National High Blood Pressure Education Program This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service.

National High Blood Pressure Education Program

This set of slides is provided by theU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health ServiceNational Institutes of Health

National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program

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

NIH PublicationNo. 98-4080November 1997


National Heart, Lung, and Blood Institute (NHLBI) publications fall within the public domain (as do all Government publications). Hence, they are not copyrighted and may be reproduced or reprinted. NHLBI does ask, however, that reprinted material include a credit line acknowledging NHLBI as the source.

Communications and Public Information BranchOffice of Prevention, Education, and Control

NIH PublicationNo. 98-4080November 1997

DISCLAIMER

The appearance of rotating Ads onthis web site

bears no relationship to JNC VI.

The slide set is provided for educational purposes.It may be disseminated freely,but may NOT to be used for

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MedSlides Board of Directors


The Sixth Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure

(JNC VI)

NIH Publication

No. 98-4080November 1997

slide 5

Sixth Joint National Committee on Prevention, Detection, Evaluation, and

Treatment of High Blood Pressure

Henry R. Black, M.D., Chair of Chapter 1Rush-Presbyterian-St. Luke’s Medical Center

Jerome D. Cohen, M.D., Chair of Chapter 2St. Louis University Health Sciences Center

Norman M. Kaplan, M.D., Chair of Chapter 3University of Texas Southwestern Medical School

Keith C. Ferdinand, M.D., Chair of Chapter 4Heartbeats Life Center

Aram V. Chobanian, M.D.Boston University

Harriet P. Dustan, M.D.University of Vermont College of Medicine

Ray W. Gifford, Jr., M.D.Cleveland Clinic Foundation

Marvin Moser, M.D.Yale University School of Medicine

Executive Committee:

Sheldon G. Sheps, M.D., ChairMayo Clinic and Mayo Foundation and Mayo Medical School

slide 6

National High Blood Pressure Education Program Coordinating Committee

Agency for Health Care Policy and ResearchAmerican Academy of Family PhysiciansAmerican Academy of Insurance MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Physician AssistantsAmerican Association of Occupational Health NursesAmerican College of CardiologyAmerican College of Chest PhysiciansAmerican College of Occupational and Environmental MedicineAmerican College of Physicians American College of Preventive MedicineAmerican Dental Association

Health Care Financing AdministrationHealth Resources and Services Administration International Society on Hypertension in BlacksNational Black Nurses’ Association, Inc.National Center for Health Statistics, Centers for Disease Control and PreventionNational Heart, Lung, and Blood InstituteNational Hypertension AssociationNational Institute of Diabetes and Digestive and Kidney DiseasesNational Kidney FoundationNational Medical AssociationNational Optometric AssociationNational Stroke AssociationNHLBI Ad Hoc Committee on Minority PopulationsSociety for Nutrition EducationU.S. Department of Veterans’ Affairs

American Diabetes AssociationAmerican Dietetic AssociationAmerican Heart AssociationAmerican Hospital AssociationAmerican Medical AssociationAmerican Nurses’ Association, Inc.American Optometric AssociationAmerican Osteopathic AssociationAmerican Pharmaceutical

AssociationAmerican Podiatric Medical

AssociationAmerican Public Health AssociationAmerican Red CrossAmerican Society of Health-System

PharmacistsAmerican Society of HypertensionAssociation of Black CardiologistsCitizens for Public Action on High

Blood Pressure and Cholesterol, Inc.

Council on Geriatric Cardiology

slide 7

JNC VI Table of Contents

1. Introduction

2. Blood Pressure Measurement and Clinical Evaluation

3. Prevention and Treatment of High Blood Pressure

4. Special Populations and Situations

slide 8

Purpose of the JNC VI Report

To use evidence-based medicine and

consensus to report on

contemporary approaches to

hypertension prevention and control

for use by primary care clinicians.

slide 9

Progress of theNational High Blood Pressure

Education Program

• Increased awareness, treatment, and control

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

slide 10

Public Health Challenges for the National High Blood Pressure

Education Program

• Prevent blood pressure rise with age

• Decrease prevalence

• Increase awareness and detection

• Improve control

• Reduce cardiovascular risks

slide 11

Public Health Challenges for the National High Blood Pressure

Education Program (continued)

