The Jnc7 Report (Hypertension)

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The Jnc7 Report (Hypertension)

  1. 1. SPECIAL COMMUNICATION CLINICIAN’S CORNER The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The JNC 7 Report Aram V. Chobanian, MD “The Seventh Report of the Joint National Committee on Prevention, De- George L. Bakris, MD tection, Evaluation, and Treatment of High Blood Pressure” provides a new Henry R. Black, MD guideline for hypertension prevention and management. The following are William C. Cushman, MD the key messages: (1) In persons older than 50 years, systolic blood pres- Lee A. Green, MD, MPH sure (BP) of more than 140 mm Hg is a much more important cardiovascular Joseph L. Izzo, Jr, MD disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning Daniel W. Jones, MD at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individu- Barry J. Materson, MD, MBA als who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension; (3) Individuals with a systolic BP of 120 to 139 Suzanne Oparil, MD mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as pre- Jackson T. Wright, Jr, MD, PhD hypertensive and require health-promoting lifestyle modifications to pre- Edward J. Roccella, PhD, MPH vent CVD; (4) Thiazide-type diuretics should be used in drug treatment for and the National High Blood most patients with uncomplicated hypertension, either alone or combined Pressure Education Program with drugs from other classes. Certain high-risk conditions are compelling Coordinating Committee indications for the initial use of other antihypertensive drug classes (angio- tensin-converting enzyme inhibitors, angiotensin-receptor blockers, -block- F OR MORE THAN 3 DECADES, THE National Heart, Lung, and ers, calcium channel blockers); (5) Most patients with hypertension will re- Blood Institute (NHLBI) has quire 2 or more antihypertensive medications to achieve goal BP ( 140/90 administered the National mm Hg, or 130/80 mm Hg for patients with diabetes or chronic kidney High Blood Pressure Education disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration Program (NHBPEP) Coordinating should be given to initiating therapy with 2 agents, 1 of which usually should Committee, a coalition of 39 major be a thiazide-type diuretic; and (7) The most effective therapy prescribed by professional, public, and voluntary the most careful clinician will control hypertension only if patients are mo- organizations and 7 federal agencies. One important function is to issue tivated. Motivation improves when patients have positive experiences with guidelines and advisories designed to and trust in the clinician. Empathy builds trust and is a potent motivator. increase awareness, prevention, treat- Finally, in presenting these guidelines, the committee recognizes that the ment, and control of hypertension responsible physician’s judgment remains paramount. (high blood pressure [BP]). Since the JAMA. 2003;289:2560-2572 www.jama.com publication of “The Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and ( JNC VI) released in 1997, 1 many Author Affiliations and Financial Disclosures are listed at the end of this article. Treatment of High Blood Pressure” large-scale clinical trials have been Corresponding Author and Reprints: Edward J. Roc- published. cella, PhD, MPH, National Heart, Lung, and Blood In- stitute, National Institutes of Health, 31 Center Dr, MSC The decision to appoint a commit- 2480, Bethesda, MD 20892 (e-mail: roccella@nih See also pp 2534 and 2573. tee for “The Seventh Report of the Joint .gov). 2560 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.
  2. 2. THE JNC 7 REPORT National Committee on Prevention, De- NHLBI Web site.2 In agreeing to com- lected,3,4 which classifies studies in tection, Evaluation, and Treatment of mission a new report, the director re- a process adapted from Last and High Blood Pressure” ( JNC 7) was quested that the Coordinating Commit- Abramson.5 based on 4 factors: publication of many tee members provide in writing a detailed The executive committee met on 6 new hypertension observational stud- rationale explaining the necessity to up- occasions, 2 of which included meet- ies and clinical trials; need for a new date the guidelines and to describe the ings with the entire Coordinating Com- clear and concise guideline that would critical issues and concepts to be con- mittee. The writing teams also met by be useful for clinicians; need to sim- sidered for a new report. The JNC 7 chair teleconference and used electronic com- plify the classification of BP; and a clear was selected in addition to a 9-member munications to develop the report. recognition that the JNC reports were executive committee appointed en- Twenty-four drafts were created and not being used to their maximum ben- tirely from the NHBPEP Coordinating reviewed in a reiterative fashion. At its efit. This JNC report is presented in 2 Committee membership. The NHBPEP meetings, the executive committee used separate publications: this current suc- Coordinating Committee served as mem- a modified nominal group process to cinct practical guide and a more com- bers of 5 writing teams, each of which identify and resolve issues. The NHB- prehensive report to be published sepa- were co-chaired by 2 executive commit- PEP Coordinating Committee reviewed rately, which will provide a broader tee members. the penultimate draft and provided discussion and justification for the cur- The concepts identified by the NH- written comments to the executive com- rent recommendations. In presenting BPEP Coordinating Committee mem- mittee. In addition, 33 national hyper- these guidelines, the committee recog- bership were used to develop the re- tension leaders reviewed and com- nizes that the responsible physician’s port outline. A timeline was developed mented on the document. The NHBPEP judgment is paramount in managing his to complete and publish the work in 5 Coordinating Committee approved the or her patients. months. Based on the identified criti- JNC 7 report. cal issues and concepts, the executive METHODS committee identified relevant Medical RESULTS Since publication of the JNC VI report, Subject Headings (MeSH) terms and Classification of BP the NHBPEP Coordinating Committee, keywords to further review the scien- TABLE 1 provides a classification of BP chaired by the director of the NHLBI, has tific literature. These MeSH terms were for adults aged 18 years or older. The regularly reviewed and discussed the hy- used to generate MEDLINE searches classification is based on the mean of pertension clinical trials at their bian- that focused on English-language, peer- 2 or more properly measured seated BP nual meetings. In many instances, the reviewed scientific literature from Janu- readings on each of 2 or more office vis- principal investigator of the larger stud- ary 1997 through April 2003. Various its. In contrast with the classification ies has presented the information di- systems of grading the evidence were provided in the JNC VI report, a new rectly to the Coordinating Committee. considered and the classification category designated prehypertension The Committee’s presentations and re- scheme used in JNC VI and other has been added, and stages 2 and 3 views are summarized and posted on the NHBPEP clinical guidelines was se- hypertension have been combined. Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older Management* Initial Drug Therapy BP Systolic Diastolic Lifestyle Classification BP, mm Hg* BP, mm Hg* Modification Without Compelling Indication With Compelling Indications† Normal 120 and 80 Encourage Prehypertension 120-139 or 80-89 Yes No antihypertensive drug Drug(s) for the compelling indicated indications‡ Stage 1 hypertension 140-159 or 90-99 Yes Thiazide-type diuretics for most; Drug(s) for the compelling may consider ACE inhibitor, indications ARB, -blocker, CCB, or Other antihypertensive drugs combination (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed Stage 2 hypertension 160 or 100 Yes 2-Drug combination for most Drug(s) for the compelling (usually thiazide-type diuretic indications and ACE inhibitor or ARB or Other antihypertensive drugs -blocker or CCB)§ (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; BP, blood pressure; CCB, calcium channel blocker. *Treatment determined by highest BP category. †See Table 6. ‡Treat patients with chronic kidney disease or diabetes to BP goal of less than 130/80 mm Hg. §Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2561
