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National High Blood Pressure Education Program
This set of slides is provided by theU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health ServiceNational Institutes of Health
National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program
Full text of JNC VI may be downloaded from the NHLBI web site.
NIH PublicationNo. 98-4080November 1997
National High Blood Pressure Education Program
National Heart, Lung, and Blood Institute (NHLBI) publications fall within the public domain (as do all Government publications). Hence, they are not copyrighted and may be reproduced or reprinted. NHLBI does ask, however, that reprinted material include a credit line acknowledging NHLBI as the source.
Communications and Public Information BranchOffice of Prevention, Education, and Control
NIH PublicationNo. 98-4080November 1997
DISCLAIMER
The appearance of rotating Ads onthis web site
bears no relationship to JNC VI.
The slide set is provided for educational purposes.It may be disseminated freely,but may NOT to be used for
commercial or product endorsement purposes.
MedSlides Board of Directors
National High Blood Pressure Education Program
The Sixth Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure
(JNC VI)
NIH Publication
No. 98-4080November 1997
slide 5
Sixth Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure
Henry R. Black, M.D., Chair of Chapter 1Rush-Presbyterian-St. Luke’s Medical Center
Jerome D. Cohen, M.D., Chair of Chapter 2St. Louis University Health Sciences Center
Norman M. Kaplan, M.D., Chair of Chapter 3University of Texas Southwestern Medical School
Keith C. Ferdinand, M.D., Chair of Chapter 4Heartbeats Life Center
Aram V. Chobanian, M.D.Boston University
Harriet P. Dustan, M.D.University of Vermont College of Medicine
Ray W. Gifford, Jr., M.D.Cleveland Clinic Foundation
Marvin Moser, M.D.Yale University School of Medicine
Executive Committee:
Sheldon G. Sheps, M.D., ChairMayo Clinic and Mayo Foundation and Mayo Medical School
slide 6
National High Blood Pressure Education Program Coordinating Committee
Agency for Health Care Policy and ResearchAmerican Academy of Family PhysiciansAmerican Academy of Insurance MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Physician AssistantsAmerican Association of Occupational Health NursesAmerican College of CardiologyAmerican College of Chest PhysiciansAmerican College of Occupational and Environmental MedicineAmerican College of Physicians American College of Preventive MedicineAmerican Dental Association
Health Care Financing AdministrationHealth Resources and Services Administration International Society on Hypertension in BlacksNational Black Nurses’ Association, Inc.National Center for Health Statistics, Centers for Disease Control and PreventionNational Heart, Lung, and Blood InstituteNational Hypertension AssociationNational Institute of Diabetes and Digestive and Kidney DiseasesNational Kidney FoundationNational Medical AssociationNational Optometric AssociationNational Stroke AssociationNHLBI Ad Hoc Committee on Minority PopulationsSociety for Nutrition EducationU.S. Department of Veterans’ Affairs
American Diabetes AssociationAmerican Dietetic AssociationAmerican Heart AssociationAmerican Hospital AssociationAmerican Medical AssociationAmerican Nurses’ Association, Inc.American Optometric AssociationAmerican Osteopathic AssociationAmerican Pharmaceutical
AssociationAmerican Podiatric Medical
AssociationAmerican Public Health AssociationAmerican Red CrossAmerican Society of Health-System
PharmacistsAmerican Society of HypertensionAssociation of Black CardiologistsCitizens for Public Action on High
Blood Pressure and Cholesterol, Inc.
