith complicating comor.id conditions# Serum potassium and creatinine should .e monitored at least DM3 timesL-ear#F/ $fter BP is at goal and sta.le follo+up visits can usuall- .e at 01 to F1month inter1 vals# Comor.idities such as heart failure associated diseases such as dia.etes and the need for la.orator- tests influence the freNuenc- of visits# &ther car1 diovascular ris, factors should .e treated to their respective goals and to.acco avoidance should .e promoted vigorousl-# (o+1dose aspirin therap- should .e considered onl- +hen BP is controlled .ecause the ris, of hemorrhagic stro,e is increased in patients +ith uncontrolled h-pertension#FD

special considerations
The patient +ith h-pertension and certain comor.idities reNuires special attention and follo+up .- the clinician#
Compelling *ndications

Ta.le G descri.es compelling indications that reNuire certain antih-pertensive drug classes for high1ris, conditions# The drug selections for these compelling indications are .ased on favora.le outcome data from clinical trials# $ com.i1 nation of agents ma- .e reNuired# &ther management considerations include medications alread- in use tolera.ilit- and desired BP targets# *n man- cases specialist consultation ma- .e indicated#

*schemic Heart !isease

*schemic heart disease 4*H!5 is the most common form of target organ damage associated +ith h-pertension# *n patients +ith h-pertension and sta.le angina pectoris the first drug of choice is usuall- a BB8 alternativel- long1acting CCBs can .e used#D *n patients +ith acute coronar- s-ndromes 4unsta.le angina or m-ocardial infarction5 h-pertension should .e treated initiall- +ith BBs and $CE*s EH +ith addition of other drugs as needed for BP control# *n patients +ith postm-ocardial infarction $CE*s BBs and aldosterone antagonists have proven to .e most .eneficial#2/ 23 20 F3 *ntensive lipid management and aspirin therap- are also indicated#

DE

Ta.le G# Clinical trial and guideline .asis for compelling indications for individual drug classes
Recommended !rugsR !iuretic Compelling *ndication Q BB $ldo $NT $CE* $RB CCB Clinical Trial BasisS

Heart failure

$CCL$H$ Heart 'ailure 6uideline E/ %ER*T1H' ED C&PERN*C"S E3 C*B*S E0 K S&()! EE $*RE E2 TR$CE EF )alHE'T E7 R$(ESEG $CCL$H$ Post1%* 6uideline EH BH$T 2/ K S$)E 2D Capricorn 23 EPHES"S20
K

Postm-ocardial infarction High coronar- disease ris,

$((H$T 00 H&PE 0E $NBP3 0F (*'E 03 C&N)*NCE0D N<'1$!$ 6uideline 3D 33 "<P!S 2E $((H$T00 N'< 6uideline 33 Captopril Trial 22 REN$$( 2F *!NT 27 RE*N 2G $$S<2H PR&6RESS02

!ia.etes

Chronic ,idne- disease Recurrent stro,e prevention

K

Compelling indications for antih-pertensive drugs are .ased on .enefits from outcome studies or existing clinical Q guidelines8 the compelling indication is managed in parallel +ith the BP#
R !rug a..reviationsB $CE* angiotensin converting en:-me inhi.itor8 $RB angiotensin receptor .loc,er8

$ldo $NT aldosterone antagonist8 BB .eta1.loc,er8 CCB calcium channel .loc,er#

S Conditions for +hich clinical trials demonstrate .enefit of specific classes of antih-pertensive drugs#

Heart 'ailure

Heart failure 4H'5 in the form of s-stolic or diastolic ventricular d-sfunction results primaril- from s-stolic h-pertension and *H!# 'astidious BP and cho1 lesterol control are the primar- preventive measures for those at high ris, for H'#E/ *n as-mptomatic individuals +ith demonstra.le ventricular d-sfunction $CE*s and BBs are recommended#23 F3 'or those +ith s-mptomatic ventricular d-sfunction or end1stage heart disease $CE*s BBs $RBs and aldosterone .loc,ers are recommended along +ith loop diuretics#E/MEG

!ia.etic H-pertension

Com.inations of t+o or more drugs are usuall- needed to achieve the target goal of OD0/LG/ mmHg#3D 33 Thia:ide diuretics BBs $CE*s $RBs and CCBs are .eneficial in reducing C)! and stro,e incidence in patients +ith dia1 .etes#00 2E F0 $CE*1 or $RB1.ased treatments favora.l- affect the progression of dia.etic nephropath- and reduce al.uminuria 22 2F and $RBs have .een sho+n to reduce progression to macroal.uminuria#2F 27

D2

Chronic <idne- !isease

*n people +ith chronic ,idne- disease 4C<!5 as defined .- either 4D5 reduced excretor- function +ith an estimated 6'R .elo+ F/ mlLmin per D#70 m3 4corresponding approximatel- to a creatinine of PD#2 mgLd( in men or PD#0 mgLd( in +omen5 3/ or 435 the presence of al.uminuria 4P0// mgLdaor 3// mg al.uminLg creatinine5 therapeutic goals are to slo+ deterioration of renal function and prevent C)!# H-pertension appears in the maAorit- of these patients and the- should receive aggressive BP management often +ith three or more drugs to reach target BP values of OD0/LG/ mmHg#2H FE $CE*s and $RBs have demonstrated favora.le effects on the progression of dia.etic and nondia.etic renal disease#22M2H FE $ limited rise in serum creatinine of as much as 02 percent a.ove .aseline +ith $CE*s or $RBs is accepta.le and is not a reason to +ithhold treatment unless h-per,alemia develops#F2 9ith advanced renal disease 4estimated 6'R O0/ mlLmin D#70 m3 corresponding to a serum creatinine of 3#2M0 mgLd(5 increasing doses of loop diuretics are usu1 all- needed in com.ination +ith other drug classes#

