National Heart, Lung, and Blood Institute National High Blood Pressure Education Program
1997JNC 6, 1999WHO/ISH Why JNC 7?
50, SBPDBP 115/75 mmhg, 20 / 10 mmhg 2. 55 90%. SBP 120 139 mmhg DBP 80 89 mmhg ( prehypertensive).
Thiazide. 2. 20/10 mmhg, 2 thiazide.
WHO/ISH, ESH/ESC JNC 7 Category Systolic BP Diastolic BP Optimal BP Normal BP High-normal <120 <130 130-139 <80 <85 85-89 Normal PreHTN Grade 1(mild) Subgroup:borderline 140-159 140-149 90-99 90-94 Stage 1 Grade2(moderate) Grade3(severe) 160-179 >180 100-109 >110 Stage 2 Isolated systolic HTN subgroup >140 140-149 <90 <90 mmhg
Prehypertension ( )?
SBP 115,DBP 75mmHg CVD SBP 20, DBP 10 mmhg StrokeIHD 2
Relative risk of stroke death 9 8 7 6 5 4 3 2 1 0 Risk of Stroke Death According SBP (mmhg) DBP (mmhg) <71 to SBP and DBP in MRFIT Systolic blood pressure (SBP) Diastolic blood pressure (DBP) 71-76- 79-81- He J, et at. Am Heart J. 1999;138:211-219. Copyright 1999, Mosby Inc. 84-86- 89- Decile 1 2 3 4 5 6 7 8 9 10 (lowest 10%) (highest 10%) <112 112-118- 121-125- 129-132- 137-142- >151 92- >98 www.hypertensiononline. org
Risk of CHD Death According to SBP and DBP in MRFIT Relative risk of CHD mortality 4 3 2 1 Systolic blood pressure (SBP) Diastolic blood pressure (DBP) 0 SBP (mmhg) DBP (mmhg) <71 71-76- 79-81- He J, et at. Am Heart J. 1999;138:211-219. Copyright 1999, Mosby Inc. 84-86- CHD=coronary heart disease 89- Decile 1 2 3 4 5 6 7 8 9 10 (lowest 10%) (highest 10%) <112 112-118- 121-125- 129-132- 137-142- >151 92- >98 www.hypertensiononline. org
Normal Prehypertension NO ET-1
Prehypertension
Horse race Optimal (Stop) High-normal(running) Normal (Start)
H y p e r t e n s I o n Optimal High-normal Normal
Risk Factors and Disease History No other risk factors Normal Average risk 1-2 risk factors Low added risk >/= 3 risk factors, TOD, or diabetes Associate CVD JNC-7 Moderate added risk High added risk Highnormal Average risk Low added risk High added risk Blood Pressure Grade 1 Grade 2 Grade 3 Low added risk,,, Moderate added risk Very high Very high added added risk risk / Moderately added risk Moderate added risk High added risk Very high added risk High High added Very added / risk risk high added risk Very high added risk Very high added risk
Risk Factor(RF) No RF 1-2 RF >3RF/TOD/DM ACC normal average low mod High High normal average low low mod mod mod high high high Very high grade1 grade2 grade3 Very high Very high high Very high Very high Very high 10 : low, <15%;Mod, 15-20%;high, 20-30%;very high, >30%.
Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m 2 ) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome.
FEASIBILITY?
Not at Goal Blood Pressure (<140/90 mmhg) (<130/80 mmhg for those with diabetes or chronic kidney disease) 1 Without Compelling Indications With Compelling Indications 1 (SBP 140 159 or DBP 90 99 mmhg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. 2 (SBP >160 or DBP >100 mmhg) 2-drug combination for most (usually thiazide-type 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.
Consider initial BP, TOD, RF Single therapy Low dose combination Goal BP not achieved Full dose switch Full dose combination add Goal BP not achieved combination Full dose 3 drug combination
ALLHAT Mean Systolic and Diastolic Blood Pressure During Follow-up Chlorthalidone Chlorthalidone Systolic BP (mmhg) 150 145 140 135 Amlodipine Lisinopril Compared to chlorthalidone: SBP significantly higher in amlodipine (~1 mmhg) and lisinopril (~2 mmhg) groups. Diastolic BP (mmhg) 90 85 80 75 Amlodipine Lisinopril Compared to chlorthalidone: DBP significantly lower in amlodipine group (~1 mmhg). 130 70 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Follow-up, yrs SBP=systolic blood pressure DBP=diastolic blood pressure ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association.
ALLHAT Primary Outcome by Treatment Group Cumulative Fatal CHD and Nonfatal MI event rate (%) No. at Risk Chlorthalidone Amlodipine Lisinopril 20 16 12 8 4 0 0 1 2 3 4 5 6 Time to event, yrs 15255 9048 9054 Chlorthalidone Amlodipine Lisinopril 14477 8576 8535 13820 8218 8123 13102 7843 7711 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. 11362 6824 6662 6340 3870 3832 2956 1878 1770 7 209 215 195
ALLHAT Heart Failure by Treatment Group Cumulative event rate (%) 15 12 9 6 3 Chlorthalidone Amlodipine Lisinopril P<0.001 for chlorthalidone vs amlodipine and chlorthalidone vs lisinopril No. at Risk Chlorthalidone Amlodipine Lisinopril 0 0 1 2 3 4 5 6 Time to event, yrs 15255 9048 9054 14528 8535 8496 13898 8185 8096 13224 7801 7689 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. 11511 6785 6698 6369 3775 3789 3016 1780 1837 7 384 210 313 www.hypertensiononline.org
*Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmhg.