  3. 3. THE JNC 7 REPORT with hypertension, but the majority will Table 2. Trends in Awareness, Treatment, and Control of High Blood Pressure in Adults With Hypertension Aged 18 to 74 Years* require 2 or more antihypertensive National Health and Nutrition Examination Surveys, Weighted % drugs.14,15 When physicians fail to pre- scribe lifestyle modifications, adequate III (Phase 1, III (Phase 2, antihypertensive drug doses, or appro- II (1976-1980) 1988-1991) 1991-1994) 1999-2000 Awareness 51 73 68 70 priate drug combinations, inadequate BP Treatment 31 55 54 59 control may result. Control† 10 29 27 34 Accurate BP Measurement *Data for 1999-2000 were computed (M. Wolz, unpublished data, 2003) from the National Heart, Lung, and Blood Institute and data for National Health and Nutrition Examination Surveys II and III (phases 1 and 2) are from “The Sixth in the Office Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pres- sure.”1 High blood pressure is systolic blood pressure of at least 140 mm Hg or diastolic blood pressure of at least The auscultatory method of BP mea- 90 mm Hg or taking antihypertensive medication. †Systolic blood pressure of less than 140 mm Hg and diastolic blood pressure of less than 90 mm Hg. surement with a properly calibrated and validated instrument should be used.16 Patients should be seated quietly for at Patients with prehypertension are at in- this goal (see “Lifestyle Modifica- least 5 minutes in a chair rather than on creased risk for progression to hyper- tions” section). an examination table, with feet on the tension; those in the 130/80 to 139/89 floor and arm supported at heart level. mm Hg BP range are at twice the risk Benefits of Lowering BP Measurement of BP in the standing po- to develop hypertension as those with In clinical trials, antihypertensive sition is indicated periodically, espe- lower values.6 therapy has been associated with 35% cially in those at risk for postural hypo- to 40% mean reductions in stroke in- tension. An appropriate-sized cuff (cuff Cardiovascular Disease Risk cidence; 20% to 25% in myocardial in- bladder encircling at least 80% of the Hypertension affects approximately 50 farction; and more than 50% in HF.10 arm) should be used to ensure accu- million individuals in the United States It is estimated that in patients with stage racy. At least 2 measurements should be and approximately 1 billion individu- 1 hypertension (systolic BP, 140-159 made. Systolic BP is the point at which als worldwide. As the population ages, mm Hg and/or diastolic BP, 90-99 the first of 2 or more sounds is heard the prevalence of hypertension will mm Hg) and additional cardiovascu- (phase 1) and diastolic BP is the point increase even further unless broad and lar risk factors, achieving a sustained before the disappearance of sounds effective preventive measures are imple- 12-mm Hg decrease in systolic BP for (phase 5). Physicians should provide to mented. Recent data from the Framing- 10 years will prevent 1 death for every patients, verbally and in writing, their ham Heart Study7 suggest that indi- 11 patients treated. In the presence of specific BP numbers and BP goals. viduals who are normotensive at 55 CVD or target-organ damage, only 9 pa- years of age have a 90% lifetime risk for tients would require this BP reduction Ambulatory BP Monitoring developing hypertension. to prevent a death.11 Ambulatory BP monitoring17 provides The relationship between BP and risk information about BP during daily ac- of cardiovascular disease (CVD) events BP Control Rates tivities and sleep. Ambulatory BP moni- is continuous, consistent, and indepen- Hypertension is the most common pri- toring is warranted for evaluation of dent of other risk factors. The higher mary diagnosis in the United States with (white-coat) hypertension in the ab- the BP, the greater the chance of myo- 35 million office visits as the primary di- sence of target-organ injury. It is also cardial infarction, heart failure (HF), agnosis.12 Current control rates (sys- helpful to assess patients with apparent stroke, and kidney disease. For indi- tolic BP 140 mm Hg and diastolic BP drug resistance, hypotensive symptoms viduals aged 40 to 70 years, each in- 90 mm Hg), although improved, are with antihypertensive medications, epi- crement of 20 mm Hg in systolic BP or still far below the Healthy People 2010 sodic hypertension, and autonomic dys- 10 mm Hg in diastolic BP doubles the goal of 50%; 30% are still unaware they function. The ambulatory BP values are risk of CVD across the entire BP range have hypertension (TABLE 2). In the ma- usually lower than clinic readings. Awake from 115/75 to 185/115 mm Hg.8 jority of patients, controlling systolic hy- hypertensive individuals have a mean BP The classification prehypertension, pertension, which is a more important of more than 135/85 mm Hg and dur- introduced in this report (Table 1), rec- CVD risk factor than diastolic BP ex- ing sleep, more than 120/75 mm Hg. The ognizes this relationship and signals the cept in patients younger than 50 years13 level of BP using ambulatory BP moni- need for increased education of health and occurs much more commonly in toring correlates better than office mea- care professionals and the public to de- older persons, has been considerably surements with target-organ injury.18 crease BP levels and prevent the devel- more difficult than controlling dias- Ambulatory BP monitoring also pro- opment of hypertension in the general tolic hypertension. Recent clinical trials vides a measure of the percentage of BP population. 9 Hypertension preven- have demonstrated that effective BP con- readings that are elevated, the overall BP tion strategies are available to achieve trol can be achieved in most patients load, and the extent of BP reduction dur- 2562 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.
  4. 4. THE JNC 7 REPORT ing sleep. In most individuals, BP de- creases by 10% to 20% during the night; Box 1. Cardiovascular Risk Factors* those in whom such decreases are not Major Risk Factors present are at increased risk for cardio- Hypertension† vascular events. Cigarette smoking Obesity (BMI 30)† Self-measurement of BP Physical inactivity Blood pressure self-measurements may Dyslipidemia† benefit patients by providing informa- Diabetes mellitus† tion on response to antihypertensive Microalbuminuria or estimated GFR 60 mL /min medication, improving patient adher- Age ( 55 years for men, 65 years for women) ence with therapy,19 and in evaluating Family history of premature cardiovascular disease (men 55 years white-coat hypertension. Individuals or women 65 years) with a mean BP of more than 135/85 Target-Organ Damage mm Hg measured at home are gener- Heart ally considered to be hypertensive. Left ventricular hypertrophy Home measurement devices should be Angina or prior myocardial infarction checked regularly for accuracy. Prior coronary revascularization Heart failure Patient Evaluation Brain Stroke or transient ischemic attack Evaluation of patients with docu- Chronic kidney disease mented hypertension has 3 objectives: Peripheral arterial disease (1) to assess lifestyle and identify other Retinopathy cardiovascular risk factors or concomi- *BMI indicates body mass index calculated as weight in kilograms divided by