• Recognize importance of controlled isolated systolic hypertension

• Recognize importance of high-normal blood pressure

• Reduce demographic variations

• Improve opportunities for treatment

slide 12

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

NHANES II1976-80

NHANES III(Phase 1)1988-91

NHANES III(Phase 2)1991-94

Awareness 51% 73% 68.4%

Treatment 31% 55% 53.6%

Control** 10% 29% 27.4%* Adults age 18 to 74 years with SBP

140 mm Hg or DBP

90 mm Hg or taking antihypertensive

medication.** SBP < 140 mm Hg and DBP < 90 mm Hg.

slide 13

-70

-60

-50

-40

-30

-20

-10

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1970 1974 1978 1982 1986 1990 1994Year

Pe

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White men

White women

Black men

Black women

The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population.

Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and

Race: United States, 1972-94

slide 14

-60

-50

-40

-30

-20

-10

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1970 1974 1978 1982 1986 1990 1994Year

Pe

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White men

White women

Black men

Black women

The decline in age-adjusted mortality for CHD in the total population is 53.2%.*Age-adjusted to the 1940 U.S. census population.

Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and

Race: United States, 1972-94

slide 15

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

50

100

150

200

250

1983 1985 1987 1989 1991 1993 1995

Year

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*Provisional data.Adjusted for age, race, and sex.

slide 16

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

0%

2%

4%

6%

8%

10%

30 35 45 55 65 75 80

Age (Years)

1988-91

1976-80

slide 17

Summary of Chapter 1

• Hypertension awareness, treatment, and control rates have increased over the past 3 decades. The rates of increase have lessened since JNC V.

• Age-adjusted mortality for stroke and CHD declined during this time but now appear to be leveling.

• The incidence of end-stage renal disease and the prevalence of heart failure are increasing.

slide 18

Summary of Chapter 1 (continued)

• Randomized controlled trials provide the best method of estimating benefit of treatment and source of information for clinical policy, but they have limitations.

• Prevention and treatment of hypertension and target organ disease remain important public health challenges that must be addressed.

slide 19

Blood Pressure Measurement

• Patients should be seated with back supported and arm bared and supported.

• Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement.

• Measurement should begin after at least 5 minutes of rest.

• Appropriate cuff size and calibrated equipment should be used.

• Both SBP and DBP should be recorded.

• Two or more readings should be averaged.

slide 20

Advantages of Self-Measurement

• Identifies “white-coat hypertension”

• Assesses response to medication

• Improves adherence to treatment

• Potentially reduces costs

• Usually provides lower readings than those recorded in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

slide 21

Ambulatory Measurement

• Ambulatory monitoring can provide:– readings throughout day during usual activities

– readings during sleep to assess nocturnal changes

– measures of SBP and DBP load

• Ambulatory readings are usually lower than in clinic (hypertension is defined as SBP > 135 or DBP > 85 mm Hg)

slide 22

Classification of Blood Pressure for Adults

CategorySBP

(mm Hg)DBP

(mm Hg)

Optimal < 120 and < 80

Normal < 130 and < 85

High-normal 130-139 or 85-89

Hypertension Stage 1 Stage 2 Stage 3

140-159160-179

180

ororor

90-99100-109110

When SBP and DBP fall into different categories, use the higher category.

slide 23

Recommendations for Followup Based on Initial Measurements

Initial Blood Pressure

SBP DBP Followup Recommended

< 130 < 85 Recheck in 2 years

130-139 85-89 Recheck in 1 year, give lifestyle advice

140-159 90-99 Confirm within 2 months, give lifestyleadvice

160-179 100-109 Evaluate/refer to care within 1 month

180 110 Evaluate/refer to care within 7 days

slide 24

Evaluation Objectives

• To identify known causes

• To assess presence or absence of target organ damage and cardiovascular disease

