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National high blood pressure education program l.jpg

National High Blood Pressure Education Program

NIH Publication

No. 98-4080

November 1997

This set of slides is provided by the

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

National High Blood Pressure Education Program

Full text of JNC VI may be downloaded from the NHLBI web site.


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National High Blood Pressure Education Program

NIH Publication

No. 98-4080

November 1997

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 Branch

Office of Prevention, Education, and Control


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DISCLAIMER

The appearance of rotating Ads on

this 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


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National High Blood Pressure Education Program

NIH Publication

No. 98-4080

November 1997

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure(JNC VI)


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Henry R. Black, M.D., Chair of Chapter 1

Rush-Presbyterian-St. Luke’s Medical Center

Jerome D. Cohen, M.D., Chair of Chapter 2

St. Louis University Health Sciences Center

Norman M. Kaplan, M.D., Chair of Chapter 3

University of Texas Southwestern Medical School

Keith C. Ferdinand, M.D., Chair of Chapter 4

Heartbeats 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

Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Executive Committee:

Sheldon G. Sheps, M.D., Chair

Mayo Clinic and Mayo Foundation and Mayo Medical School


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Agency for Health Care Policy and Research

American Academy of Family Physicians

American Academy of Insurance Medicine

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician Assistants

American Association of Occupational Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational and Environmental Medicine

American College of Physicians

American College of Preventive Medicine

American Dental Association

Health Care Financing Administration

Health Resources and Services Administration

International Society on Hypertension in Blacks

National Black Nurses’ Association, Inc.

National Center for Health Statistics, Centers for Disease Control and Prevention

National Heart, Lung, and Blood Institute

National Hypertension Association

National Institute of Diabetes and Digestive and Kidney Diseases

National Kidney Foundation

National Medical Association

National Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on Minority Populations

Society for Nutrition Education

U.S. Department of Veterans’ Affairs

National High Blood Pressure Education Program Coordinating Committee

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses’ Association, Inc.

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

Association of Black Cardiologists

Citizens for Public Action on High Blood Pressure and Cholesterol, Inc.

Council on Geriatric Cardiology


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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


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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.


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Progress of theNational High Blood Pressure Education Program

  • Increased awareness, treatment, and control

  • Decreased morbidity and mortality from stroke and coronary heart disease (CHD)


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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


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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


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Awareness, Treatment, and Control of High Blood Pressure in Adults*


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Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: United States, 1972-94

The decline in age-adjusted mortality for stroke in the total population is 59.0%.

*Age-adjusted to the 1940 U.S. census population.


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Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States, 1972-94

The decline in age-adjusted mortality for CHD in the total population is 53.2%.

*Age-adjusted to the 1940 U.S. census population.


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Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995

253*

*Provisional data.

Adjusted for age, race, and sex.


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Prevalence of Heart Failure,by Age, 1976-80 and 1988-91

1988-91

1976-80


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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.


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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.


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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.


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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)


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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)


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Classification of Blood Pressure for Adults


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Recommendations for Followup Based on Initial Measurements


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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


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Evaluation Components

  • Medical history

  • Physical examination

  • Routine laboratory tests

  • Optional tests


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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


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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


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Laboratory Tests and Other Diagnostic Procedures

  • Determine presence of target organ damage and other risk factors

  • Seek specific causes of hypertension


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Urinalysis

Complete blood count

Blood chemistry (potassium, sodium, creatinine, and fasting glucose)

Lipid profile (total cholesterol and HDL cholesterol)

12-lead electrocardiogram

Laboratory Tests Recommended Before Initiating Therapy


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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

Optional Tests and Procedures


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Examples of IdentifiableCauses of Hypertension

  • Renovascular disease

  • Renal parenchymal disease

  • Polycystic kidneys

  • Aortic coarctation

  • Pheochromocytoma

  • Primary aldosteronism

  • Cushing syndrome

  • Hyperparathyroidism

  • Exogenous causes


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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


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Clinical Risk Factors forStratification of Patients With Hypertension

  • Heart diseases

  • Stroke or transient ischemic attack

  • Nephropathy

  • Peripheral arterial disease

  • Retinopathy


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Risk Stratification


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Treatment Strategies andRisk Stratification


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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.


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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.


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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.


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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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Algorithm forTreatment of Hypertension

Add agent from different class

Inadequate response but well tolerated

Continue adding agents from other classes. Consider referral to a hypertension specialist.