Cere.rovascular !isease

The ris,s and .enefits of acute lo+ering of BP during an acute stro,e are still unclear8 control of BP at intermediate levels 4approximatel- DF/LD// mmHg5 is appropriate until the condition has sta.ili:ed or improved# Recurrent stro,e rates are lo+ered .- the com.ination of an $CE* and thia:ide1t-pe diuretic# 02
&ther Special Situations

%inorities BP control rates var- in minorit- populations and are lo+est in %exican $mericans and Native $mericans#D *n general the treatment of h-pertension is similar for all demographic groups .ut socioeconomic factors and lifest-le ma- .e important .arriers to BP control in some minorit- patients# The prevalence severit- and impact of h-pertension are increased in $frican $mericans +ho also demonstrate some+hat reduced BP responses to monotherap- +ith BBs $CE*s or $RBs compared to diuretics or CCBs# These differential responses are largel- eliminated .- drug com.inations that include adeNuate doses of a diuretic# $CE*1induced angioedema occurs 3ME times more freNuentl- in $frican $merican patients +ith h-pertension than in other groups#00

&.esit- and the meta.olic s-ndrome &.esit- 4B%* P0/ ,gLm35 is an increasingl- prevalent ris, factor for the devel1 opment of h-pertension and C)!# The $dult Treatment Panel *** guideline
DF

for cholesterol management defines the meta.olic s-ndrome as the presence of three or more of the follo+ing conditionsB a.dominal o.esit- 4+aist circum1 ference PE/ inches in men or P02 inches in +omen5 glucose intolerance 4fast1 ing glucose PDD/ mgLd(5 BP PD0/LG2 mmHg high trigl-cerides 4PD2/ mgLd(5 or lo+ H!( 4OE/ mgLd( in men or O2/ mgLd( in +omen5#FF *ntensive lifest-le modification should .e pursued in all individuals +ith the meta.olic s-ndrome and appropriate drug therap- should .e instituted for each of its components as indicated#

(eft ventricular h-pertroph(eft ventricular h-pertroph- 4()H5 is an independent ris, factor that increases the ris, of su.seNuent C)!# Regression of ()H occurs +ith aggressive BP management including +eight loss sodium restriction and treatment +ith all classes of antih-pertensive agents except the direct vasodilators h-drala:ine and minoxidil#D F7

Peripheral arterial disease Peripheral arterial disease 4P$!5 is eNuivalent in ris, to *H!# $n- class of antih-pertensive drugs can .e used in most P$! patients# &ther ris, factors should .e managed aggressivel- and aspirin should .e used#

H-pertension in older persons H-pertension occurs in more than t+o1thirds of individuals after age F2#D This is also the population +ith the lo+est rates of BP control#FG Treatment recom1 mendations for older people +ith h-pertension including those +ho have iso1 lated s-stolic h-pertension should follo+ the same principles outlined for the general care of h-pertension# *n man- individuals lo+er initial drug doses ma.e indicated to avoid s-mptoms8 ho+ever standard doses and multiple drugs are needed in the maAorit- of older people to reach appropriate BP targets#

Postural h-potension $ decrease in standing SBP PD/ mmHg +hen associated +ith di::iness or faint1 ing is more freNuent in older patients +ith s-stolic h-pertension dia.etes and those ta,ing diuretics venodilators 4e#g# nitrates alpha1.loc,ers and sildenafil1 li,e drugs5 and some ps-chotropic drugs# BP in these individuals should also .e monitored in the upright position# Caution should .e used to avoid volume depletion and excessivel- rapid dose titration of antih-pertensive drugs#

!ementia !ementia and cognitive impairment occur more commonl- in people +ith h-pertension# Reduced progression of cognitive impairment ma- occur +ith effective antih-pertensive therap-#FH 7/

D7

H-pertension in +omen &ral contraceptives ma- increase BP and the ris, of h-pertension increases +ith duration of use# 9omen ta,ing oral contraceptives should have their BP chec,ed regularl-# !evelopment of h-pertension is a reason to consider other forms of contraception# *n contrast menopausal hormone therap- does not raise BP#7D

9omen +ith h-pertension +ho .ecome pregnant should .e follo+ed carefull.ecause of increased ris,s to mother and fetus# %eth-ldopa BBs and vasodila1 tors are preferred medications for the safet- of the fetus#73 $CE* and $RBs should not .e used during pregnanc- .ecause of the potential for fetal defects and should .e avoided in +omen +ho are li,el- to .ecome pregnant# Preeclampsia +hich occurs after the 3/th +ee, of pregnanc- is characteri:ed .- ne+1onset or +orsening h-pertension al.uminuria and h-peruricemia sometimes +ith coagulation a.normalities# *n some patients preeclampsia madevelop into a h-pertensive urgenc- or emergenc- and ma- reNuire hospitali:a1 tion intensive monitoring earl- fetal deliver- and parenteral antih-pertensive and anticonvulsant therap-#73