Council on Geriatric Cardiology
slide 7
JNC VI Table of Contents
1. Introduction
2. Blood Pressure Measurement and Clinical Evaluation
3. Prevention and Treatment of High Blood Pressure
4. Special Populations and Situations
slide 8
Purpose of the JNC VI Report
To use evidence-based medicine and
consensus to report on
contemporary approaches to
hypertension prevention and control
for use by primary care clinicians.
slide 9
Progress of theNational High Blood Pressure
Education Program
• Increased awareness, treatment, and control
• Decreased morbidity and mortality from stroke and coronary heart disease (CHD)
slide 10
Public Health Challenges for the National High Blood Pressure
Education Program
• Prevent blood pressure rise with age
• Decrease prevalence
• Increase awareness and detection
• Improve control
• Reduce cardiovascular risks
slide 11
Public Health Challenges for the National High Blood Pressure
Education Program (continued)
• Recognize importance of controlled isolated systolic hypertension
• Recognize importance of high-normal blood pressure
• Reduce demographic variations
• Improve opportunities for treatment
slide 12
Awareness, Treatment, and Control of High Blood Pressure in Adults*
NHANES II1976-80
NHANES III(Phase 1)1988-91
NHANES III(Phase 2)1991-94
Awareness 51% 73% 68.4%
Treatment 31% 55% 53.6%
Control** 10% 29% 27.4%* Adults age 18 to 74 years with SBP
140 mm Hg or DBP
90 mm Hg or taking antihypertensive
medication.** SBP < 140 mm Hg and DBP < 90 mm Hg.
slide 13
-70
-60
-50
-40
-30
-20
-10
0
1970 1974 1978 1982 1986 1990 1994Year
Pe
rce
nt
de
clin
e
White men
White women
Black men
Black women
The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population.
Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and
Race: United States, 1972-94
slide 14
-60
-50
-40
-30
-20
-10
0
1970 1974 1978 1982 1986 1990 1994Year
Pe
rce
nt
de
cli
ne
White men
White women
Black men
Black women
The decline in age-adjusted mortality for CHD in the total population is 53.2%.*Age-adjusted to the 1940 U.S. census population.
Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and
Race: United States, 1972-94
slide 15
Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995
50
100
150
200
250
1983 1985 1987 1989 1991 1993 1995
Year
Rat
e p
er M
illi
on
Po
pu
lati
on
253*
*Provisional data.Adjusted for age, race, and sex.
slide 16
Prevalence of Heart Failure,by Age, 1976-80 and 1988-91
0%
2%
4%
6%
8%
10%
30 35 45 55 65 75 80
Age (Years)
1988-91
1976-80
slide 17
Summary of Chapter 1
• Hypertension awareness, treatment, and control rates have increased over the past 3 decades. The rates of increase have lessened since JNC V.
• Age-adjusted mortality for stroke and CHD declined during this time but now appear to be leveling.
• The incidence of end-stage renal disease and the prevalence of heart failure are increasing.
slide 18
Summary of Chapter 1 (continued)
• Randomized controlled trials provide the best method of estimating benefit of treatment and source of information for clinical policy, but they have limitations.
• Prevention and treatment of hypertension and target organ disease remain important public health challenges that must be addressed.
slide 19
Blood Pressure Measurement
• Patients should be seated with back supported and arm bared and supported.
• Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement.
• Measurement should begin after at least 5 minutes of rest.
• Appropriate cuff size and calibrated equipment should be used.
• Both SBP and DBP should be recorded.
• Two or more readings should be averaged.
slide 20
Advantages of Self-Measurement
• Identifies “white-coat hypertension”
• Assesses response to medication
• Improves adherence to treatment
• Potentially reduces costs
• Usually provides lower readings than those recorded in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)
slide 21
Ambulatory Measurement
• Ambulatory monitoring can provide:– readings throughout day during usual activities
– readings during sleep to assess nocturnal changes
– measures of SBP and DBP load
• Ambulatory readings are usually lower than in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)
slide 22
Classification of Blood Pressure for Adults
CategorySBP
(mm Hg)DBP
(mm Hg)
Optimal < 120 and < 80
Normal < 130 and < 85
High-normal 130-139 or 85-89
Hypertension Stage 1 Stage 2 Stage 3
140-159160-179
180
ororor
90-99100-109110
When SBP and DBP fall into different categories, use the higher category.