Begin or Continue

Lifestyle Modifications

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Initial Drug Choices

Substitute drug from different class

No response or troublesome side effects


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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

Algorithm for Treatment of Hypertension (continued)

Not at Goal Blood Pressure


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Algorithm for Treatment of Hypertension (continued)

Begin or Continue Lifestyle Modifications

Not at Goal Blood Pressure (< 140/90 mm Hg)

lower goals for patients with diabetes or renal disease

Initial Drug Choices


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Algorithm for Treatment of Hypertension(continued)

Not at Goal Blood Pressure

Initial Drug Choices

Uncomplicated

Specific Indications

  • Compelling Indications

  • Start at low dose and titrate upward.

  • Low-dose combinations may be appropriate.

Not at Goal Blood Pressure


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Algorithm for Treatment ofHypertension (continued)

Initial Drug Choices*

  • Uncomplicated

    • Diuretics

    • -blockers

*Based on randomized controlled trials.


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Algorithm for Treatment of Hypertension(continued)

Initial Drug Choices*

  • 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.


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Algorithm for Treatment ofHypertension(continued)

Initial Drug Choices

Specific indications for the following drugs:

  • ACE inhibitors

  • Angiotensin II receptor

  • blockers

  • -blockers

  • --blockers

  • -blockers

  • Calcium antagonists

  • Diuretics


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Angina

-blockers

Calcium antagonists

Atrial tachycardia and fibrillation

-blockers

Nondihydropyridine

calcium antagonists

Heart failure

Carvedilol

Losartan

Myocardial infarction

Diltiazem

Verapamil

Specific Drug Indications

Some antihypertensive drugs may have favorable effects on comorbid conditions:


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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

Specific Indications (continued)

Some antihypertensive drugs may have favorable effects on comorbid conditions:


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Essential tremor

Noncardioselective -blockers

Hyperthyroidism

-blockers

Migraine

Noncardioselective -blockers

Nondihydropyridine calcium

antagonists

Osteoporosis

Thiazides

Perioperative hypertension

-blockers

Specific Indications(continued)

Some antihypertensive drugs may have favorable effects on comorbid conditions:


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Algorithm for Treatment ofHypertension(continued)

Initial Drug Choices

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)


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Algorithm for Treatment of Hypertension (continued)

Substitute drug from different class

Add second agent from different class

Not at Goal Blood Pressure (< 140/90 mm Hg)

Continue adding agents from other classes.

Consider referral to a hypertension specialist.


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Algorithm for Treatment of Hypertension

Add agent from different class

Inadequate response but well tolerated

Continue adding agents from other classes. Consider referral to a hypertension specialist.

Begin or Continue

Lifestyle Modifications

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Initial Drug Choices

Substitute drug from different class

No response or troublesome side effects


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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.

Lifestyle Modifications


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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.


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Special Considerationsin Selecting Drug Therapy

  • Demographics

  • Coexisting diseases and therapies

  • Quality of life

  • Physiological and biochemical measurements

  • Drug interactions

  • Economic considerations


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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.


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Classes ofAntihypertensive Drugs

  • ACE inhibitors

  • Adrenergic inhibitors

  • Angiotensin II receptor blockers

  • Calcium antagonists

  • Direct vasodilators

  • Diuretics


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Combination Therapies

  • -adrenergic blockers and diuretics

  • ACE inhibitors and diuretics

  • Angiotensin II receptor antagonists and diuretics

  • Calcium antagonists and ACE inhibitors

  • Other combinations


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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 after

  • 1 year at or below goal.


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Causes for InadequateResponse to Drug Therapy

  • Pseudoresistance

  • Nonadherence to therapy

  • Volume overload

  • Drug-related causes

  • Associated conditions

  • Identifiable causes of hypertension


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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.

Guidelines for ImprovingAdherence to Therapy


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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.

Guidelines for ImprovingAdherence to Therapy(continued)


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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.


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Vasodilators

Nitroprusside

Nicardipine

Fenoldopam

Nitroglycerin

Enalaprilat

Hydralazine

Adrenergic Inhibitors

Labetalol

Esmolol

Phentolamine

Drugs Available forHypertensive Emergencies


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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.


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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.


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Special Populations

  • Racial and ethnic groups

  • Children and adolescents

  • Women

  • Older persons


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Racial and Ethnic Groups


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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.


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95th Percentile of Blood Pressure by Selected Ages and Height in Girls


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95th Percentile of Blood Pressure by Selected Ages and Height in Boys


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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.


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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.


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Antihypertensive Drugs Used in Pregnancy


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Antihypertensive Drugs Used in Pregnancy (continued)


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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.


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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.


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Special Situations

  • Cardiovascular diseases

  • Renal disease

  • Diabetes mellitus

  • Dyslipidemia

  • Sleep apnea

  • Bronchial asthma

  • Gout

  • Surgery

  • Various chemical agents


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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


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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


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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Immunosuppressive Agents

  • Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations.

  • Treatment is based on vasodilation including dihydropyridine calcium antagonists.


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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


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