• To identify other risk factors or disorders that may guide treatment

slide 25

Evaluation Components

• Medical history

• Physical examination

• Routine laboratory tests

• Optional tests

slide 26

Medical History

• Duration and classification of hypertension

• Patient history of cardiovascular disease

• Family history

• Symptoms suggesting causes of hypertension

• Lifestyle factors

• Current and previous medications

slide 27

Physical Examination

• Blood pressure readings (2 or more)

• Verification in contralateral arm

• Height, weight, and waist circumference

• Funduscopic examination

• Examination of the neck, heart, lungs, abdomen, and extremities

• Neurological assessment

slide 28

Laboratory Tests and Other Diagnostic Procedures

• Determine presence of target organ damage and other risk factors

• Seek specific causes of hypertension

slide 29

Laboratory Tests Recommended Before Initiating Therapy

•Urinalysis

•Complete blood count

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

•Lipid profile (total cholesterol and HDL cholesterol)

•12-lead electrocardiogram

slide 30

Optional Tests and Procedures

•Creatinine clearance•Microalbuminuria•24-hour urinary protein•Serum calcium•Serum uric acid•Fasting triglycerides•LDL cholesterol•Glycosolated hemoglobin

•Thyroid-stimulating hormone•Plasma renin activity/ urinary sodium determination•Limited echocardiography•Ultrasonography•Measurement of ankle/arm index

slide 31

Examples of IdentifiableCauses of Hypertension

• Renovascular disease

• Renal parenchymal disease

• Polycystic kidneys

• Aortic coarctation

• Pheochromocytoma

• Primary aldosteronism

• Cushing syndrome

• Hyperparathyroidism

• Exogenous causes

slide 32

Components of Cardiovascular Risk in Patients With Hypertension

Major Risk Factors:

• Smoking

• Dyslipidemia

• Diabetes mellitus

• Age older than 60 years

• Sex (men or postmenopausal women)

• Family history of cardiovascular disease

slide 33

Clinical Risk Factors forStratification of Patients With

Hypertension

• Heart diseases

• Stroke or transient ischemic attack

• Nephropathy

• Peripheral arterial disease

• Retinopathy

slide 34

Risk Stratification

Risk Group A No risk factorsNo target organ disease/clinical cardiovascular disease

Risk Group B At least one risk factor, not including diabetesNo target organ disease/clinical cardiovascular disease

Risk Group C Target organ disease/clinical cardiovascular diseaseand/or diabetes

With or without other risk factors

slide 35

Treatment Strategies andRisk Stratification

Blood PressureStages (mm Hg) Risk Group A Risk Group B Risk Group C

High-normal(130-139/85-89)

Lifestyle modification Lifestyle modification Drug therapy*Lifestyle modification

Stage 1(140-159/90-99)

Lifestyle modification(up to 12 months)

Lifestyle modification(up to 6 months)**

Drug therapyLifestyle modification

Stages 2 and 3( 160/ 100)




*For those with heart failure, renal insufficiency, or diabetes.**For those with multiple risk factors, clinicians should consider drugs as initial therapy plus lifestyle modifications.

slide 36


• Blood pressure classified as optimal, normal, high-normal, or stages 1, 2, or 3.

• Recommendations for detection, confirmation, and evaluation remain consistent with those in the JNC V report.

• In self-monitoring and ambulatory measurement, hypertension is now defined as SBP >135 mm Hg and DBP 85 mm Hg.

slide 37


• New sections discuss genetics and clinical clues to identifiable causes of hypertension.

• New tables list cardiovascular risk factors and describe risk stratification.

slide 38

Primary Prevention

• Primary prevention offers an opportunity to interrupt the costly cycle of managing hypertension.

• A population-wide approach can reduce morbidity and mortality.

• Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.

• Blood pressure rise with age is not inevitable.

• Lifestyle modifications have been shown to lower blood pressure.

slide 39

Goal of HypertensionPrevention and Management

• To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining:

– SBP < 140 mm Hg

– DBP < 90 mm Hg

– controlling other cardiovascular risk factors

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slide 41Not at Goal Blood Pressure

Algorithm for Treatment of Hypertension (continued)

Begin or Continue Lifestyle Modifications

• Lose weight• Limit alcohol• Increase physical

activity• Reduce Sodium

• Maintain potassium• Maintain calcium and

magnesium• Stop smoking• Reduce saturated fat,

cholesterol

slide 42

Initial Drug Choices


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

lower goals for patients with diabetes or renal disease

Begin or Continue Lifestyle Modifications

slide 43Not at Goal Blood Pressure


Uncomplicated

Compelling Indications

Not at Goal Blood Pressure


– Start at low dose and titrate upward.– Low-dose combinations may be appropriate.