the square of tant disorders that may affect progno- height in meters; GFR, glomerular filtration rate. sis and guide treatment (BOX 1); (2) to †Components of the metabolic syndrome. reveal identifiable causes of high BP (BOX 2); and (3) to assess the presence or absence of target-organ damage and sis; blood glucose and hematocrit; CVD. The data needed are acquired serum potassium, creatinine (or the cor- Box 2. Identifiable Causes of through medical history, physical ex- responding estimated glomerular fil- Hypertension amination, routine laboratory tests, and tration rate), and calcium20; and a lipid Sleep apnea other diagnostic procedures. profile (after a 9- to 12-hour fast) that Drug-induced or drug-related The physical examination should in- includes high-density lipoprotein cho- (see Box 3) clude an appropriate measurement of BP, lesterol, low-density lipoprotein cho- Chronic kidney disease with verification in the contralateral arm; lesterol, and triglycerides. Optional tests Primary aldosteronism examination of the optic fundi; body include measurement of urinary albu- Renovascular disease mass index calculated as weight in ki- min excretion or albumin/creatinine Chronic steroid therapy and Cushing syndrome lograms divided by the square of height ratio. More extensive testing for iden- Pheochromocytoma in meters (measurement of waist cir- tifiable causes is not indicated gener- Coarctation of the aorta cumference also may be useful); aus- ally unless BP control is not achieved. Thyroid or parathyroid disease cultation for carotid, abdominal, and femoral bruits; palpation of the thyroid Treatment gland; thorough examination of the heart Goals of Therapy.The ultimate public and lungs; examination of the abdo- health goal of antihypertensive therapy ated with a decrease in CVD compli- men for enlarged kidneys, masses, and is the reduction of cardiovascular and cations. In patients with hypertension abnormal aortic pulsation; palpation of renal morbidity and mortality. Be- with diabetes or renal disease, the BP the lower extremities for edema and cause most patients with hyperten- goal is less than 130/80 mm Hg.21,22 pulses; and neurological assessment. sion, especially those aged at least 50 Lifestyle Modifications. Adoption of years, will reach the diastolic BP goal healthy lifestyles by all individuals is Laboratory Tests and once systolic BP is at goal, the primary critical for the prevention of high BP and Other Diagnostic Procedures focus should be on achieving the sys- an indispensable part of the manage- Routine laboratory tests recom- tolic BP goal (FIGURE). Treating sys- ment of those with hypertension. Ma- mended before initiating therapy in- tolic BP and diastolic BP to targets that jor lifestyle modifications shown to clude an electrocardiogram; urinaly- are less than 140/90 mm Hg is associ- lower BP include weight reduction in ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2563
  5. 5. THE JNC 7 REPORT those individuals who are overweight (TABLE 3).30 Lifestyle modifications de- of 2 or more lifestyle modifications can or obese23,24; adoption of Dietary Ap- crease BP, enhance antihypertensive achieve even better results. proaches to Stop Hypertension eating drug efficacy, and decrease cardiovas- Pharmacologic Treatment. Excel- plan, 25 which is rich in potassium cular risk. For example, a 1600-mg so- lent clinical trial outcome data prove and calcium26; dietary sodium reduc- dium Dietary Approaches to Stop Hy- that lowering BP with several classes tion 25-27 ; physical activity 28,29 ; and pertension eating plan has effects similar of drugs, including angiotensin- moderation of alcohol consumption to single drug therapy.25 Combinations converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), -blockers, calcium channel blockers Figure. Algorithm for Treatment of Hypertension (CCBs), and thiazide-type diuretics, will all reduce the complications of hyper- Lifestyle Modifications tension.10,31-37 TABLE 4 and TABLE 5 pro- Not at Goal BP vide a list of commonly used antihy- (<140/90 mm Hg or <130/80 mm Hg for Those With Diabetes pertensive agents. or Chronic Kidney Disease) Thiazide-type diuretics have been the Initial Drug Choices basis of antihypertensive therapy in most outcome trials.37 In these trials, includ- ing the recently published Antihyper- Hypertension Without Hypertension With tensive and Lipid-Lowering Treatment Compelling Indications Compelling Indications to Prevent Heart Attack Trial,33 diuret- ics have been virtually unsurpassed in Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the preventing the cardiovascular compli- (Systolic BP 140-159 mm Hg (Systolic BP ≥160 mm Hg or Compelling Indications cations of hypertension. The exception or Diastolic BP 90-99 mm Hg) Diastolic BP ≥100 mm Hg) (See Table 6) Thiazide-Type Diuretics for Most 2-Drug Combination for Most Other Antihypertensive Drugs is the Second Australian National Blood May Consider ACE Inhibitor, ARB, (Usually Thiazide-Type Diuretic (Diuretics, ACE Inhibitor, ARB, Pressure trial36 that reported slightly bet- and ACE Inhibitor or ARB or β-Blocker, CCB) as Needed β-Blocker, CCB, or Combination ter outcomes in white men with a regi- β-Blocker or CCB) men that began with an ACE inhibitor compared with one starting with a di- Not at Goal BP uretic. Diuretics enhance the antihyper- tensive efficacy of multidrug regimens, Optimize Dosages or Add Additional Drugs Until Goal BP Is Achieved Consider Consultation With Hypertension Specialist can be useful in achieving BP control, and are more affordable than other antihy- BP indicates blood pressure; ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; and CCB, pertensive agents. Despite these find- calcium channel blocker. ings, diuretics remain underused.39 Thiazide-type diuretics should be used as initial therapy for most patients with Table 3. Lifestyle Modifications to Manage Hypertension* hypertension, either alone or in combi- Approximate Systolic BP nation with 1 of the other classes (ACE Modification Recommendation Reduction, Range inhibitors, ARBs, -blockers, CCBs) Weight reduction Maintain normal body weight (BMI, 18.5-24.9) 5-20 mm Hg/10-kg weight loss23,24 demonstrated to be beneficial in ran- Adopt DASH eating Consume a diet rich in fruits, vegetables, and 8-14 mm Hg25,26 domized controlled outcome trials. The plan low-fat dairy products with a reduced list of compelling indications requiring content of saturated and total fat the use of other antihypertensive drugs Dietary sodium Reduce dietary sodium intake to no more than 2-8 mm Hg25-27 reduction 100 mEq/L (2.4 g sodium or 6 g sodium as initial therapy are listed in TABLE 6. chloride) If a drug is not tolerated or is contrain- Physical activity Engage in regular aerobic physical activity 4-9 mm Hg28,29 dicated, then 1 of the other classes proven such as brisk walking (at least 30 minutes per day, most days of the week) to reduce cardiovascular events should Moderation of alcohol Limit consumption to no more than 2 drinks 2-4 mm Hg30 be used instead. consumption per day (1 oz or 30 mL ethanol [eg, 24 oz Achieving BP Control in Indi- beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and no more than vidual Patients. Most patients with hy- 1 drink per day in women and pertension will require 2 or more anti- lighter-weight persons hypertensive medications to achieve their Abbreviations: BMI, body mass index calculated as weight in kilograms divided by the square of height in meters; BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension. BP goals.14,15 Addition of a second drug *For overall cardiovascular risk reduction, stop smoking. The effects of implementing these modifications are dose and from a different class should be initi- time dependent and could be higher for some individuals. ated when use of a single drug in ad- 2564 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.