H-pertension in children and adolescents *n children and adolescents h-pertension is defined as BP that is on repeated measurement at the H2th percentile or greater adAusted for age height and gender#70 The fifth <orot,off sound is used to define !BP# Clinicians should .e alert to the possi.ilit- of identifia.le causes of h-pertension in -ounger children 4i#e# ,idne- disease coarctation of the aorta5# (ifest-le interventions are strongl- recommended +ith pharmacologic therap- instituted for higher levels of BP or if there is insufficient response to lifest-le modifications# 7E Choices of antih-pertensive drugs are similar in children and adults .ut effec1 tive doses for children are often smaller and should .e adAusted carefull-# $CE*s and $RBs should not .e used in pregnant or sexuall- active girls# "ncomplicated h-pertension should not .e a reason to restrict children from participating in ph-sical activities particularl- .ecause long1term exercise malo+er BP# "se of ana.olic steroids should .e strongl- discouraged# )igorous interventions also should .e conducted for other existing modifia.le ris, fac1 tors 4e#g# smo,ing5#

H-pertensive urgencies and emergencies Patients +ith mar,ed BP elevations and acute target1organ damage 4e#g# encephalopath- m-ocardial infarction unsta.le angina pulmonar- edema eclampsia stro,e head trauma life1threatening arterial .leeding or aortic dissection5 reNuire hospitali:ation and parenteral drug therap-#D Patients +ith mar,edl- elevated BP .ut +ithout acute target organ damage usuall- do not reNuire hospitali:ation .ut the- should receive immediate com.ination oral
DG

antih-pertensive therap-# The- should .e carefull- evaluated and monitored for h-pertension1induced heart and ,idne- damage and for identifia.le causes of h-pertension# 4See ta.le E#5
$dditional Considerations in $ntih-pertensive !rug Choices

$ntih-pertensive drugs can have favora.le or unfavora.le effects on other comor.idities# Potential favora.le effects Thia:ide1t-pe diuretics are useful in slo+ing deminerali:ation in osteoporosis# BBs can .e useful in the treatment of atrial tach-arrh-thmiasLfi.rillation migraine th-rotoxicosis 4short term5 essential tremor or perioperative h-per1 tension# CCBs ma- .e useful in Ra-naud7s s-ndrome and certain arrh-thmias and alpha1.loc,ers ma- .e useful in prostatism#

Potential unfavora.le effects Thia:ide diuretics should .e used cautiousl- in patients +ho have gout or +ho have a histor- of significant h-ponatremia# BBs should generall- .e avoided in individuals +ho have asthma reactive air+a-s disease or second or third degree heart .loc,# $CE*s and $RBs should not .e given to +omen li,el- to .ecome pregnant and are contraindicated in those +ho are# $CE*s should not .e used in individuals +ith a histor- of angioedema# $ldosterone antagonists and potassium1sparing diuretics can cause h-per,alemia and should generall- .e avoided in patients +ho have serum potassium values more than 2#/ mENL( +hile not ta,ing medications#

improving h-pertension control

$dherence to Regimens

Behavioral models suggest that the most effective therap- prescri.ed .the most careful clinician +ill control h-pertension onl- if the patient is motivated to ta,e the prescri.ed medication and to esta.lish and maintain a health1promoting lifest-le# %otivation improves +hen patients have positive experiences +ith and trust in their clinicians# Empath- .oth .uilds trust and is a potent motivator#72

Patient attitudes are greatl- influenced .- cultural differences .eliefs and previous experiences +ith the health care s-stem#7F These attitudes must .e understood if the clinician is to .uild trust and increase communication +ith patients and families#
DH

'ailure to titrate or com.ine medications despite ,no+ing the patient is not at goal BP represents clinical inertia and must .e overcome#77 !ecision sup1 port s-stems 4i#e# electronic and paper5 flo+ sheets feed.ac, reminders and involvement of nurse clinicians and pharmacists can .e helpful#7G

The clinician and the patient must agree upon BP goals# $ patient1centered strateg- to achieve the goal and an estimation of the time needed to reach goal are important#7H 9hen BP is a.ove goal alterations in the plan should .e documented# BP self1monitoring can also .e useful#

Patients7 nonadherence to therap- is increased .- misunderstanding of the condition or treatment denial of illness .ecause of lac, of s-mptoms or per1 ception of drugs as s-m.ols of ill health lac, of patient involvement in the care plan or unexpected adverse effects of medications# The patient should .e made to feel comforta.le in telling the clinician all concerns and fears of unexpected or distur.ing drug reactions#

The cost of medications and the complexit- of care 4i#e# transportation patient difficult- +ith pol-pharmac- difficult- in scheduling appointments and life7s competing demands5 are additional .arriers that must .e overcome to achieve goal BP#

$ll mem.ers of the health care team 4e#g# ph-sicians nurse case managers and other nurses ph-sician assistants pharmacists dentists registered dieti1 tians optometrists and podiatrists5 must +or, together to influence and rein1 force instructions to improve patients7 lifest-les and BP control#G/

Resistant H-pertension

Resistant h-pertension is the failure to reach goal BP in patients +ho are adhering to full doses of an appropriate three1drug regimen that includes a diuretic# $fter excluding potential identifia.le h-pertension 4see ta.le E5 clini1 cians should carefull- explore reasons +h- the patient is not at goal BP# 4See ta.le H#5 Particular attention should .e paid to diuretic t-pe and dose in rela1 tion to renal function# 4See IChronic <idne- !iseaseJ section#5 Consultation +ith a h-pertension specialist should .e considered if goal BP cannot .e achieved#