slide 23
Recommendations for Followup Based on Initial Measurements
Initial Blood Pressure
SBP DBP Followup Recommended
< 130 < 85 Recheck in 2 years
130-139 85-89 Recheck in 1 year, give lifestyle advice
140-159 90-99 Confirm within 2 months, give lifestyleadvice
160-179 100-109 Evaluate/refer to care within 1 month
180 110 Evaluate/refer to care within 7 days
slide 24
Evaluation Objectives
• To identify known causes
• To assess presence or absence of target organ damage and cardiovascular disease
• To identify other risk factors or disorders that may guide treatment
slide 25
Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
• Optional tests
slide 26
Medical History
• Duration and classification of hypertension
• Patient history of cardiovascular disease
• Family history
• Symptoms suggesting causes of hypertension
• Lifestyle factors
• Current and previous medications
slide 27
Physical Examination
• Blood pressure readings (2 or more)
• Verification in contralateral arm
• Height, weight, and waist circumference
• Funduscopic examination
• Examination of the neck, heart, lungs, abdomen, and extremities
• Neurological assessment
slide 28
Laboratory Tests and Other Diagnostic Procedures
• Determine presence of target organ damage and other risk factors
• Seek specific causes of hypertension
slide 29
Laboratory Tests Recommended Before Initiating Therapy
•Urinalysis
•Complete blood count
•Blood chemistry (potassium, sodium, creatinine, and fasting glucose)
•Lipid profile (total cholesterol and HDL cholesterol)
•12-lead electrocardiogram
slide 30
Optional Tests and Procedures
•Creatinine clearance•Microalbuminuria•24-hour urinary protein•Serum calcium•Serum uric acid•Fasting triglycerides•LDL cholesterol•Glycosolated hemoglobin
•Thyroid-stimulating hormone•Plasma renin activity/ urinary sodium determination•Limited echocardiography•Ultrasonography•Measurement of ankle/arm index
slide 31
Examples of IdentifiableCauses of Hypertension
• Renovascular disease
• Renal parenchymal disease
• Polycystic kidneys
• Aortic coarctation
• Pheochromocytoma
• Primary aldosteronism
• Cushing syndrome
• Hyperparathyroidism
• Exogenous causes
slide 32
Components of Cardiovascular Risk in Patients With Hypertension
Major Risk Factors:
• Smoking
• Dyslipidemia
• Diabetes mellitus
• Age older than 60 years
• Sex (men or postmenopausal women)
• Family history of cardiovascular disease
slide 33
Clinical Risk Factors forStratification of Patients With
Hypertension
• Heart diseases
• Stroke or transient ischemic attack
• Nephropathy
• Peripheral arterial disease
• Retinopathy
slide 34
Risk Stratification
Risk Group A No risk factorsNo target organ disease/clinical cardiovascular disease
Risk Group B At least one risk factor, not including diabetesNo target organ disease/clinical cardiovascular disease
Risk Group C Target organ disease/clinical cardiovascular diseaseand/or diabetes
With or without other risk factors
slide 35
Treatment Strategies andRisk Stratification
Blood PressureStages (mm Hg) Risk Group A Risk Group B Risk Group C
High-normal(130-139/85-89)
Lifestyle modification Lifestyle modification Drug therapy*Lifestyle modification
Stage 1(140-159/90-99)
Lifestyle modification(up to 12 months)
Lifestyle modification(up to 6 months)**
Drug therapyLifestyle modification
Stages 2 and 3( 160/ 100)
Drug therapyLifestyle modification
Drug therapyLifestyle modification
Drug therapyLifestyle modification
*For those with heart failure, renal insufficiency, or diabetes.**For those with multiple risk factors, clinicians should consider drugs as initial therapy plus lifestyle modifications.
slide 36
Summary of Chapter 2
• Blood pressure classified as optimal, normal, high-normal, or stages 1, 2, or 3.