  6. 6. THE JNC 7 REPORT equate doses fails to achieve the BP goal. tions already in use, tolerability, and de- CCBs can be used.1 In patients with When BP is more than 20/10 mm Hg sired BP targets. In many cases, specialist acute coronary syndromes (unstable an- above goal, consideration should be given consultation may be indicated. gina or myocardial infarction), hyper- to initiating therapy with 2 drugs, ei- Ischemic Heart Disease. Ischemic tension should be treated initially with ther as separate prescriptions or in fixed- heart disease is the most common form -blockers and ACE inhibitors,49 with dose combinations (Figure). The initia- of target-organ damage associated with addition of other drugs as needed for tion of drug therapy with more than 1 hypertension. In patients with hyper- BP control. In patients with postmyo- agent may increase the likelihood of tension and stable angina pectoris, cardial infarction, ACE inhibitors, achieving the BP goal in a more timely the first drug of choice is usually a -blockers, and aldosterone antago- fashion, but particular caution is ad- -blocker; alternatively, long-acting nists have proven to be most benefi- vised in those at risk for orthostatic hy- potension, such as patients with diabe- Table 4. Oral Antihypertensive Drugs* tes, autonomic dysfunction, and some Usual Dose, Daily older persons. Use of generic drugs or Class Drug (Trade Name) Range, mg/d Frequency combination drugs should be consid- Thiazide diuretics Chlorothiazide (Diuril) 125-500 1 ered to reduce prescription costs. Chlorthalidone (generic) 12.5-25 1 Follow-up and Monitoring. Once an- Hydrochlorothiazide 12.5-50 1 tihypertensive drug therapy is initi- (Microzide, HydroDIURIL)† ated, most patients should return for Polythiazide (Renese) 2-4 1 follow-up and adjustment of medica- Indapamide (Lozol)† 1.25-2.5 1 Metolazone (Mykrox) 0.5-1.0 1 tions at approximately monthly inter- Metolazone (Zaroxolyn) 2.5-5 1 vals until the BP goal is reached. More Loop diuretics Bumetanide (Bumex)† 0.5-2 2 frequent visits will be necessary for pa- Furosemide (Lasix)† 20-80 2 tients with stage 2 hypertension or with Torsemide (Demadex)† 2.5-10 1 complicating comorbid conditions. Se- Potassium-sparing diuretics Amiloride (Midamor)† 5-10 1-2 rum potassium and creatinine should Triamterene (Dyrenium) 50-100 1-2 be monitored at least 1 to 2 times per Aldosterone-receptor blockers Eplerenone (Inspra) 50-100 1-2 year.60 After BP is at goal and stable, fol- Spironolactone (Aldactone)† 25-50 1-2 low-up visits can usually be at 3- to -Blockers Atenolol (Tenormin)† 25-100 1 6-month intervals. Comorbidities, such Betaxolol (Kerlone)† 5-20 1 as HF, associated diseases, such as dia- Bisoprolol (Zebeta)† 2.5-10 1 betes, and the need for laboratory tests Metoprolol (Lopressor)† 50-100 1-2 influence the frequency of visits. Other Metoprolol extended release 50-100 1 cardiovascular risk factors should be (Toprol XL) treated to their respective goals, and to- Nadolol (Corgard)† 40-120 1 bacco avoidance should be promoted Propranolol (Inderal)† 40-160 2 vigorously. Low-dose aspirin therapy Propranolol long-acting 60-180 1 should be considered only when BP is (Inderal LA)† controlled, because the risk of hemor- Timolol (Blocadren)† 20-40 2 -Blockers with intrinsic Acebutolol (Sectral)† 200-800 2 rhagic stroke is increased in patients sympathomimetic activity Penbutolol (Levatol) 10-40 1 with uncontrolled hypertension.61 Pindolol (generic) 10-40 2 Special Considerations Combined - and -blockers Carvedilol (Coreg) 12.5-50 2 Labetalol (Normodyne, 200-800 2 The patient with hypertension and cer- Trandate)† tain comorbidities requires special at- ACE inhibitors Benazepril (Lotensin)† 10-40 1-2 tention and follow-up by the clinician. Captopril (Capoten)† 25-100 2 Compelling Indications. Table 6 de- Enalapril (Vasotec)† 2.5-40 1-2 scribes compelling indications that re- Fosinopril (Monopril) 10-40 1 quire certain antihypertensive drug Lisinopril (Prinivil, Zestril)† 10-40 1 classes for high-risk conditions. The drug Moexipril (Univasc) 7.5-30 1 selections for these compelling indica- Perindopril (Aceon) 4-8 1-2 tions are based on favorable outcome Quinapril (Accupril) 10-40 1 data from clinical trials. Combination of Ramipril (Altace) 2.5-20 1 agents may be required. Other manage- Trandolapril (Mavik) 1-4 1 ment considerations include medica- (continued) ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2565
  7. 7. THE JNC 7 REPORT cial.50,52,53,62 Intensive lipid manage- symptomatic ventricular dysfunction or favorably affect the progression of dia- ment and aspirin therapy are also end-stage heart disease, ACE inhibi- betic nephropathy and reduce albu- indicated. tors, -blockers, ARBs, and aldoste- minuria,55,56 and ARBs have been shown Heart Failure. Heart failure, in the rone blockers are recommended along to reduce progression to macroalbu- form of systolic or diastolic ventricu- with loop diuretics.40,41-48 minuria.56,57 lar dysfunction, results primarily from Diabetic Hypertension. Combina- Chronic Kidney Disease. In pa- systolic hypertension and ischemic tions of 2 or more drugs are usually tients with chronic kidney disease, de- heart disease. Fastidious BP and cho- needed to achieve the target BP goal of fined by either (1) reduced excretory lesterol control are the primary pre- less than 130/80 mm Hg.21,22 Thiazide function with an estimated glomerular ventive measures for those at high risk diuretics, -blockers, ACE inhibitors, filtration rate of less than 60 mL/min per for HF.40 In asymptomatic individuals ARBs, and CCBs are beneficial in re- 1.73 m2 (corresponding approximately with demonstrable ventricular dysfunc- ducing CVD and stroke incidence in pa- to a creatinine of 1.5 mg/dL [ 132.6 tion, ACE inhibitors and -blockers are tients with diabetes.33,54,63 The ACE in- µmol/L] in men or 1.3 mg/dL [ 114.9 recommended. 52,62 For those with hibitor– or ARB-based treatments µmol/L] in women)20 or (2) the pres- ence of albuminuria ( 300 mg/d or 200 Table 4. Oral Antihypertensive Drugs (cont)* mg albumin per gram of creatinine), therapeutic goals are to slow deteriora- Usual Dose, Daily Class Drug (Trade Name) Range, mg/d Frequency tion of renal function and prevent CVD. Angiotensin II antagonists Candesartan (Atacand) 8-32 1 Hypertension appears in the majority of Eprosartan (Tevetan) 400-800 1-2 these patients and they should receive Irbesartan (Avapro) 150-300 1 aggressive BP management, often with Losartan (Cozaar) 25-100 1-2 3 or more drugs to reach target BP val- Olmesartan (Benicar) 20-40 1 ues of less than 130/80 mm Hg.59,64 Telmisartan (Micardis) 20-80 1 The ACE inhibitors and ARBs have Valsartan (Diovan) 80-320 1 demonstrated favorable effects on the Calcium channel Diltiazem extended release 180-420 1 progression of diabetic and nondia- blockers−non-dihydropyridines (Cardizem CD, Dilacor XR, Tiazac)† betic renal disease.55-59,64 A limited in- Diltiazem extended release 120-540 1 crease in serum creatinine of as much (Cardizem LA) as 35% above baseline with ACE in- Verapamil immediate release 80-320 2 hibitors or ARBs is acceptable and not (Calan, Isoptin)† a reason to withhold treatment unless Verapamil long-acting 120-360 1-2 hyperkalemia develops. 65 With ad- (Calan SR, Isoptin SR)† Verapamil-coer (Covera HS, 120-360 1 vanced renal disease (estimated glo- Verelan PM) merular filtration rate 30 mL/min per Calcium channel Amlodipine (Norvasc) 2.5-10 1 1.73 m2, corresponding to a serum cre- blockers−dihydropyridines Felodipine (Plendil) 2.5-20 1 atinine of 2.5-3.0 mg/dL [221-265 Isradipine (Dynacirc CR) 2.5-10 2 µmol/L]), increasing doses of loop di- Nicardipine sustained release 60-120 2 uretics are usually needed in combina- (Cardene SR) tion with other drug classes. Nifedipine long-acting (Adalat CC, 30-60 1 Procardia XL) Cerebrovascular Disease. The risks Nisoldipine (Sular) 10-40 1 and benefits of acute lowering of BP dur- 1-Blockers Doxazosin (Cardura) 1-16 1 ing an acute stroke are still unclear; con- Prazosin (Minipress)† 2-20 2-3 trol of BP at intermediate levels (approxi- Terazosin (Hytrin) 1-20 1-2 mately 160/100 mm Hg) is appropriate Central 2-agonists and other Clonidine (Catapres)† 0.1-0.8 2 until the condition has stabilized or im- centrally acting drugs Clonidine patch (Catapres TTS) 0.1-0.3 1 weekly proved. Recurrent stroke rates are low- Methyldopa (Aldomet)† 250-1000 2 ered by the combination of an ACE in- Reserpine (generic) 0.05-0.25 1‡ hibitor and thiazide-type diuretic.35 Guanfacine (generic) 0.5-2 1 Other Special Situations. Minority Direct vasodilators Hydralazine (Apresoline)† 25-100 2 Populations. Blood pressure control rates Minoxidil (Loniten)† 2.5-80 1-2 vary in minority populations and are Abbreviation: ACE, angiotensin-converting enzyme. lowest in Mexican Americans and Na- *Dosages may vary from those listed in the Physicians’ Desk Reference,38 which may be consulted for additional in- formation. tive Americans.1 In general, the treat- †Are now or will soon become available in generic preparations. ment of hypertension is similar for all ‡A 0.1-mg dose may be given every other day to achieve this dosage. demographic groups, but socioeco- 2566 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.