3/

Ta.le H# Causes of resisitant h-pertension

*mproper BP %easurement )olume &verload and Pseudotolerance
K Excess sodium inta,e K )olume retention from ,idne- disease K *nadeNuate diuretic therap-

!rug1*nduced or &ther Causes K Nonadherence K *nadeNuate doses

K *nappropriate com.inations K Nonsteroidal anti1inflammator- drugs8 c-cloox-genase 3 inhi.itors K Cocaine amphetamines other illicit drugs K S-mpathomimetics 4decongestants anorectics5 K &ral contraceptives K $drenal steroids K C-closporine and tacrolimus K Er-thropoietin K (icorice 4including some che+ing to.acco5 K Selected over1the1counter dietar- supplements and medicines

4e#g# ephedra ma haung .itter orange5 $ssociated Conditions K &.esitK Excess alcohol inta,e

*dentifia.le Causes of H-pertension# 4See ta.le E#5

pu.lic health challenges and communit- programs

Pu.lic health approaches such as reducing calories saturated fat and salt in processed foods and increasing communit-Lschool opportunities for ph-sical activit- can achieve a do+n+ard shift in the distri.ution of a population7s BP thus potentiall- reducing mor.idit- mortalit- and the lifetime ris, of an indi1 vidual7s .ecoming h-pertensive# This .ecomes especiall- critical as the increase in B%* of $mericans has reached epidemic levels# No+ D33 million adults are over+eight or o.ese +hich contri.utes to the rise in BP and related con1 ditions#GD The JNC 7 endorses the $merican Pu.lic Health $ssociation resolu1 tion that the food manufacturers and restaurants reduce sodium in the food suppl- .- 2/ percent over the next decade# 9hen pu.lic health intervention strategies address the diversit- of racial ethnic cultural linguistic religious and social factors in the deliver- of their services the li,elihood of their acceptance .- the communit- increases# These pu.lic health approaches can provide an attractive opportunit- to interrupt and prevent the continuing costl- c-cle of managing h-pertension and its complications#

3D

e v i d e n c e c l a s s i f i c at i o n
The studies that provided evidence supporting the recommendations of this report +ere classified and revie+ed .- the staff and the Executive Committee# The classification scheme is from the JNC F report#3 % %eta1anal-sis8 use of statistical methods to com.ine the results from clinical trials Randomi:ed controlled trials8 also ,no+n as experimental studies Retrospective anal-ses8 also ,no+n as case1control studies Prospective stud-8 also ,no+n as cohort studies including historical or prospective follo+up studies# Cross1sectional surve-8 also ,no+n as prevalence studies Previous revie+ or position statements Clinical interventions 4nonrandomi:ed5

R$ RE '

@ PR C

30

stud- a..reviations
$$S< $CCL$H$ $*RE $((H$T $NBP3 BH$T C*B*S C&N)*NCE $frican $merican Stud- of <idne- !isease and H-pertension $merican College of Cardiolog-L$merican Heart $ssociation $cute *nfarction Ramipril Efficac$ntih-pertensive and (ipid1(o+ering Treatment To Prevent Heart $ttac, Trial Second $ustralian National Blood Pressure StudX1Bloc,er Heart $ttac, Trial Cardiac *nsufficienc- Bisoprolol StudControlled &nset )erapamil *nvestigation of Cardiovascular End Points Carvedilol Prospective Randomi:ed Cumulative Survival StudEplerenone Post1$cute %-ocardial *nfarction Heart 'ailure Efficac- and Survival StudHeart &utcomes Prevention Evaluation Stud*r.esartan !ia.etic Nephropath- Trial (osartan *ntervention 'or Endpoint Reduction in H-pertension Stud%etoprolol CRL@( Randomi:ed *ntervention Trial in Congestive Heart 'ailure National <idne- 'oundation1$merican !ia.etes $ssociation Perindopril Protection $gainst Recurrent Stro,e StudRandomi:ed $ldactone Evaluation StudRamipril Efficac- in Nephropath- StudReduction of Endpoints in Non *nsulin !ependent !ia.etes %ellitus 9ith the $ngiotensin ** $ntagonist (osartan StudSurvival and )entricular Enlargement StudStudies of (eft )entricular !-sfunction Trandolapril Cardiac Evaluation Stud"nited <ingdom Prospective !ia.etes Stud)alsartan Heart 'ailure Trial

C&PERN*C"S EPHES"S H&PE *!NT (*'E %ER*T1H' N<'1$!$ PR&6RESS R$(ES RE*N REN$$(

S$)E S&()! TR$CE "<P!S )alHE'T

32

reference list
D# National High Blood Pressure Education Program# The sixth report of the Joint National Committee on Prevention !etection Evaluation and Treatment of High Blood Pressure# $rch *ntern %ed# DHH78D27B3ED01EF# PR

3#

"#S# !epartment of Health and Human Services National Heart (ung and Blood *nstitute# National High Blood Pressure Education Program# $vaila.le atB httpBLL+++#nhl.i#nih#govLa.outLnh.pepLindex#htm# $ccessed %arch 2 3//0#

0#

Sheps S6 Roccella EJ# Reflections on the sixth report of the Joint National Committee on Prevention !etection Evaluation and Treatment of High Blood Pressure# Curr H-pertens Rep# DHHH8DB0E312# PR