• Recommendations for detection, confirmation, and evaluation remain consistent with those in the JNC V report.
• In self-monitoring and ambulatory measurement, hypertension is now defined as SBP >135 mm Hg and DBP 85 mm Hg.
slide 37
Summary of Chapter 2 (continued)
• New sections discuss genetics and clinical clues to identifiable causes of hypertension.
• New tables list cardiovascular risk factors and describe risk stratification.
slide 38
Primary Prevention
• Primary prevention offers an opportunity to interrupt the costly cycle of managing hypertension.
• A population-wide approach can reduce morbidity and mortality.
• Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.
• Blood pressure rise with age is not inevitable.
• Lifestyle modifications have been shown to lower blood pressure.
slide 39
Goal of HypertensionPrevention and Management
• To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining:
– SBP < 140 mm Hg
– DBP < 90 mm Hg
– controlling other cardiovascular risk factors
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slide 41Not at Goal Blood Pressure
Algorithm for Treatment of Hypertension (continued)
Begin or Continue Lifestyle Modifications
• Lose weight• Limit alcohol• Increase physical
activity• Reduce Sodium
• Maintain potassium• Maintain calcium and
magnesium• Stop smoking• Reduce saturated fat,
cholesterol
slide 42
Initial Drug Choices
Algorithm for Treatment of Hypertension (continued)
Not at Goal Blood Pressure (< 140/90 mm Hg)
lower goals for patients with diabetes or renal disease
Begin or Continue Lifestyle Modifications
slide 43Not at Goal Blood Pressure
Initial Drug Choices
Uncomplicated
Compelling Indications
Not at Goal Blood Pressure
Algorithm for Treatment of Hypertension (continued)
– Start at low dose and titrate upward.– Low-dose combinations may be appropriate.
Specific Indications
slide 44
Initial Drug Choices*
Uncomplicated• Diuretics• -blockers
Algorithm for Treatment ofHypertension (continued)
*Based on randomized controlled trials.
slide 45
Initial Drug Choices*
Algorithm for Treatment of Hypertension (continued)
Compelling Indications • Heart failure
– ACE inhibitors– Diuretics
• Myocardial infarction -blockers (non-ISA)– ACE inhibitors (with systolic dysfunction)
• Diabetes mellitus (type 1) with proteinuria– ACE inhibitors
• Isolated systolic hypertension (older persons) – Diuretics preferred– Long-acting dihydropyridine calcium antagonists
*Based on randomized controlled trials.
slide 46
Initial Drug Choices
Specific indications for the following drugs:
Algorithm for Treatment ofHypertension (continued)
• ACE inhibitors
• Angiotensin II receptor
blockers
• -blockers
• --blockers
• -blockers
• Calcium antagonists
• Diuretics
slide 47
Specific Drug Indications
• Angina
– -blockers
– Calcium antagonists
• Atrial tachycardia and fibrillation
– -blockers
– Nondihydropyridine calcium antagonists
Some antihypertensive drugs may have favorable effects on comorbid conditions:
•Heart failure
–Carvedilol
–Losartan
•Myocardial infarction
–Diltiazem
–Verapamil
slide 48
Specific Indications (continued)
• Cyclosporine-induced hypertension– Calcium antagonists
• Diabetes mellitus (1 and 2) with proteinuria– ACE inhibitors (preferred)– Calcium antagonists
• Diabetes mellitus (type 2)– Low-dose diuretics
•Dyslipidemia-blockers
•Prostatism (benign prostatic hyperplasia)
-blockers•Renal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL
[ 265.2 mol/L])–ACE inhibitors
Some antihypertensive drugs may have favorable effects on comorbid conditions:
slide 49
Specific Indications (continued)
• Essential tremor
– Noncardioselective -blockers
• Hyperthyroidism
– -blockers
• Migraine
– Noncardioselective -blockers
– Nondihydropyridine calcium antagonists
•Osteoporosis
– Thiazides
•Perioperative hypertension
– -blockers
Some antihypertensive drugs may have favorable effects on comorbid conditions:
slide 50
Not at Goal Blood Pressure (< 140/90 mm Hg)
No response or troublesome side effects
Inadequate response but well tolerated
Substitute another drug from different class
Add second agent from different class (diuretic if
not already used)
Not at Goal Blood Pressure (<140/90 mmHg)
Initial Drug Choices
Algorithm for Treatment ofHypertension (continued)
slide 51
Not at Goal Blood Pressure (< 140/90 mm Hg)
Continue adding agents from other classes.