Specific Indications

slide 44

Initial Drug Choices*

Uncomplicated• Diuretics• -blockers

Algorithm for Treatment ofHypertension (continued)

*Based on randomized controlled trials.

slide 45

Initial Drug Choices*


Compelling Indications • Heart failure

– ACE inhibitors– Diuretics

• Myocardial infarction -blockers (non-ISA)– ACE inhibitors (with systolic dysfunction)

• Diabetes mellitus (type 1) with proteinuria– ACE inhibitors

• Isolated systolic hypertension (older persons) – Diuretics preferred– Long-acting dihydropyridine calcium antagonists

*Based on randomized controlled trials.

slide 46


Specific indications for the following drugs:


• ACE inhibitors

• Angiotensin II receptor

blockers

• -blockers

• --blockers

• -blockers

• Calcium antagonists

• Diuretics

slide 47

Specific Drug Indications

• Angina

– -blockers

– Calcium antagonists

• Atrial tachycardia and fibrillation

– -blockers

– Nondihydropyridine calcium antagonists

Some antihypertensive drugs may have favorable effects on comorbid conditions:

•Heart failure

–Carvedilol

–Losartan

•Myocardial infarction

–Diltiazem

–Verapamil

slide 48

Specific Indications (continued)

• Cyclosporine-induced hypertension– Calcium antagonists

• Diabetes mellitus (1 and 2) with proteinuria– ACE inhibitors (preferred)– Calcium antagonists

• Diabetes mellitus (type 2)– Low-dose diuretics

•Dyslipidemia-blockers

•Prostatism (benign prostatic hyperplasia)

-blockers•Renal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL

[ 265.2 mol/L])–ACE inhibitors


slide 49

Specific Indications (continued)

• Essential tremor

– Noncardioselective -blockers

• Hyperthyroidism

– -blockers

• Migraine

– Noncardioselective -blockers

– Nondihydropyridine calcium antagonists

•Osteoporosis

– Thiazides

•Perioperative hypertension

– -blockers


slide 50


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)



slide 51


Continue adding agents from other classes.

Consider referral to a hypertension specialist.

Substitute drug from different class

Add second agent from different class


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slide 53

Lifestyle Modifications

For Prevention and Management

• Lose weight if overweight.

• Limit alcohol intake.

• Increase aerobic physical activity.

• Reduce sodium intake.

• Maintain adequate intake of potassium.

For Overall and Cardiovascular Health

• Maintain adequate intake of calcium and magnesium.

• Stop smoking.

• Reduce dietary saturated fat and cholesterol.

slide 54

Pharmacologic Treatment

• Decreases cardiovascular morbidity and mortality based on randomized controlled trials.

• Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

slide 55

Special Considerationsin Selecting Drug Therapy

• Demographics

• Coexisting diseases and therapies

• Quality of life

• Physiological and biochemical measurements

• Drug interactions

• Economic considerations

slide 56

Drug Therapy

• A low dose of initial drug should be used, slowly titrating upward.

• Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours.

• Combination therapies may provide additional efficacy with fewer adverse effects.

slide 57

Classes ofAntihypertensive Drugs

• ACE inhibitors

• Adrenergic inhibitors

• Angiotensin II receptor blockers

• Calcium antagonists

• Direct vasodilators

• Diuretics

slide 58

Combination Therapies

� -adrenergic blockers and diuretics

� ACE inhibitors and diuretics

� Angiotensin II receptor antagonists and diuretics

� Calcium antagonists and ACE inhibitors

� Other combinations

slide 59

Followup

• Follow up within 1-2 months after initiating therapy.

• Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications.

• Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose.