E#

Roccella EJ <aplan N%# *nterpretation and evaluation of clinical guidelines# *nB *::o J( Jr Blac, HR eds# H-pertension Primer# !allas T@B $merican Heart $ssociation 3//08D3FBD3F17# PR

2#

(ast J% $.ramson JH eds# $ dictionar- of epidemiolog-# 0rd ed# Ne+ ;or, N;B &xford "niversit- Press DHH2#

F#

)asan RS (arson %6 (eip EP et al# $ssessment of freNuenc- of progression to h-perten1 sion in nonh-pertensive participants in the 'ramingham Heart Stud-B $ cohort stud-# (ancet# 3//D802GBDFG31F# '

7#

)asan RS Beiser $ Seshadri S et al# Residual lifetime ris, for developing h-pertension in middle1aged +omen and menB The 'ramingham Heart Stud-# J$%$# 3//383G7BD//01D/# '

G#

(e+ington S Clar,e R Ci:il.ash N et al# $ge1specific relevance of usual .lood pressure to vascular mortalit-B $ meta1anal-sis of individual data for one million adults in FD prospective studies# (ancet# 3//380F/BDH/01D0# %

H#

9helton P< He J $ppel (J et al# Primar- prevention of h-pertensionB Clinical and pu.lic health advisor- from The National High Blood Pressure Education Program# J$%$# 3//383GGBDGG31G# PR

D/# Neal B %ac%ahon S Chapman N# Effects of $CE inhi.itors calcium antagonists and other .lood1pressure1lo+ering drugsB Results of prospectivel- designed overvie+s of ran1 domised trials# Blood Pressure (o+ering Treatment TrialistsW Colla.oration# (ancet# 3///802FBDH221FE# %

37

DD# &gden (6 He J (-dic, E 9helton P<# (ong1term a.solute .enefit of lo+ering .lood pressure in h-pertensive patients according to the JNC )* ris, stratification# H-pertension# 3///802B20H1E0# @

D3# Cherr- !< 9ood+ell !$# National $m.ulator- %edical Care Surve-B 3/// Summar-# $dvance !ata# 3//3803G# PR

D0# *::o J( Jr (ev- ! Blac, HR# Clinical $dvisor- Statement# *mportance of s-stolic .lood pressure in older $mericans# H-pertension# 3///802BD/3D1E# PR

DE# Cushman 9C 'ord CE Cutler J$ et al# Success and predictors of .lood pressure control in diverse North $merican settingsB The $ntih-pertensive and (ipid1(o+ering Treatment to Prevent Heart $ttac, Trial 4$((H$T5# J Clin H-pertens 46reen+ich5# 3//38EB0H01E/E# R$

D2# Blac, HR Elliott 9J Neaton J! et al# Baseline characteristics and elderl- .lood pressure control in the C&N)*NCE trial# H-pertension# 3//D807BD31G# R$

DF# 9orld H-pertension (eague# %easuring -our .lood pressure# $vaila.le atB httpBLL+++#mco#eduLorgL+hlL.loodpre#html# $ccessed $pril D 3//0#

D7# Pic,ering T# Recommendations for the use of home 4self5 and am.ulator- .lood pressure monitoring# $merican Societ- of H-pertension $d Hoc Panel# $m J H-pertens# DHHF8HBD1DD# PR

DG# )erdecchia P# Prognostic value of am.ulator- .lood pressureB current evidence and clinical implications# H-pertension# 3///802BGEE12D# PR

DH# $merican Heart $ssociation# Home monitoring of high .lood pressure# $vaila.le atB httpBLL+++#americanheart#orgLpresenter#AhtmlYidentifierZ27F# $ccessed $pril D 3//0# 3/# 6'R L D#70 %3 .- %!R! 4[ S"N and S$l.5 Calculator# $vaila.le atB httpBLL+++#hdcn#comLcalcfLgfr#htm# $ccessed $pril D 3//0#

3D# $merican !ia.etes $ssociation# Treatment of h-pertension in adults +ith dia.etes# !ia.etes Care# 3//083F4suppl D5BSG/1SG3# PR

33# National <idne- 'oundation 6uideline# <L!&C* clinical practice guidelines for chronic ,idne- diseaseB Evaluation classification and stratification# <idne- !isease &utcome Cualit- *nitiative# $m J <idne- !is# 3//380H4suppl 35BSD1S3EF# PR

3G

30# The Trials of H-pertension Prevention Colla.orative Research 6roup# Effects of +eight loss and sodium reduction intervention on .lood pressure and h-pertension incidence in over+eight people +ith high1normal .lood pressure# The Trials of H-pertension Prevention phase **# $rch *ntern %ed# DHH78D27BF271F7# R$

3E# He J 9helton P< $ppel (J Charleston J <lag %J# (ong1term effects of +eight loss and dietar- sodium reduction on incidence of h-pertension# H-pertension# 3///802B2EE1H# '

32# Sac,s '% Svet,e- (P )ollmer 9% et al# Effects on .lood pressure of reduced dietarsodium and the !ietar- $pproaches to Stop H-pertension 4!$SH5 diet# !$SH1Sodium Colla.orative Research 6roup# N Engl J %ed# 3//D80EEB01D/# R$

3F# )ollmer 9% Sac,s '% $rd J et al# Effects of diet and sodium inta,e on .lood pressureB Su.group anal-sis of the !$SH1sodium trial# $nn *ntern %ed# 3//D8D02BD/DH13G# R$