  8. 8. THE JNC 7 REPORT nomic factors and lifestyle may be im- managed aggressively and aspirin est rates of BP control.68 Treatment rec- portant barriers to BP control in some should be used. ommendations for older individuals minority patients. The prevalence, se- Hypertension in Older Individuals. Hy- with hypertension, including those who verity, and impact of hypertension are pertension occurs in more than two have isolated systolic hypertension, increased in blacks, who also demon- thirds of individuals after age 65 years.1 should follow the same principles out- strate somewhat reduced BP responses This is also the population with the low- lined for the general care of hyperten- to monotherapy with -blockers, ACE inhibitors, or ARBs compared with di- Table 5. Combination Drugs for Hypertension uretics or CCBs. These differential re- Combination Type Fixed-Dose Combination, mg* Trade Name sponses are largely eliminated by drug ACE inhibitors and CCBs Amlodipine/benazepril hydrochloride Lotrel combinations that include adequate (2.5/10, 5/10, 5/20, 10/20) doses of a diuretic. Angiotensin- Enalapril maleate/felodipine (5/5) Lexxel converting enzyme inhibitor–induced Trandolapril/verapamil (2/180, 1/240, Tarka 2/240, 4/240) angioedema occurs 2 to 4 times more fre- ACE inhibitors and diuretics Benazepril/hydrochlorothiazide (5/6.25, Lotensin HCT quently in black patients with hyper- 10/12.5, 20/12.5, 20/25) tension than in other groups.33 Captopril/hydrochlorothiazide (25/15, Capozide Obesity and the Metabolic Syndrome. 25/25, 50/15, 50/25) Obesity (body mass index 30) is an in- Enalapril maleate/hydrochlorothiazide Vaseretic (5/12.5, 10/25) creasingly prevalent risk factor for the Lisinopril/hydrochlorothiazide (10/12.5, Prinzide development of hypertension and CVD. 20/12.5, 20/25) The Adult Treatment Panel III guide- Moexipril HCl/hydrochlorothiazide Uniretic line for cholesterol management de- (7.5/12.5, 15/25) fines the metabolic syndrome as the Quinapril HCl/hydrochlorothiazide Accuretic (10/12.5, 20/12.5, 20/25) presence of 3 or more of the following ARBs and diuretics Candesartan cilexetil/hydrochlorothiazide Atacand HCT conditions: abdominal obesity (waist cir- (16/12.5, 32/12.5) cumference 102 cm [ 40 in] in men Eprosartan mesylate/hydrochlorothiazide Teveten HCT or 89 cm [ 35 in] in women), glu- (600/12.5, 600/25) cose intolerance (fasting glucose 110 Irbesartan/hydrochlorothiazide (75/12.5, Avalide 150/12.5, 300/12.5) mg/dL [ 6.1 mmol/L]), BP of at least Losartan potassium/hydrochlorothiazide Hyzaar 130/85 mm Hg, high triglycerides ( 150 (50/12.5, 100/25) mg/dL [ 1.70 mmol/L]), or low high- Telmisartan/hydrochlorothiazide Micardis HCT density lipoprotein cholesterol ( 40 (40/12.5, 80/12.5) mg/dL [ 1.04 mmol/L] in men or 50 Valsartan/hydrochlorothiazide (80/12.5, Diovan HCT 160/12.5) mg/dL [ 1.30 mmol/L] in women).66 -Blockers and diuretics Atenolol/chlorthalidone (50/25, 100/25) Tenoretic Intensive lifestyle modification should Bisoprolol fumarate/hydrochlorothiazide Ziac be pursued in all individuals with the (2.5/6.25, 5/6.25, 10/6.25) metabolic syndrome, and appropriate Propranolol LA/hydrochlorothiazide Inderide drug therapy should be instituted for (40/25, 80/25) each of its components as indicated. Metoprolol tartrate/hydrochlorothiazide Lopressor HCT (50/25, 100/25) Left Ventricular Hypertrophy. Left ven- Nadolol/bendroflumethiazide (40/5, Corzide tricular hypertrophy is an independent 80/5) risk factor that increases the risk of sub- Timolol maleate/hydrochlorothiazide Timolide sequent CVD. Regression of left ven- (10/25) tricular hypertrophy occurs with ag- Centrally acting drug and diuretic Methyldopa/hydrochlorothiazide Aldoril (250/15, 250/25, 500/30, 500/50) gressive BP management, including Reserpine/chlorothiazide (0.125/250, Diupres weight loss, sodium restriction, and 0.25/500) treatment with all classes of antihyper- Reserpine/hydrochlorothiazide Hydropres tensive agents except the direct vasodi- (0.125/25, 0.125/50) lators, hydralazine and minoxidil.1,67 Diuretic and diuretic Amiloride HCl/hydrochlorothiazide (5/50) Moduretic Peripheral Arterial Disease. Periph- Spironolactone/hydrochlorothiazide Aldactone (25/25, 50/50) eral arterial disease is equivalent in risk Triamterene/hydrochlorothiazide Dyazide, Maxzide to ischemic heart disease. Any class of (37.5/25, 50/25, 75/50) antihypertensive drugs can be used in Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker; most patients with peripheral arterial HCl, hydrochloride; HCT, hydrochlorothiazide; LA, long-acting. *Some drug combinations are available in multiple fixed doses. Each drug dose is reported in milligrams. disease. Other risk factors should be ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2567