Consider referral to a hypertension specialist.
Substitute drug from different class
Add second agent from different class
Algorithm for Treatment of Hypertension (continued)
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slide 53
Lifestyle Modifications
For Prevention and Management
• Lose weight if overweight.
• Limit alcohol intake.
• Increase aerobic physical activity.
• Reduce sodium intake.
• Maintain adequate intake of potassium.
For Overall and Cardiovascular Health
• Maintain adequate intake of calcium and magnesium.
• Stop smoking.
• Reduce dietary saturated fat and cholesterol.
slide 54
Pharmacologic Treatment
• Decreases cardiovascular morbidity and mortality based on randomized controlled trials.
• Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.
slide 55
Special Considerationsin Selecting Drug Therapy
• Demographics
• Coexisting diseases and therapies
• Quality of life
• Physiological and biochemical measurements
• Drug interactions
• Economic considerations
slide 56
Drug Therapy
• A low dose of initial drug should be used, slowly titrating upward.
• Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours.
• Combination therapies may provide additional efficacy with fewer adverse effects.
slide 57
Classes ofAntihypertensive Drugs
• ACE inhibitors
• Adrenergic inhibitors
• Angiotensin II receptor blockers
• Calcium antagonists
• Direct vasodilators
• Diuretics
slide 58
Combination Therapies
� -adrenergic blockers and diuretics
� ACE inhibitors and diuretics
� Angiotensin II receptor antagonists and diuretics
� Calcium antagonists and ACE inhibitors
� Other combinations
slide 59
Followup
• Follow up within 1-2 months after initiating therapy.
• Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications.
• Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose.
• Consider reducing dose and number of agents after1 year at or below goal.
slide 60
Causes for InadequateResponse to Drug Therapy
• Pseudoresistance
• Nonadherence to therapy• Volume overload• Drug-related causes• Associated conditions• Identifiable causes of hypertension
slide 61
Guidelines for ImprovingAdherence to Therapy
• Be aware of signs of nonadherence.
• Establish goal of therapy.
• Encourage a positive attitude about achieving goals.
• Educate patients about the disease and therapy.
• Maintain contact with patients.
• Encourage lifestyle modifications.
• Keep care inexpensive and simple.
slide 62
Guidelines for ImprovingAdherence to Therapy (continued)
• Integrate therapy into daily routine.
• Prescribe long-acting drugs.
• Adjust therapy to minimize adverse affects.
• Continue to add drugs systematically to meet goal.
• Consider using nurse case management.
• Utilize other health professionals.
• Try a new approach if current regime is inadequate.
slide 63
Hypertensive Emergencies and Urgencies
• Emergencies require immediate blood pressure reduction to prevent or limit target organ damage.
• Urgencies benefit from reducing blood pressure within a few hours.
• Elevated blood pressure alone rarely requires emergency therapy.
• Fast-acting drugs are available.
slide 64
Drugs Available forHypertensive Emergencies
Vasodilators
•Nitroprusside
•Nicardipine
•Fenoldopam
•Nitroglycerin
•Enalaprilat
•Hydralazine
Adrenergic Inhibitors
•Labetalol
•Esmolol
•Phentolamine
slide 65
Summary of Chapter 3
• Modifying lifestyles in populations can have a major protective effect against high blood pressure and cardiovascular disease.