37# Cho.anian $) Hill %# National Heart (ung and Blood *nstitute 9or,shop on Sodium and Blood PressureB $ critical revie+ of current scientific evidence# H-pertension# 3///802BG2G1F0# PR

3G# <elle- 6$ <elle- <S# Progressive resistance exercise and resting .lood pressureB $ meta1anal-sis of randomi:ed controlled trials# H-pertension# 3///802BG0G1E0# %

3H# 9helton SP Chin $ @in @ He J# Effect of aero.ic exercise on .lood pressureB $ meta1anal-sis of randomi:ed controlled trials# $nn *ntern %ed# 3//38D0FBEH012/0# %

0/# @in @ He J 'rontini %6 et al# Effects of alcohol reduction on .lood pressureB $ meta1anal-sis of randomi:ed controlled trials# H-pertension# 3//D80GBDDD317# %

0D# Blac, HR Elliott 9J 6randits 6 et al# Principal results of the Controlled &Nset )erapamil *Nvestigation of Cardiovascular Endpoints 4C&N)*NCE5 trial# J$%$# 3//083GHB3/701G3# R$

03# !ahlof B !evereux RB <Aeldsen SE et al# Cardiovascular mor.idit- and mortalit- in the (osartan *ntervention 'or Endpoint reduction in h-pertension stud- 4(*'E5B $ randomised trial against atenolol# (ancet# 3//3802HBHH21D//0# R$

00# The $((H$T &fficers and Coordinators for the $((H$T Colla.orative Research 6roup# %aAor outcomes in high1ris, h-pertensive patients randomi:ed to angiotensin1 converting en:-me inhi.itor or calcium channel .loc,er vs diureticB The $ntih-pertensive and (ipid1(o+ering Treatment to Prevent Heart $ttac, Trial 4$((H$T5# J$%$# 3//383GGB3HGD1H7# R$

3H

0E# The Heart &utcomes Prevention Evaluation Stud- *nvestigators# Effects of an angiotensin1 converting1en:-me inhi.itor ramipril on cardiovascular events in high1ris, patients# N Engl J %ed# 3///80E3BDE2120# R$

02# PR&6RESS Colla.orative 6roup# Randomised trial of a perindopril1.ased .lood1pressure1 lo+ering regimen among F D/2 individuals +ith previous stro,e or transient ischaemic attac,# (ancet# 3//D802GBD/001ED# R$

0F# 9ing (%H Reid C% R-an P et al# $ comparison of outcomes +ith angiotensin1 converting1en:-me inhi.itors and diuretics for h-pertension in the elderl-# N Engl J %ed# 3//080EGB2G01H3# R$

07# Psat- B% Smith N( Siscovic, !S et al# Health outcomes associated +ith antih-perten1 sive therapies used as first1line agents# $ s-stematic revie+ and meta1anal-sis# J$%$# DHH78377B70H1E2# %

0G# Ph-sicians7 !es, Reference# 27 ed# &radell NJB %edical Economics 3//0# 0H# Psat- B% %anolio T$ Smith N( et al# Time trends in high .lood pressure control and the use of antih-pertensive medications in older adultsB The Cardiovascular Health Stud-# $rch *ntern %ed# 3//38DF3B3032103# @

E/# Hunt S$ Ba,er !9 Chin %H et al# $CCL$H$ guidelines for the evaluation and management of chronic heart failure in the adultB Executive summar-# $ report of the $merican College of Cardiolog-L$merican Heart $ssociation Tas, 'orce on Practice 6uidelines 4Committee to revise the DHH2 6uidelines for the Evaluation and %anagement of Heart 'ailure5# J $m Coll Cardiol# 3//D80GB3D/D1D0# PR

ED# Tepper !# 'rontiers in congestive heart failureB Effect of %etoprolol CRL@( in chronic heart failureB %etoprolol CRL@( Randomised *ntervention Trial in Congestive Heart 'ailure 4%ER*T1H'5# Congest Heart 'ail# DHHH82BDGE12# R$

E3# Pac,er % Coats $J 'o+ler %B et al# Effect of carvedilol on survival in severe chronic heart failure# N Engl J %ed# 3//D80EEBDF2D1G# R$

E0# C*B*S *nvestigators and Committees# $ randomi:ed trial of .eta1.loc,ade in heart failure# The Cardiac *nsufficienc- Bisoprolol Stud- 4C*B*S5# Circulation# DHHE8H/BD7F2170# R$

EE# The S&()! *nvestigators# Effect of enalapril on survival in patients +ith reduced left ventric1 ular eAection fractions and congestive heart failure# N Engl J %ed# DHHD8032B3H010/3# R$

0/

E2# The $cute *nfarction Ramipril Efficac- 4$*RE5 Stud- *nvestigators# Effect of ramipril on mortalit- and mor.idit- of survivors of acute m-ocardial infarction +ith clinical evidence of heart failure# (ancet# DHH080E3BG3D1G# R$

EF# <o.er ( Torp1Pedersen C Carlsen JE et al# $ clinical trial of the angiotensin1converting1 en:-me inhi.itor trandolapril in patients +ith left ventricular d-sfunction after m-ocardial infarction# Trandolapril Cardiac Evaluation 4TR$CE5 Stud- 6roup# N Engl J %ed# DHH28000BDF7/1F# R$

E7# Cohn JN Tognoni 6# $ randomi:ed trial of the angiotensin1receptor .loc,er valsartan in chronic heart failure# N Engl J %ed# 3//D80E2BDFF7172# R$