  9. 9. THE JNC 7 REPORT sion. In many individuals, lower ini- should have their BP checked regu- defined as BP that is, on repeated mea- tial drug doses may be indicated to larly. Development of hypertension is a surement, at the 95th percentile or avoid symptoms; however, standard reason to consider other forms of con- greater adjusted for age, height, and sex.73 doses and multiple drugs are needed in traception. In contrast, hormone replace- The fifth Korotkoff sound is used to the majority of older individuals to ment therapy does not raise BP.71 define diastolic BP. Clinicians should be reach appropriate BP targets. Women with hypertension who be- alert to the possibility of identifiable Postural Hypotension. A decrease in come pregnant should be followed care- causes of hypertension in younger chil- standing systolic BP of more than 10 fully because of increased risks to mother dren (ie, kidney disease, coarctation of mm Hg, when associated with dizzi- and fetus. Methyldopa, -blockers, and the aorta). Lifestyle interventions are ness or fainting, is more frequent in vasodilators are preferred medications for strongly recommended, with pharma- older patients with systolic hyperten- the safety of the fetus.72 Angiotensin- cologic therapy instituted for higher lev- sion, diabetes, and those taking diuret- converting enzyme inhibitors and ARBs els of BP, or if there is insufficient ics, venodilators (eg, nitrates, -block- should not be used during pregnancy be- response to lifestyle modifications.74 ers, and sildenafil-like drugs), and some cause of the potential for fetal defects and Choices of antihypertensive drugs are psychotropic drugs. Blood pressure in should be avoided in women who are similar in children and adults, but effec- these individuals should also be moni- likely to become pregnant. Preeclamp- tive doses for children are often smaller tored in the upright position. Caution sia, which occurs after the 20th gesta- and should be adjusted carefully. Angio- should be used to avoid volume deple- tion week of pregnancy, is character- tensin-converting enzyme inhibitors and tion and excessively rapid dose titra- ized by new-onset or worsening ARBs should not be used in pregnant or tion of antihypertensive drugs. hypertension, albuminuria, and hyper- sexually active girls. Uncomplicated Dementia. Dementia and cognitive uricemia, sometimes with coagulation hypertension should not be a reason to impairment occur more commonly in abnormalities. In some patients, pre- restrict children from participating in patients with hypertension. Reduced eclampsia may develop into a hyperten- physical activities, particularly because progression of cognitive impairment sive urgency or emergency and may re- long-term exercise may lower BP. Use may occur with effective antihyperten- quire hospitalization, intensive of anabolic steroids should be strongly sive therapy.69,70 monitoring, early fetal delivery, and par- discouraged. Vigorous interventions also Hypertension in Women. Oral contra- enteral antihypertensive and anticon- should be conducted for other existing ceptives may increase BP and the risk of vulsant therapy.72 modifiable risk factors (eg, smoking). hypertension increases with duration of Children and Adolescents. In chil- Hypertensive Urgencies and Emergen- use. Women taking oral contraceptives dren and adolescents, hypertension is cies. Patients with marked BP eleva- Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes Recommended Drugs High-Risk Conditions With Compelling ACE Aldosterone Indication* Diuretic -Blocker Inhibitor ARB CCB Antagonist Clinical Trial Basis† Heart failure ‰ ‰ ‰ ‰ ‰ ACC/AHA Heart Failure Guideline,40 MERIT-HF,41 COPERNICUS,42 CIBIS,43 SOLVD,44 AIRE,45 TRACE,46 ValHEFT,47 RALES48 Post–myocardial infarction ‰ ‰ ‰ ACC/AHA Post-MI Guideline,49 BHAT,50 SAVE,51 Capricorn,52 EPHESUS53 High coronary disease risk ‰ ‰ ‰ ‰ ALLHAT,33 HOPE,34 ANBP2,36 LIFE,32 CONVINCE31 Diabetes ‰ ‰ ‰ ‰ ‰ NKF-ADA Guideline,21,22 UKPDS,54 ALLHAT33 Chronic kidney disease ‰ ‰ NKF Guideline,22 Captopril Trial,55 RENAAL,56 IDNT,57 REIN,58 AASK59 Recurrent stroke prevention ‰ ‰ PROGRESS35 Abbreviations: AASK, African American Study of Kidney Disease and Hypertension; ACC/AHA, American College of Cardiology/American Heart Association; ACE, angiotensin- converting enzyme; AIRE, Acute Infarction Ramipril Efficacy; ALLHAT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ANBP2, Second Australian National Blood Pressure Study; ARB, angiotensin-receptor blocker; BHAT, -Blocker Heart Attack Trial; CCB, calcium channel blocker; CIBIS, Cardiac Insufficiency Bisoprolol Study; CONVINCE, Controlled Onset Verapamil Investigation of Cardiovascular End Points; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival Study; EPHESUS, Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; HOPE, Heart Outcomes Prevention Evaluation Study; IDNT, Inbesartan Dia- betic Nephropathy Trial; LIFE, Losartan Intervention For Endpoint Reduction in Hypertension Study; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure; NKF-ADA, National Kidney Foundation–American Diabetes Association; PROGRESS, Perindopril Protection Against Recurrent Stroke Study; RALES, Randomized Aldactone Evaluation Study; REIN, Ramipril Efficacy in Nephropathy Study; RENAAL, Reduction of Endpoints in Non–Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan Study; SAVE, Survival and Ventricular Enlargement Study; SOLVD, Studies of Left Ventricular Dysfunction; TRACE, Trandolapril Cardiac Evaluation Study; UKPDS, United Kingdom Prospective Diabetes Study; ValHEFT, Valsartan Heart Failure Trial. *Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the blood pressure. †Conditions for which clinical trials demonstrate benefit of specific classes of antihypertensive drugs. 2568 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.
