Joint national committe 7

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Joint national committe 7

  1. 1. Joint National Committe-7 Recommendations Noel.M.Isaac
  2. 2. ABSTRACT In 2003, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) issued its seventh report, which provided guidelines for the diagnosis and management of this disease. Included in the guidelines were: a new classification system for hypertension; recommendations for lifestyle modifications; and recom- mendations for pharmacologic therapy.
  3. 3. CHANGES IN BLOOD PRESSURE CLASSIFICATION In the JNC 7 guidelines, the 7 categories of blood Pressure(BP) defined in JNC 6 were simplified and reduced to 4 categories- • Normal blood pressure: SBP <120 mm Hg and diastolic blood pressure (DBP) <80 mm Hg • Prehypertension: These are patients on the cusp of developing hypertension. It is defined as a SBP of 120-139 mm Hg or a DBP of 80-89 mm Hg • Stage I hypertension: SBP 140-159 mm Hg or DBP 90-99 mm Hg • Stage II hypertension: SBP ≥160 mm Hg or DBP ≥ 100 mm Hg
  4. 4. TREATMENT ALGORITHM FOR HYPERTENSION  In the pre-hypertensive stage: Lifestyle modifications alone are recommended  Stage I hypertension: Lifestyle modifications combined with single- drug therapy(usually a thiazide-type diuretic) is recommended.  Stage II hypertension: Lifestyle modifications are recommended, but initial therapy is aggressive, and typically includes a thiazide type diuretic in combination with an ACE inhibitor ARB,CCB, or a beta-blocker.
  5. 5. LIFE STYLE MODIFICATION • Weight Reduction Maintaining a normal body mass index (18.5-24.9 kg/m2) helps control blood pressure. In fact, SBP can be reduced between 5- 10 mm Hg for every 10 kg of body weight that is lost. • Diet The Dietary Approaches to Stop Hypertension (DASH)diet is a plan that emphasizes eating fruits, vegetables, and low fat dairy products while discouraging the consumption of saturated and total fats. It is associate d with reductions in SBP ranging from 8-14 mm Hg, and can help reduce and control weight and sodium intake.
  6. 6. LIFE STYLE MODIFICATION • Dietary Sodium Intake Current recommendation is to limit the sodium intake to less than 2.4g per day which helps in the mean BP reduction by 5/2.7mm Hg. • Regular physical activity Regular physical activity must be done atleast 30 min/day or atleast 5 days a week. This will help reduce the systolic blood pressure(SBP) by 9mm Hg • Moderate alcohol consumption JNC 7 defines 2 drinks as 24oz of beer, 10 oz of wine, and 3 oz of 80 proof whisky. Consumption of 1-2 drinks per day decreases the SBP but greater than 2 drinks may increase the SBP.
  7. 7. Class Drug Usual dose range, mg/day Usual daily frequency* Diuretics Loop diuretics Bumetanide Furosemide Torsemide 0.5-2 20-80 5-40 2 2 1 Potassium-sparing diuretics Amiloride Triamterene 5-10 50-100 1-2 1-2 Thiazide and thiazide-like diuretics Chlorthalidone Hydrochlorothiazide Indapamide Metolazone 12.5-25 12.5-50 1.25-2.5 0.5-5 1 1 1 1 ACE Inhibitors Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril 10-40 25-100 5-40 10-40 10-40 7.5-30 4-8 10-80 2.5-20 1-4 1 2-3 1-2 1 1 1 1 1-2 1 1 ARBs Candesartan Irbesartan Losartan Olmesartan Telmisartan Valsartan 8-32 150-300 25-100 20-40 20-80 80-320 1 1 1-2 1 1 1 COMMON ANTIHYPERTENSIVE MEDICATIONS AND RECOMMENDED DOSAGES:
  8. 8. Aldosterone receptor blockers Eplerenone Spironolactone 50-100 25-50 1 1 Beta-blockers Atenolol Bisoprolol Metoprolol Nadolol Propranolol Carvedilol 25-100 2.5-10 50-100 40-120 40-160 12.5-50 1-2 1 1-2 1 2 2 Calcium channel blockers Dihydropyridine Amlodipine Felodipine Isradipine Nifedipine (sustained released) 2.5-10 2.5-20 2.5-10 30-60 1 1 2 1-2 Nondihydropyridine Diltiazem (extended release) Verapamil (ER) 180-420 120-360 1 1 Alpha-blockers Doxazosin Prazosin Terazosin 1-16 2-20 1-20 1 2-3 1 Direct vasodilators Hydralazine Minoxidil 25-100 2.5-80 2-3 1-2
  9. 9. COMPELLING INDICATIONS • Diabetes Mellitus ACEI/ARBs reduces the risk of progression of DM, and its having reno- protective activity. ACEI/ARBs can overt diabetic nephropathy and are therefore considered to be the first line of therapy Thiazide diuretics, β-blockers or CCBs can be used as an sequential add on therapy for controlling the blood pressure.
  10. 10. • Chronic Kidney Disease Initially presents with microalbuminuria-( 30-299mg of albumin in 24hr urine culture)- which progresses over several years to kidney failure. ACEI/ ARBs along with diuretics reduces this progression to complete renal failure and hence used as a first line of therapy. In case if  The GFR is <60ml/min,  Serum creatinine in females is greater than 1.3mg/dl or greater than 1.5mg/dl in men  Albuminuria-( >300mg/day), Then typically 3 or more anti hypertensive would be required.
  11. 11. • Acute Coronary Artery Disease Includes: Unstable angina, Non-ST segment elevated MI ST- segment elevated MI β-blockers decreases the risk of Subsequent MI/ Sudden cardiac death, therefore considered as first line of therapy. If there is any presence of AWMI, LVD, or any other condition where BP lowering is needed then ACEI/ARBs can be given.
  12. 12. • Chronic Coronary Artery Disease Includes: Post MI Chronic stable angina Core regimen= β-blockers + ACEI ACEI improves cardiac functions and reduces the risk of CV events
  13. 13. • Add on’s:  Thiazide diuretics, for additional BP reduction  Dihydropyridine CCBs, for treating ischemic symptoms for those with chronic stable angina  Non Dihydopyridine CCBs, for to those whom β-blockers cant be used
  14. 14. • Stroke ACEI and Thiazide diuretic can reduce the recurrence of stroke in patient who have had stroke and therefore considered the first line of therapy
  15. 15. • Left Ventricular Dysfunction ACEI has been found to reduce morbidity and mortality rates in LVD cases Diuretics is used for the symptomatic treatment of edema β-blockers has been found to reduce morbidity and mortality rates when added with ACEI and a Diuretic.  Standard first line: ACEI + β-blockers + Diuretics. However only metoprolol, carvedilol and bisoprolol should be used Add on’s: Aldosterone antagonist.
  16. 16. Compelling indication Diuretic Beta- blockers ACE inhibitors ARBs CCB Aldosterone blockers Clinical trial supporting Heart Failure • • • • • ACC/AHA Heart Failure Guidelines, COPERNICUS, SOLVD,ValHEFT, CHARM, RALES Post-MI • • • • ACC/AHA Post MI Guidelines, Capricorn, SAVE,VALIANT, EPHESUS High Coronary Risk • • • • • ALLHAT, HOPE, LIFE, EUROPA, ONTARGET Chronic Kidney Disease • • • NKF HTN Guidelines, REIN, ROAD, RENAAL Stroke • • • ALLHAT, PROGRESS, MOSES, LIFE Diabetes • • IRMA-2, Micro-HOPE Elderly • • SHEP, Sys-EURO CLINICAL TRIAL AND GUIDELINE BASIS FOR COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES
  17. 17. CONCLUSION Hypertension is among the most commonly encountered disorders in the ambulatory setting. The guidelines from the JNC 7 are practical and easily applied to hypertensive patients. Compliance with the guidelines will result in improved patient outcomes.

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