EG# Pitt B =annad ' Remme 9J et al# The effect of spironolactone on mor.idit- and mortalitin patients +ith severe heart failure# Randomi:ed $ldactone Evaluation Stud*nvestigators# N Engl J %ed# DHHH80EDB7/H1D7# R$

EH# Braun+ald E $ntman E% Beasle- J9 et al# $CCL$H$ 3//3 guideline update for the management of patients +ith unsta.le angina and non1ST1segment elevation m-ocardial infarction>summar- articleB $ report of the $merican College of Cardiolog-L$merican Heart $ssociation tas, force on practice guidelines 4Committee on the %anagement of Patients 9ith "nsta.le $ngina5# J $m Coll Cardiol# 3//38E/BD0FF17E# PR

2/# \1Bloc,er Heart $ttac, Trial Research 6roup# $ randomi:ed trial of propranolol in patients +ith acute m-ocardial infarction# *# %ortalit- results# J$%$# DHG383E7BD7/71DE# R$

2D# Hager 9! !avis BR Ri.a $ et al# $.sence of a deleterious effect of calcium channel .loc,ers in patients +ith left ventricular d-sfunction after m-ocardial infarctionB The S$)E Stud- Experience# S$)E *nvestigators# Survival and )entricular Enlargement# $m Heart J# DHHG8D02BE/F1D0# R$

23# The Capricorn *nvestigators# Effect of carvedilol on outcome after m-ocardial infarction in patients +ith left1ventricular d-sfunctionB The C$PR*C&RN randomised trial# (ancet# 3//D8027BD0G21H/# R$

20# Pitt B Remme 9 =annad ' et al# Eplerenone a selective aldosterone .loc,er in patients +ith left ventricular d-sfunction after m-ocardial infarction# N Engl J %ed# 3//080EGBD0/H13D# R$

2E# "< Prospective !ia.etes Stud- 6roup# Efficac- of atenolol and captopril in reducing ris, of macrovascular and microvascular complications in t-pe 3 dia.etesB "<P!S 0H# B%J# DHHG80D7B7D013/# R$

0D

22# (e+is EJ Hunsic,er (6 Bain RP Rohde R!# The effect of angiotensin1converting1en:-me inhi.ition on dia.etic nephropath-# The Colla.orative Stud- 6roup# N Engl J %ed# DHH0803HBDE2F1F3# R$

2F# Brenner B% Cooper %E de =eeu+ ! et al# Effects of losartan on renal and cardio1 vascular outcomes in patients +ith t-pe 3 dia.etes and nephropath-# N Engl J %ed# 3//D80E2BGFD1H# R$

27# (e+is EJ Hunsic,er (6 Clar,e 9R et al# Renoprotective effect of the angiotensin1receptor antagonist ir.esartan in patients +ith nephropath- due to t-pe 3 dia.etes# N Engl J %ed# 3//D80E2BG2D1F/# R$

2G# The 6*SEN 6roup 46ruppo *taliano di Studi Epidemiologici in Nefrologia5# Randomised place.o1controlled trial of effect of ramipril on decline in glomerular filtration rate and ris, of terminal renal failure in proteinuric non1dia.etic nephropath-# (ancet# DHH780EHBDG271F0# R$

2H# 9right JT Jr $godoa ( Contreras 6 et al# Successful .lood pressure control in the $frican $merican Stud- of <idne- !isease and H-pertension# $rch *ntern %ed# 3//38DF3BDF0F1E0# R$

F/# Ba,ris 6( 9eir %R on .ehalf of the Stud- of H-pertension and Efficac- of (otrel in !ia.etes 4SH*E(!5 *nvestigators# $chieving goal .lood pressure in patients +ith t-pe 3 dia.etesB Conventional versus fixed1dose com.ination approaches# J Clin H-pertens# 3//082B3/D1D/# R$

FD# $ntithrom.otic Trialist Colla.oration# Colla.orative meta1anal-sis of randomised trials of antiplatelet therap- for prevention of death m-ocardial infarction and stro,e in high ris, patients# B%J# 3//3803EB7D1GF# %

F3# Pfeffer %$ Braun+ald E %o-e ($ et al# Effect of captopril on mortalit- and mor.iditin patients +ith left ventricular d-sfunction after m-ocardial infarction# Results of the Survival $nd )entricular Enlargement trial# The S$)E *nvestigators# N Engl J %ed# DHH38037BFFH177# R$

F0# (indholm (H *.sen H !ahlof B et al# Cardiovascular mor.idit- and mortalit- in patients +ith dia.etes in the (osartan *ntervention 'or Endpoint reduction in h-pertension stud4(*'E5B a randomised trial against atenolol# (ancet# 3//3802HBD//E1D/# R$

FE# Ba,ris 6( 9illiams % !+or,in ( et al# Preserving renal function in adults +ith h-perten1 sion and dia.etesB $ consensus approach# National <idne- 'oundation H-pertension and !ia.etes Executive Committees 9or,ing 6roup# $m J <idne- !is# 3///80FBFEF1FD# PR

03

F2# Ba,ris 6( 9eir %R# $ngiotensin1converting en:-me inhi.itor1associated elevations in serum creatinineB *s this a cause for concernY $rch *ntern %ed# 3///8DF/BFG21H0# %