• Consider reducing dose and number of agents after1 year at or below goal.

slide 60

Causes for InadequateResponse to Drug Therapy

• Pseudoresistance

• Nonadherence to therapy• Volume overload• Drug-related causes• Associated conditions• Identifiable causes of hypertension

slide 61

Guidelines for ImprovingAdherence to Therapy

• Be aware of signs of nonadherence.

• Establish goal of therapy.

• Encourage a positive attitude about achieving goals.

• Educate patients about the disease and therapy.

• Maintain contact with patients.

• Encourage lifestyle modifications.

• Keep care inexpensive and simple.

slide 62

Guidelines for ImprovingAdherence to Therapy (continued)

• Integrate therapy into daily routine.

• Prescribe long-acting drugs.

• Adjust therapy to minimize adverse affects.

• Continue to add drugs systematically to meet goal.

• Consider using nurse case management.

• Utilize other health professionals.

• Try a new approach if current regime is inadequate.

slide 63

Hypertensive Emergencies and Urgencies

• Emergencies require immediate blood pressure reduction to prevent or limit target organ damage.

• Urgencies benefit from reducing blood pressure within a few hours.

• Elevated blood pressure alone rarely requires emergency therapy.

• Fast-acting drugs are available.

slide 64

Drugs Available forHypertensive Emergencies

Vasodilators

•Nitroprusside

•Nicardipine

•Fenoldopam

•Nitroglycerin

•Enalaprilat

•Hydralazine

Adrenergic Inhibitors

•Labetalol

•Esmolol

•Phentolamine

slide 65


• Modifying lifestyles in populations can have a major protective effect against high blood pressure and cardiovascular disease.

• Lowering blood pressure decreases death from stroke, coronary events, and heart failure; slows progression of renal failure; prevents progression to more severe hypertension; and reduces all-cause mortality.

• A diuretic and/or a -blocker should be chosen as initial therapy unless there are compelling or specific indications for another drug.

slide 66


• Management strategies can improve adherence through the use of multidisciplinary teams.

• The reductions in cardiovascular events demonstrated in randomized controlled trials have important implications for managed care organizations.

• Management of hypertensive emergencies requires immediate action whereas urgencies benefit from reducing blood pressure within a few hours.

slide 67

Special Populations

• Racial and ethnic groups

• Children and adolescents

• Women

• Older persons

slide 68

Racial and Ethnic Groups

African Americans Among the highest prevalenceEarly onsetDelayed treatment

Hispanics Generally low prevalenceLowest control rate in Mexican Americans

Asian and Pacific Islanders May be more responsive to treatment thanother groups

American Indians Similar prevalence to general populationHigh prevalence of diabetes and obesity

slide 69

Children and Adolescents

• Blood pressure at 95th or higher percentile is considered elevated.

• Lifestyle modifications should be recommended.

• Drug therapy should be prescribed for higher levels of blood pressure.

• Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.

slide 70

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

SBP/DBP (mm Hg)

Age 50th Percentile forHeight

75th Percentile forHeight

1 104/58 105/59

6 111/73 112/73

12 123/80 124/81

17 129/84 130/85

slide 71

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

SBP/DBP (mm Hg)

Age 50th Percentile forHeight

75th Percentile forHeight

1 102/57 104/58

6 114/74 115/75

12 123/81 125/82

17 136/87 138/88

slide 72

Women

• Clinical trials have not demonstrated significant differences between men and women in treatment response and outcomes.

• Some women using oral contraceptives may have significant increases in blood pressure.

• High blood pressure in not a contraindication to hormone replacement therapy.

slide 73

Pregnant Women

• Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation.

• Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both.

• ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women.

• Methyldopa is recommended for women diagnosed during pregnancy.

slide 74

Antihypertensive Drugs Used in Pregnancy

These agents* may be used with chronic hypertension(DBP > 100 mm Hg) or acute hypertension (DBP > 105 mm Hg).

Central -agonists Methyldopa is the drug of choice.

-blockers and --blockers

Atenolol, metoprolol, and labetalol appear safeand effective in late pregnancy.

Calcium antagonists Potential synergism with magnesium sulfate maylead to precipitous hypotension.

