Reference Card from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

Full text

Originally published by the National Heart, Lung, and Blood Institute (NIH Publication No. 03-5231). U.S. government work, public domain. Reproduced as archived reference, not current guidance.

Reference Card From the

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

EVALUATION

Classification of Blood Pressure (BP)*

Category SBP mmHg DBP mmHg

• See Blood Pressure Measurement Techniques (reverse side) Key: SBP = systolic blood pressure DBP = diastolic blood pressure

Diagnostic Workup of Hypertension

• Assess risk factors and comorbidities.
• Reveal identifiable causes of hypertension.
• Assess presence of target organ damage.
• Conduct history and physical examination.
• Obtain laboratory tests: urinalysis, blood glucose, hematocrit and lipid panel, serum potassium, creatinine, and calcium. Optional: urinary albumin/creatinine ratio.
• Obtain electrocardiogram.

Assess for Major Cardiovascular Disease (CVD) Risk Factors

• Hypertension • Physical inactivity
• Obesity • Microalbuminuria, estimated

Assess for Identifiable Causes of Hypertension

• Sleep apnea
• Drug induced/related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Cushing’s syndrome or steroid

therapy

• Pheochromocytoma
• Coarctation of aorta
• Thyroid/parathyroid disease

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes o f Health National Heart, Lung, and Blood Institute

TREATMENT

Principles of Hypertension Treatment

• Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
• Majority of patients will require two medications to reach goal.

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for patients with diabetes or chronic kidney disease)

See Strategies for Improving Adherence to Therapy

Initial Drug Choices

Without Compelling With Compelling Indications Indications

Drug Classes Thiazide-type diuretics 2-drug combination for

for most. May consider ACEI, ARB, BB, CCB, or combination.

most (usually thiazidetype diuretic and ACEI, or ARB, or BB, or CCB).

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

See Strategies for Improving Adherence to Therapy

Blood Pressure Measurement Techniques

Method Notes In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring Indicated for evaluation of “white coat hypertension.” Absence of 10–20 percent BP decrease during sleep may indicate increased CVD risk.

Patient self-check Provides information on response to therapy. May help improve adherence to therapy and is useful for evaluating “white coat hypertension.”

Causes of Resistant Hypertension

• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Inadequate doses
• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
• Excess alcohol intake
• Identifiable causes of hypertension (see reverse side)

Compelling indications for Individual Drug Classes

Compelling Indication

• Heart failure
• Post myocardial infarction
• High CVD risk
• Diabetes
• Chronic kidney disease
• Recurrent stroke prevention

Initial Therapy Options

THIAZ, BB, ACEI, ARB, ALDO ANT

BB, ACEI, ALDO ANT

THIAZ, BB, ACEI, CCB

THIAZ, BB, ACEI, ARB, CCB

ACEI, ARB

THIAZ, ACEI

Key: THIAZ = thiazide diuretic, ACEI= angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosterone antagonist

Strategies for Improving Adherence to Therapy

• Clinician empathy increases patient trust, motivation, and adherence to therapy.
• Physicians should consider their patients’ cultural beliefs and individual attitudes in formulating therapy.

Principles of Lifestyle Modification

• Encourage healthy lifestyles for all individuals.
• Prescribe lifestyle modifications for all patients with prehypertension and hypertension.
• Components of lifestyle modifications include weight reduction, DASH eating plan, dietary sodium reduction, aerobic physical activity, and moderation of alcohol consumption.

Lifestyle Modification Recommendations

Modification Recommendation Avg. SBP Reduction Range†

Weight Maintain normal body weight 5–20 mmHg/10 kg reduction (body mass index 18.5–24.9 kg/m ).

DASH eating Adopt a diet rich in fruits, plan vegetables, and lowfat dairy 8–14 mmHg products with reduced content of saturated and total fat.

Dietary sodium reduction Aerobic physical activity

Reduce dietary sodium intake to <100 mmol per day (2.4 g sodi- 2–8 mmHg um or 6 g sodium chloride). Regular aerobic physical activity (e.g., brisk walking) at least 4–9 mmHg 30 minutes per day, most days of the week.

Moderation Men: limit to <2 drinks* per day. of alcohol Women and lighter weight per- 2–4 mmHg consumption sons: limit to <1 drink* per day.

• 1 drink = 1/2 oz or 15 mL ethanol (e.g., 12 oz beer, 5 oz wine, 1.5 oz 80-proof whiskey).

† Effects are dose and time dependent.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes o f Health

National Heart, Lung, and Blood Institute

National High Blood Pressure Education Program

NIH Publication No. 03-5231

May 2003