FF# National Cholesterol Education Program# Third Report of the National Cholesterol Education Program 4NCEP5 Expert Panel on !etection Evaluation and Treatment of High Blood Cholesterol in $dults 4$dult Treatment Panel ***5 final report# Circulation# 3//38D/FB0DE01E3D# PR

F7# <Aeldsen SE !ahlof B !evereux RB et al# Effects of losartan on cardiovascular mor.iditand mortalit- in patients +ith isolated s-stolic h-pertension and left ventricular h-pertro1 ph-B a (osartan *ntervention for Endpoint Reduction 4(*'E5 su.stud-# J$%$# 3//383GGBDEHD1G# R$

FG# H-man !J Pavli, )N# Characteristics of patients +ith uncontrolled h-pertension in the "nited States# N Engl J %ed# 3//D80E2BE7H1GF# @

FH# Staessen J$ 9ang J# Blood1pressure lo+ering for the secondar- prevention of stro,e# UCommentar-V# (ancet# 3//D802GBD/3F17#

7/# !i Bari % Pahor % 'ranse () et al# !ementia and disa.ilit- outcomes in large h-perten1 sion trialsB lessons learned from the s-stolic h-pertension in the elderl- program 4SHEP5 trial# $m J Epidemiol# 3//D8D20B731G# R$

7D# 9riting 6roup for the 9omenWs Health *nitiative *nvestigators# Ris,s and .enefits of estrogen plus progestin in health- postmenopausal +omenB Principal results from the 9omenWs Health *nitiative randomi:ed controlled trial# J$%$# 3//383GGB03D100# R$

73# National High Blood Pressure Education Program# Report of the National High Blood Pressure Education Program 9or,ing 6roup on High Blood Pressure in Pregnanc-# $m J &.stet 6-necol# 3///8DG0BSD1S33# PR

70# National High Blood Pressure Education Program# "pdate on the DHG7 Tas, 'orce Report on High Blood Pressure in Children and $dolescentsB $ +or,ing group report from the National High Blood Pressure Education Program# National High Blood Pressure Education Program 9or,ing 6roup on H-pertension Control in Children and $dolescents# Pediatrics# DHHF8HG4pt D5BFEH12G# PR

7E# Barlo+ SE !iet: 9H# &.esit- evaluation and treatmentB Expert Committee recommen1 dations# The %aternal and Child Health Bureau Health Resources and Services $dministration and the !epartment of Health and Human Services# Pediatrics# DHHG8D/3BE3H# PR

00

72# Barrier P$ (i JT Jensen N%# T+o +ords to improve ph-sician1patient communicationB 9hat elseY %a-o Clin Proc# 3//087GB3DD1E# PR

7F# Betancourt JR Carrillo JE 6reen $R# H-pertension in multicultural and minorit- popula1 tionsB (in,ing communication to compliance# Curr H-pertens Rep# DHHH8DBEG31G#

77# Phillips (S Branch 9T Coo, CB et al# Clinical inertia# $nn *ntern %ed# 3//D8D02BG3210E# 7G# Balas E$ 9eingarten S 6ar. CT et al# *mproving preventive care .- prompting ph-si1 cians# $rch *ntern %ed# 3///8DF/B0/D1G# C

7H# Boul+are (E !aumit 6( 'ric, <! et al# $n evidence1.ased revie+ of patient1centered .ehavioral interventions for h-pertension# $m J Prev %ed# 3//D83DB33D103# PR %

G/# Hill %N %iller NH# Compliance enhancement# $ call for multidisciplinar- team approaches# Circulation# DHHF8H0BE1F#

GD# 'legal <% Carroll %! &gden C( Johnson C(# Prevalence and trends in o.esit- among "S adults DHHH13///# J$%$# 3//383GGBD73017# @

0E

!iscrimination Prohi.itedB "nder provisions of applica.le pu.lic la+s enacted .- Congress since DHFE no person in the "nited States shall on the grounds of race color national origin handicap or age .e excluded from partici1 pation in .e denied the .enefits of or .e su.Aected to discrimination under an- program or activit- 4or on the .asis of sex +ith respect to an- education program or activit-5 receiving 'ederal financial assistance# *n addition Executive &rder DDDED prohi.its discrimination on the .asis of age .- contractors and su.contractors in the performance of 'ederal contracts and Executive &rder DD3EF states that no federall- funded contractor madiscriminate against an- emplo-ee or applicant for emplo-ment .ecause of race color religion sex or national origin# Therefore the National Heart (ung and Blood *nstitute must .e operated in compliance +ith these la+s and Executive &rders#

'or %ore *nformation The NH(B* Health *nformation Center is a service of the National Heart (ung and Blood *nstitute 4NH(B*5 of the National *nstitutes of Health# The NH(B* Health *nformation Center provides information to health profes1 sionals patients and the pu.lic a.out the treatment diagnosis and prevention of heart lung and .lood diseases# 'or more information contactB

NH(B* Health *nformation Center P Box 0/D/2#&# Bethesda %! 3/G3E1/D/2 PhoneB 0/D12H31G270 TT;B 3E/1F3H10322 'axB 0/D12H31G2F0 9e. siteB httpBLL+++#nhl.i#nih#gov

" # S # ! E P$ R T % E N T & ' H E $ (T H $ N ! H " % $ N S E R ) * C E S National *nstitutes of Health National Heart (ung and Blood *nstitute National High Blood Pressure Education Program

N*H Pu.lication No# /012300 !ecem.er 3//0