• Lowering blood pressure decreases death from stroke, coronary events, and heart failure; slows progression of renal failure; prevents progression to more severe hypertension; and reduces all-cause mortality.
• A diuretic and/or a -blocker should be chosen as initial therapy unless there are compelling or specific indications for another drug.
slide 66
Summary of Chapter 3 (continued)
• Management strategies can improve adherence through the use of multidisciplinary teams.
• The reductions in cardiovascular events demonstrated in randomized controlled trials have important implications for managed care organizations.
• Management of hypertensive emergencies requires immediate action whereas urgencies benefit from reducing blood pressure within a few hours.
slide 67
Special Populations
• Racial and ethnic groups
• Children and adolescents
• Women
• Older persons
slide 68
Racial and Ethnic Groups
African Americans Among the highest prevalenceEarly onsetDelayed treatment
Hispanics Generally low prevalenceLowest control rate in Mexican Americans
Asian and Pacific Islanders May be more responsive to treatment thanother groups
American Indians Similar prevalence to general populationHigh prevalence of diabetes and obesity
slide 69
Children and Adolescents
• Blood pressure at 95th or higher percentile is considered elevated.
• Lifestyle modifications should be recommended.
• Drug therapy should be prescribed for higher levels of blood pressure.
• Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.
slide 70
95th Percentile of Blood Pressure by Selected Ages and Height in Girls
SBP/DBP (mm Hg)
Age 50th Percentile forHeight
75th Percentile forHeight
1 104/58 105/59
6 111/73 112/73
12 123/80 124/81
17 129/84 130/85
slide 71
95th Percentile of Blood Pressure by Selected Ages and Height in Boys
SBP/DBP (mm Hg)
Age 50th Percentile forHeight
75th Percentile forHeight
1 102/57 104/58
6 114/74 115/75
12 123/81 125/82
17 136/87 138/88
slide 72
Women
• Clinical trials have not demonstrated significant differences between men and women in treatment response and outcomes.
• Some women using oral contraceptives may have significant increases in blood pressure.
• High blood pressure in not a contraindication to hormone replacement therapy.
slide 73
Pregnant Women
• Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation.
• Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both.
• ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women.
• Methyldopa is recommended for women diagnosed during pregnancy.
slide 74
Antihypertensive Drugs Used in Pregnancy
These agents* may be used with chronic hypertension(DBP > 100 mm Hg) or acute hypertension (DBP > 105 mm Hg).
Central -agonists Methyldopa is the drug of choice.
-blockers and --blockers
Atenolol, metoprolol, and labetalol appear safeand effective in late pregnancy.
Calcium antagonists Potential synergism with magnesium sulfate maylead to precipitous hypotension.
*Limited or no controlled trials in pregnant women.
slide 75
Antihypertensive Drugs Used in Pregnancy (continued)
These agents* may be used with chronic hypertension (DBP > 100 mm Hg) or acutehypertension (DBP > 105).
Diuretics Diuretics are recommended for chronic hypertension ifprescribed before gestation, but they are not recommendedfor preeclampsia.
Direct vasodilators
Hydralazine is the parenteral drug of choice based on its longhistory of safety and efficacy.
*Limited or no controlled trials in pregnant women.
ACE inhibitors and angiotensin II receptor blockers are contraindicated.
slide 76
Older Persons
• Hypertension is common.
• SBP is better predictor of events than DBP.
• Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office.
• Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.
slide 77
Older Persons (continued)
• Therapy should begin with lifestyle modifications.
• Starting doses for drug therapy should be lower than those used in younger adults.
• Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.
slide 78
Special Situations
• Cardiovascular diseases
• Renal disease
• Diabetes mellitus
• Dyslipidemia
• Sleep apnea
• Bronchial asthma
• Gout
• Surgery
• Various chemical agents
slide 79
Cardiovascular Diseases
• Cerebrovascular disease– Indication for treatment, except immediately
after ischemic cerebral infarction
• Coronary artery disease– Benefits of therapy well established
• Left ventricular hypertrophy– Antihypertensive agents (except direct
vasodilators) indicated– Reduced weight and decreased sodium intake
beneficial
slide 80
Cardiovascular Diseases (continued)
• Cardiac failure– ACE inhibitors, especially with digoxin or
diuretics, shown to prevent subsequent heart failure
• Peripheral arterial disease– Limited or no data available
slide 81
Renal Disease
• Hypertension may result from renal disease that reduces functioning nephrons.
• Evidence shows a clear relationship between high blood pressure and end-stage renal disease.
• Blood pressure should be controlled to < 130/85 mm Hg or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours.
• ACE inhibitors work well to control blood pressure and slow progression of renal failure.
slide 82
Diabetes Mellitus
• Drug therapy should begin along with lifestyle modifications to reduce blood pressure to< 130/85 mm Hg.
• ACE inhibitors, -blockers, calcium antagonists, and low dose-diuretics are preferred.
• Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering agents.
slide 83
Dyslipidemia
• Coexistence of hypertension and dyslipidemia requires aggressive management.
• Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity.
• Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals.
slide 84
Sleep Apnea
• Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences.
• Improved hypertension control has been reported following treatment of sleep apnea.
slide 85
Bronchial Asthma or Chronic Airway Disease
• Elevated blood pressure is common in acute asthma and is possibly related to treatment with systemic corticosteroids or -agonists.
-blockers and--blockers may exacerbate asthma.
• ACE inhibitors only rarely induce bronchospasm.
• Over-the-counter medications are generally safe in limited doses for patients on drug therapy.
slide 86
Gout
• Diuretics can increase serum uric acid levels.
• Diuretics should be avoided in patients with gout.
• Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.
slide 87
Patients Undergoing Surgery
• When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg.
• Those not on prior drug therapy may be best treated with cardioselective-blockers before and after surgery.
• Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.
slide 88
Cocaine and Amphetamines
• Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems.
• Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction.
• Acute amphetamine toxicity is similar to that of cocaine but longer in duration.
• Ongoing cocaine abuse does not appear to cause chronic hypertension.
slide 89
Immunosuppressive Agents
• Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations.
• Treatment is based on vasodilation including dihydropyridine calcium antagonists.
slide 90
Erythropoietin
• Erythropoietin often increases blood pressure in treatment of patients with end-stage renal disease.
• Management includes optimal volume control, antihypertensive agents, and reducing erythopoietin dose or changing method of administration.
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Other Chemical AgentsThat May Induce Hypertension
• Mineralocorticoids and derivatives
• Anabolic steroids
• Monoamine oxidase inhibitors
• Lead
• Cadmium
• Bromocriptine
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Summary of Chapter 4
• Racial and ethnic groups are growing segments of our society. The prevalence of hypertension and control rates differ across groups. Clinicians should be aware of social and cultural factors when managing hypertension.
• Guidelines are provided for management of children and women with hypertension.
• In older persons, diuretics are preferred and long-acting dihydropyridine calcium antagonists may be considered.
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Summary of Chapter 4 (continued)
• Specific therapy for patients with left ventricular hypertrophy, coronary artery disease, and heart failure are outlined.
• Patients with renal insufficiency with greater than 1 g/day of proteinuria should be treated to a goal of 125/75 mm Hg; those with less proteinuria should be treated to 130/85 mm Hg. ACE inhibitors have additional renoprotective effects.
• Patients with diabetes should be treated to a therapy goal of below 130/85 mm Hg.
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A population-wide strategy to reduce
overall blood pressure by only a few
mm Hg could affect overall
cardiovascular morbidity and mortality
as much as or more than treatment
alone.
A Population-Wide Strategy