JNC 7 blood pressure classification in adults aged ≥18 years

BPClassification

SBP(mm HG)

DBP(mm HG)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension 160 or 100

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

JNC 7 hypertension treatment algorithm

Not at goal blood pressure (<140/90 mm HG) (<130/80 mm HG for those with diabetes or chronic kidney disease)

Initial drug choices

Drug(s) for compelling indications

Other antihypertensivedrugs (diuretics, ACEI,

ARB, BB, CCB) as needed.

With compelling indications

Lifestyle modifications

Stage 2 Hypertension(SBP >160 or DBP >100 mm HG)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB).

Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mm HG)

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB,

or combination.0

Without compelling indications

Not at goal blood pressure

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

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

Definition of hypertension subtypes

1. National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

2. Pickering TG, et al. Hypertension. 2002;40:795-796. 3. Staessen JA, et al. Blood Press Monit. 2001;6:355-370.

True HypertensionDefinition1

>140/90 mm HG by clinic measurement>130/80 mm HG by home or ambulatory measurement

White-Coat HypertensionSynonym Isolated office hypertension2

DefinitionHypertensive by clinic (office) measurement and normotensive by home and ambulatory measurement3

Masked HypertensionSynonyms White-coat normotension; reverse white-coat hypertension; undetected ambulatory hypertension2

Definition Normotensive by clinic measurement and hypertensive by home and ambulatory measurement1

Recommendations for clinical use of ambulatory blood pressure monitoring:

US guidelines

• Suspected white-coat hypertension• Drug-resistant hypertension• Hypotensive symptoms with medications• Episodic hypertension• Autonomic dysfunction

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

Use of ambulatory blood pressure in hypertension management

Adapted from White WB. N Engl J Med. 2003;348:2377-2378.

24-hour BP <130/80 mm HG 24 hour BP ≥130/80 mm HG

Change antihypertensive therapy to improve control(target <130/80 mm HG)

• Maintain present therapy• Follow up with an ABPM

every two yearsFollow up with ABPM every 2

years

TREA

TED

Office blood pressure>140/90 mm HG in low-risk patients (no target organ disease)

>130/80 mm HG in high-risk patients (target organ disease, diabetes)

Self-monitored BP <130/80 mm HG Self-monitored BP ≥130/80 mm HG

Perform ambulatory BP monitoring

24-hour BP <130/80 mm HG 24-hour BP ≥130/80 mm HG

Initiate antihypertensive therapy• Follow up with

non-drug therapy on a 6-12 month basis

• Repeat ambulatory BP measurement every

1-2 years

Perform ambulatory blood-pressure monitoring

Clinical conclusions: The usefulness of ABPM

• Accounts for BP variations over time• Diagnosis of white-coat hypertension and

masked hypertension • Allows for evaluation of consistency of drug

effect over dosing periods 24 hours• More reproducible than clinic BP

Mancia G, et al. J Hypertens. 1997;15(Suppl 2):S43-S50.

ACE inhibitors1

Angiotensin-receptor blockers1

Angiotensin I

Renin Impaired release of renin due to NSAIDs,

beta-blockers, cyclosporine, tacrolimus, diabetes,

or advanced age

Proximal tubule

Glomerular capsule

Juxtaglomerular cells

Afferent arteriole

Distal convoluted

tubule

Angiotensin II

Angiotensin receptor

Adrenal gland

 Impaired

aldosterone metabolism

due to adrenal disease, heparin, or ketoconazole

Aldosterone

Aldosterone-receptor blockers: spironolactone and

eplerenone4

Collecting duct

Apical membrane

Aldosterone

Aldosterone-receptor

Collecting duct

Collecting duct(principal cell)

K+

Na+

Na-

K-

Lumen

Sodium-channel blockers: amiloride, triamterene,

trimethoprim, and pentamidine

BP3

Renin inhibitors2

1. Palmer BF. N Engl J Med. 2004;351:585-592. 2. Maibaum J, et al. Expert Opin Ther Patients. 2003;13:589-603. 3. Ooi S-YS, et al. Prescriber. 2004;5:33-46. 4. Givertz MM. Circulation. 2005;111:1012-1018.

Potential targets for therapeutic intervention on kidney function

ACE

Renin

ACE

Angiotensinogen

ANG I

ANG II

AT1 Receptor

Bradykinin

Frag ments

ACE-independent ANG II Formation

Unger T. Am J Cardiol. 2002;89(suppl):3A-10A.

Vascular Endothelium

AT2 ReceptorARBARB

Angiotensin receptor blockers (ARBs): Mechanism of action

End-stageheart

disease

Heartfailure

ACE inhibitionAngiotensin receptor blockade

GISSI-3ISIS-4

AIRESAVESOLVD-PreventionTRACECHARM-PreservedOPTIMAALVALIANT

SOLVD-TreatCHARM-AddedCHARM-AlternativeELITE IIVal-HeFT

CONSENSUS

HOPEEUROPA

ALLHATANBP2ASCOTINVESTLIFEVALUE

Studies investigating effects of RAAS manipulation on CV disease outcomes

Adapted from: Dzau V, et al. Am Heart J. 1991;121:1244-1263.

Ventriculardilation

Remodeling

LVDysfunctionArrhythmia

MyocardialInfarctionCoronary

thrombosis

Myocardialischemia

CAD

Athero-sclerosisLVH

Hypertension