  10. 10. THE JNC 7 REPORT tions and acute target-organ damage (eg, encephalopathy, myocardial in- Box 3. Causes of Resistant Hypertension farction, unstable angina, pulmonary Improper blood pressure measurement edema, eclampsia, stroke, head trauma, Volume overload and pseudotolerance life-threatening arterial bleeding, or aor- Excess sodium intake tic dissection) require hospitalization Volume retention from kidney disease and parenteral drug therapy.1 Patients Inadequate diuretic therapy with markedly elevated BP but with- Drug-induced or other causes Nonadherence out acute target-organ damage usually Inadequate doses do not require hospitalization, but they Inappropriate combinations should receive immediate combina- Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors tion oral antihypertensive therapy. They Cocaine, amphetamines, other illicit drugs should be carefully evaluated and moni- Sympathomimetics (decongestants, anorectics) tored for hypertension-induced heart Oral contraceptives and kidney damage and for identifi- Adrenal steroids able causes of hypertension (Box 2). Cyclosporine and tacrolimus Additional Considerations in Anti- Erythropoietin hypertensive Drug Choices. Antihyper- Licorice (including some chewing tobacco) tensive drugs can have favorable or un- Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma haung, bitter orange) favorable effects on other comorbidities. Associated conditions Potential Favorable Effects. Thiazide- Obesity type diuretics are useful in slowing de- Excess alcohol intake mineralization in osteoporosis. -Block- Identifiable causes of hypertension (see Box 2) ers can be useful in the treatment of atrial tachyarrhythmias/fibrillation, mi- graine, thyrotoxicosis (short-term), es- sential tremor, or perioperative hyper- therapy prescribed by the most careful alterations in the plan should be docu- tension. Calcium channel blockers may clinician will control hypertension only mented. Blood pressure self-monitor- be useful in Raynaud syndrome and cer- if the patient is motivated to take the pre- ing can also be useful. Patients’ nonad- tain arrhythmias, and -blockers may scribed medication and to establish and herence to therapy is increased by be useful in prostatism. maintain a health-promoting lifestyle. misunderstanding of the condition or Potential Unfavorable Effects. Thia- Motivation improves when patients have treatment, denial of illness because of zide diuretics should be used cau- positive experiences with and trust in lack of symptoms or perception of drugs tiously in patients who have gout or their clinicians. Empathy builds trust as symbols of ill health, lack of patient who have a history of significant hy- and is a potent motivator.75 Patient at- involvement in the care plan, or unex- ponatremia. -Blockers should gener- titudes are greatly influenced by cul- pected adverse effects of medications. ally be avoided in individuals who have tural differences, beliefs, and previous The patient should be made to feel com- asthma, reactive airways disease, or sec- experiences with the health care sys- fortable in telling the clinician all con- ond- or third-degree heart block. An- tem.76 These attitudes must be under- cerns and fears of unexpected or dis- giotensin-converting enzyme inhibi- stood if the clinician is to build trust and turbing drug reactions. tors and ARBs should not be given to increase communication with patients The cost of medications and the women likely to become pregnant and and families. complexity of care (ie, transportation, are contraindicated in those who are; Failure to titrate or combine medica- patient difficulty with polypharmacy, ACE inhibitors should not be used in tions, despite knowing the patient is not difficulty in scheduling appointments, individuals with a history of angio- at goal BP, represents clinical inertia and and life’s competing demands) are edema. Aldosterone antagonists and po- must be overcome.77 Decision support additional barriers that must be over- tassium-sparing diuretics can cause hy- systems (ie, electronic and paper), flow come to achieve goal BP. All members perkalemia and should generally be sheets, feedback reminders, and involve- of the health care team (eg, physi- avoided in patients who have serum po- ment of nurse clinicians and pharma- cians, nurse case managers, other tassium values of more than 5.0 mEq/L cists can be helpful.78 nurses, physician assistants, pharma- while not taking medications. The patient and clinician must agree cists, dentists, registered dietitians, on BP goals. A patient-centered strat- optometrists, and podiatrists) must Improving Hypertension Control egy to achieve the goal and an estima- work together to influence and rein- Adherence to Regimens. Behavioral tion of the time needed to reach the goal force instructions to improve patients’ models suggest that the most effective are important.79 When BP is above goal, lifestyles and BP control.80 ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2569
  11. 11. THE JNC 7 REPORT Resistant Hypertension. Resistant ter, Memphis (Dr Cushman); Department of Family (Mayo Clinic and Mayo Medical School, Rochester, Medicine, University of Michigan, Ann Arbor (Dr Minn); Gerald J. Wilson, MA, MBA (Citizens for Public hypertension is the failure to reach goal Green); Department of Medicine and Pharmacology, Action on High Blood Pressure and Cholesterol, Inc, BP in patients who are adhering to full State University of New York at Buffalo School of Medi- Potomac, Md); Mary Winston, EdD, RD (American Heart cine, Buffalo (Dr Izzo); Department of Medicine and Association, Dallas, Tex); Jackson T. Wright, Jr, MD, doses of an appropriate 3-drug regi- Center for Excellence in Cardiovascular-Renal Re- PhD (Case Western Reserve University, Cleveland, Ohio); men that includes a diuretic. After ex- search, University of Mississippi Medical Center, Jack- Staff: Joanne Karimbakas, MS, RD (American Insti- cluding potential identifiable hyper- son (Dr Jones); Department of Medicine, University tutes for Research Health Program, Silver Spring, Md). of Miami School of Medicine, Miami, Fla (Dr Mater- Financial Disclosures: The following authors have re- tension (Box 2), clinicians should son); Department of Medicine, Physiology, and Bio- ceived honoraria for serving as a speaker: Dr Choba- carefully explore reasons why the pa- physics, Division of Cardiovascular Disease, Univer- nian (Monarch, Wyeth, Astra-Zeneca, Solvay, Bristol- sity of Alabama at Birmingham (Dr Oparil); Myers Squibb); Dr Bakris (Astra-Zeneca, Abbott, tient is not at goal BP (BOX 3). Particu- Departments of Medicine, University Hospitals of Alteon, Biovail, Boerhinger-Ingelheim, Bristol-Myers lar attention should be paid to di- Cleveland and the Louis Stokes Cleveland Veterans Squibb, Forest, GlaxoSmithKline, Merck, Novartis, Sa- Affairs Medical Center, Cleveland, Ohio (Dr Wright); nofi, Sankyo, Solvay); Dr Black (Astra-Zeneca, Bristol- uretic type and dose in relation to renal and National High Blood Pressure Education Pro- Myers Squibb, Novartis, Pfizer, Pharmacia, Wyeth- function (see “Chronic Kidney Dis- gram, National Heart, Lung, and Blood Institute, Na- Ayerst); Dr Izzo (Boehringer-Ingelheim, Merck, Pfizer, ease” section). Consultation with a hy- tional Institutes of Health, Bethesda, Md (Dr Roccella). Astra-Zeneca, Solvay, Novartis, Forest, Sankyo); Dr Additional Authors/National High Blood Pressure Edu- Sowers (Med Com Vascular Biology Working Group, pertension specialist should be consid- cation Program Coordinating Committee Partici- Joslin Clinic Foundation); Dr Wright (Astra, Aventis, ered if goal BP cannot be achieved. pants: Claude Lenfant, MD, chair (National Heart, Lung, Bayer, Bristol-Myers Squibb, Forest, Merck, Norvar- and Blood Institute, Bethesda, Md); George L. Bakris, tis, Pfizer, Phoenix Pharmaceuticals, GlaxoSmith- MD, Henry R. Black, MD (Rush Presbyterian-St Luke’s Kline, Solvay/Unimed). Public Health Challenges Medical Center, Chicago, Ill); Barry L. Carter, PharmD The following authors have received funding/grant and Community Programs (University of Iowa, Iowa City); Jerome D. Cohen, MD support for research projects: Dr Bakris (National Insti- (St Louis University School of Medicine, St Louis, Mo); tutes of Health, Astra-Zeneca, Abbott, Alteon, Boer- Public health approaches, such as re- Pamela J. Colman, DPM (American Podiatric Medical hinger-Ingelheim, Forest, GlaxoSmithKline, Merck, ducing calories, saturated fat, and salt in Association, Bethesda, Md); William C. Cushman, MD Novartis, Sankyo, Solvay); Dr Black (Bristol-Myers (Veterans Affairs Medical Center, Memphis, Tenn); Mark Squibb, Boehringer-Ingelheim, Merck, Pfizer, Pharma- processed foods and increasing com- J. Cziraky, PharmD (Health Core, Inc, Newark, Del); John cia); Dr Cushman (Astra-Zeneca, Merck, Pfizer, Kos, munity and school opportunities for J. Davis, PA-C (American Academy of Physician Assis- Aventis Pharma, King Pharmaceuticals, GlaxoSmith- tants, Memphis, Tenn); Keith Copelin Ferdinand, MD Kline, Boehringer-Ingelheim); Dr Izzo (Boehringer- physical activity, can achieve a down- (Heartbeats Life Center, New Orleans, La); Ray W. Gif- Ingelheim, Merck, Astra-Zeneca, Novartis, GlaxoSmith- ward shift in the distribution of a popu- ford, Jr, MD (Cleveland Clinic Foundation, Fountain Hills, Kline, Biovail); Dr Oparil (Abbott Laboratories, Astra- lation’s BP, thus potentially reducing Ariz); Michael Glick, DMD (UMDNJ, New Jersey Den- Zeneca, Aventis, Boehringer-Ingelheim, Bristol-Myers tal School, Newark); Lee A. Green, MD, MPH (Univer- Squibb, Eli Lilly, Forest, GlaxoSmithKline, Monarch, morbidity, mortality, and the lifetime sity of Michigan, Ann Arbor); Stephen Havas, MD, MPH, Novartis [Ciba], Merck, Pfizer, Sanofi/BioClin, Scher- risk of an individual becoming hyper- MS (University of Maryland School of Medicine, Bal- ing Plough, Schwarz Pharma, Scios Inc, GD Searle, Wy- timore); Thomas H. Hostetter, MD (National Institute eth-Ayerst, Sankyo, Solvay, Texas Biotechnology Cor- tensive. This becomes especially criti- of Diabetes and Digestive and Kidney Diseases, Bethesda, poration); Dr Sowers (Novartis, Astra-Zeneca); Dr Wright cal as the body mass index of individu- Md); Joseph L. Izzo, Jr, MD (State University of New (Astra, Aventis, Bayer, Biovail, Bristol-Myers Squibb, For- als in the United States has increased to York at Buffalo School of Medicine, Buffalo); Daniel W. est, Merck, Norvartis, Pfizer, Phoenix Pharmaceuti- Jones, MD (University of Mississippi Medical Center, cals, GlaxoSmithKline, Solvay/Unimed). epidemic levels. Currently, 122 mil- Jackson); Lynn Kirby, RN, NP, COHNS (Sanofi- The following authors have served as a consultant/ lion adults are overweight or obese, Synthelabo Research, Malvern, Pa); Kathryn M. Kolasa, advisor: Dr Bakris (Astra-Zeneca, Abbott, Alteon, PhD, RD, LDN (Brody School of Medicine at East Caro- Biovail, Boerhinger-Ingelheim, Bristol-Myers Squibb, which contributes to the rise in BP and lina University, Greenville, NC); Stuart Linas, MD (Uni- Forest, GlaxoSmithKline, Merck, Novartis, Sanofi, San- related conditions.81 The JNC 7 en- versity of Colorado Health Sciences Center, Denver); kyo, Solvay); Dr Black (Abbott, Astra-Zeneca, Biovail, William M. Manger, MD, PhD (New York University Bristol-Myers Squibb, GlaxoSmithKline, Merck, Pfizer, dorses the American Public Health As- Medical Center, New York); Edwin C. Marshall, OD, Pharmacia); Dr Carter (Bristol-Myers Squibb); Dr Cush- sociation resolution that the food manu- MS, MPH (Indiana University School of Optometry, man (Bristol-Myers Squibb, Sanofi, GlaxoSmithKline, facturers and restaurants reduce sodium Bloomington); Barry J. Materson, MD, MBA (Univer- Novartis, Pfizer, Solvay, Pharmacia, Takeda, Sankyo, sity of Miami, Miami, Fla); Jay Merchant, MHA (Cen- Forest, Biovail); Dr Izzo (Merck, Astra-Zeneca, Novar- in the food supply by 50% during the ters for Medicare and Medicaid Services, Washington, tis, Intercure, Sankyo, Nexcura); Dr Jones (Pfizer, Bristol- next decade. When public health inter- DC); Nancy Houston Miller, RN, BSN (Stanford Uni- Myers Squibb, Merck, Forest, Novartis); Dr Manger versity School of Medicine, Palo Alto, Calif ); Marvin (NHBPEP Coordinating Committee); Dr Materson vention strategies address the diversity Moser, MD (Yale University School of Medicine, (Unimed, Merck, GlaxoSmithKline, Novartis, Reliant, of racial, ethnic, cultural, linguistic, re- Scarsdale, NY); William A. Nickey, DO (Philadelphia Col- Tanabe, Bristol-Myers Squibb, Pfizer, Pharmacia, No- lege of Osteopathic Medicine, Philadelphia, Pa); Suzanne ven, Boehringer-Ingelheim, Solvay); Dr Oparil (Bristol- ligious, and social factors in the deliv- Oparil, MD (University of Alabama at Birmingham); Ote- Myers Squibb, Merck, Pfizer, Sanofi, Novartis, The Salt ery of their services, the likelihood of lio S. Randall, MD (Howard University Hospital, Wash- Institute, Wyeth-Ayerst). their acceptance by the community in- ington, DC); James W. Reed, MD (Morehouse School The following author has stock holdings: Dr Izzo (In- of Medicine, Atlanta, Ga); Edward J. Roccella, PhD, MPH tercure, Nexcura). creases. These public health ap- (National Heart, Lung, and Blood Institute, Bethesda, Dr Oparil is also on the Board of Directors for the proaches can provide an attractive op- Md); Lee Shaughnessy (National Stroke Association, Texas Biotechnology Corporation. Englewood, Colo); Sheldon G. Sheps, MD (Mayo Clinic, The NHBPEP Coordinating Committee Thanks the Fol- portunity to interrupt and prevent the Rochester, Minn); David B. Snyder, RPh, DDS (Health lowing Reviewers: William B. Applegate, MD, MPH continuing costly cycle of managing hy- Resources and Services Administration, Rockville, Md); (Wake Forest University School of Medicine, Wins- pertension and its complications. James R. Sowers, MD (SUNY Health Science Center at ton Salem, NC); Jan N. Basile, MD (Veterans Admin- Brooklyn, Brooklyn, NY); Leonard M. Steiner, MS, OD istration Hospital, Charleston, SC); Robert Carey, MD (Eye Group, Oakhurst, NJ); Ronald Stout, MD, MPH (University of Virginia Health System, Charlottes- Author Affiliations: Department of Medicine, Bos- (Procter and Gamble, Mason, Ohio); Rita D. Strick- ville, Va); Victor Dzau, MD (Brigham and Women’s ton University School of Medicine, Boston, Mass (Dr land, EdD, RN (New York Institute of Technology, Hospital, Boston, Mass); Brent M. Egan, MD (Medi- Chobanian); Department of Preventive Medicine, Springfield Gardens, NY); Carlos Vallbona, MD (Bay- cal University of South Carolina, Charleston, SC); Bo- Rush-Presbyterian-St Luke’s Medical Center, Chi- lor College of Medicine, Houston, Tex); Howard S. Weiss, nita Falkner, MD ( Jefferson Medical College, Phila- cago, Ill (Drs Bakris and Black); Veterans Affairs Medi- MD, MPH (Georgetown University Medical Center, delphia, Pa); John M. Flack, MD, MPH (Wayne State cal Center, Departments of Preventive Medicine and Washington Hospital Center, Walter Reed Army Medi- University School of Medicine, Detroit, Mich); Ed- Medicine, University of Tennessee Health Science Cen- cal Center, Washington, DC); Jack P. Whisnant, MD ward D. Frohlich, MD (Ochsner Clinic Foundation, New 2570 JAMA, May 21, 2003—Vol 289, No. 19 (Reprinted) ©2003 American Medical Association. All rights reserved.

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