*Limited or no controlled trials in pregnant women.

slide 75

Antihypertensive Drugs Used in Pregnancy (continued)

These agents* may be used with chronic hypertension (DBP > 100 mm Hg) or acutehypertension (DBP > 105).

Diuretics Diuretics are recommended for chronic hypertension ifprescribed before gestation, but they are not recommendedfor preeclampsia.

Direct vasodilators

Hydralazine is the parenteral drug of choice based on its longhistory of safety and efficacy.

*Limited or no controlled trials in pregnant women.

ACE inhibitors and angiotensin II receptor blockers are contraindicated.

slide 76

Older Persons

• Hypertension is common.

• SBP is better predictor of events than DBP.

• Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office.

• Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.

slide 77

Older Persons (continued)

• Therapy should begin with lifestyle modifications.

• Starting doses for drug therapy should be lower than those used in younger adults.

• Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.

slide 78

Special Situations

• Cardiovascular diseases

• Renal disease

• Diabetes mellitus

• Dyslipidemia

• Sleep apnea

• Bronchial asthma

• Gout

• Surgery

• Various chemical agents

slide 79

Cardiovascular Diseases

• Cerebrovascular disease– Indication for treatment, except immediately

after ischemic cerebral infarction

• Coronary artery disease– Benefits of therapy well established

• Left ventricular hypertrophy– Antihypertensive agents (except direct

vasodilators) indicated– Reduced weight and decreased sodium intake

beneficial

slide 80

Cardiovascular Diseases (continued)

• Cardiac failure– ACE inhibitors, especially with digoxin or

diuretics, shown to prevent subsequent heart failure

• Peripheral arterial disease– Limited or no data available

slide 81

Renal Disease

• Hypertension may result from renal disease that reduces functioning nephrons.

• Evidence shows a clear relationship between high blood pressure and end-stage renal disease.

• Blood pressure should be controlled to < 130/85 mm Hg or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours.

• ACE inhibitors work well to control blood pressure and slow progression of renal failure.

slide 82

Diabetes Mellitus

• Drug therapy should begin along with lifestyle modifications to reduce blood pressure to< 130/85 mm Hg.

• ACE inhibitors, -blockers, calcium antagonists, and low dose-diuretics are preferred.

• Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering agents.

slide 83

Dyslipidemia

• Coexistence of hypertension and dyslipidemia requires aggressive management.

• Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity.

• Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals.

slide 84

Sleep Apnea

• Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences.

• Improved hypertension control has been reported following treatment of sleep apnea.

slide 85

Bronchial Asthma or Chronic Airway Disease

• Elevated blood pressure is common in acute asthma and is possibly related to treatment with systemic corticosteroids or -agonists.

-blockers and--blockers may exacerbate asthma.

• ACE inhibitors only rarely induce bronchospasm.

• Over-the-counter medications are generally safe in limited doses for patients on drug therapy.

slide 86

Gout

• Diuretics can increase serum uric acid levels.

• Diuretics should be avoided in patients with gout.

• Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.

slide 87

Patients Undergoing Surgery

• When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg.

• Those not on prior drug therapy may be best treated with cardioselective-blockers before and after surgery.

• Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.

slide 88

Cocaine and Amphetamines

• Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems.

• Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction.

• Acute amphetamine toxicity is similar to that of cocaine but longer in duration.

• Ongoing cocaine abuse does not appear to cause chronic hypertension.

slide 89

Immunosuppressive Agents

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

• Treatment is based on vasodilation including dihydropyridine calcium antagonists.

slide 90

Erythropoietin

• Erythropoietin often increases blood pressure in treatment of patients with end-stage renal disease.

• Management includes optimal volume control, antihypertensive agents, and reducing erythopoietin dose or changing method of administration.

slide 91

Other Chemical AgentsThat May Induce Hypertension

• Mineralocorticoids and derivatives

• Anabolic steroids

• Monoamine oxidase inhibitors

• Lead

• Cadmium

• Bromocriptine

slide 92


• 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.

slide 93


• 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.

slide 94

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

National High Blood Pressure Education Program This set of slides is provided by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service.

Documents

treatment slide

national center

slide set

normal blood pressure

blood pressure measurement

prevention national

joint national committee

mayo medical school