α α ß
(JNC JNC-7) 7)
Eldarly hypertensives Isolated systolic hypertension Hypertensives of African origin Pregnancy Congestive heart failure Post-myocardial infarction Angina pectoris Tachyarrhythmias Supraventricular tachycardia LV dysfunction Left ventricular hypertrophy Renal insufficiency Non-diabetic nephropathy Type 1diabetic nephropathy Proteinuria Type 2 diabetic nephropathy Diabetic microalbuminuria Peripheral vascular disease Carotid atherosclerosis ACE-inhibitor cough Hyperlipidaemia Conditions favouring the use Diuretics (thiazides) Heart Disease Renal Desease Other Diuretics (loop) Diuretics (anti-aldosterone) -Blockers Calcium antagonists (dihydropyridines) Calcium antagonists (verapamil, diltiazem) ACE inhibitors AT 1 -blockers -Blockers Class Prostatic hyperplasia (BPH) A-V, atrioventricular; LV, left ventricular.
SBP Distributions After Intervention Before Intervention Reduction in BP Reduction in SBP mmhg 2 3 5 % Reduction in Mortality Stroke CHD Total 6 4 3 8 5 4 14 9 7
(high normal) RF/DM/ACC/TOD (1/2) RF/DM/ACC/TOD (3) LSM/RF LSM/RF RF/DM/ACC/TOD LSM/RF L m s vs m L NN O D D LSM for 3 m LSM for 3-12 m HT HT- HT O D
ALLHAT CHD Death and Nonfatal MI Relative Risk Favors (95% CI) amlodipine Favors chlorthalidone Relative Risk (95% CI) Favors lisinopril Favors chlorthalidone TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabetic 0.98 (0.90-1.07) 0.99 (0.85-1.16) 0.97 (0.88-1.08) 0.98 (0.87-1.09) 0.99 (0.85-1.15) 1.01 (0.86-1.18) 0.97 (0.87-1.08) 0.99 (0.87-1.13) 0.97 (0.86-1.09) 0.99 (0.91-1.08) 1.08) 0.95 (0.81-1.12) 1.12) 1.01 (0.91-1.12) 1.12) 0.94 (0.85-1.05) 1.06 (0.92-1.23) 1.10 (0.94-1.28) 0.94 (0.85-1.05) 1.00 (0.87-1.14) 0.99 (0.88-1.11) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association.
ALLHAT Combined CV Disease Relative Risk Favors (95% CI) amlodipine Favors chlorthalidone Relative Risk (95% CI) Favors lisinopril Favors chlorthalidone TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabetic 1.04 (0.99-1.09) 1.03 (0.94-1.12) 1.05 (0.99-1.12) 1.04 (0.98-1.11) 1.04 (0.96-1.13) 1.06 (0.96-1.16) 1.04 (0.97-1.10) 1.06 (0.98-1.15) 1.02 (0.96-1.09) 1.10 (1.05-1.16) 1.16) 1.05 (0.97-1.15) 1.13 (1.06-1.20) 1.20) 1.08 (1.02-1.15) 1.15) 1.12 (1.03-1.21) 1.21) 1.19 (1.09-1.30) 1.30) 1.06 (1.00-1.13) 1.13) 1.08 (1.00-1.17) 1.17) 1.12 (1.05-1.19) 1.19) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline.org
New Features and Key Messages(JNC-7) For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmhg, CVD risk doubles with each increment of 20/10 mmhg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120 139 mmhg or DBP 80 89 mmhg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.
ALLHAT Conclusions Better control of systolic BP was achieved with chlorthalidone than with amlodipine or lisinopril There were no differences in risk for CHD death/nonfatal MI between chlorthalidone and amlodipine or lisinopril In secondary endpoints, chlorthalidone was associated with lower risk for stroke, combined CVD, and HF compared with lisinopril HF compared with amlodipine MI=myocardial infarction CHD=coronary heart disease HF=heart failure ALLHAT Research Group. JAMA. 2002;288:2981-2997.
ALLHAT? HOPE ANBP2? LIFE CONVINCE?
35 40% 20 25% 50%
Stage 1 10 12mmHg 11 1.
awareness(25%), treatment(20%), and control(5%) of high blood pressure; (2001 ) Sources: Unpublished data for 1999 2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
3 ; 1. 2. 3.
Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
Heart LVH Angina or prior MI Prior coronary revascularization CHF Brain Stroke or TIA Chronic kidney disease Peripheral arterial disease Retinopathy
(Goals) (Lifestyle modification) Algorithm Followup and monitoring
. BP140/90 mmhg 130/80 mmhg. 50.
followup. 2 1 1-2K creatinine
3-6 (, )
; slowing demineralization ; /, or perioperative HTN.,, thyrotoxicosis ( ), ; Raynaud,. ;.
; or Na. ;, 2-3 ACEIs and ARB;. ACEI; angioedema. Aldosterone K- ; K
Adherence to regimens Resistant hypertension
The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator. The responsible physician s judgment remains paramount
: 1. 2. ( adherence) 3. white-coat 135/ 85 mmhg.
(e.g., NSAIDs, illicit drugs, sympathomimetics, ) Over-the-counter (OTC) 2
Public health approaches (e.g. ) ; ;,, ;
HOPE BP change SBP/DBP (mm Hg) Baseline 1 month 2 years final Ramipril 139/79 133/76 135/76 136/76 Placebo 139/79 137/78 138/78 139/77 Extremely small decrease in BP in the ramipril group (3/3 mmhg) and even less in the placebo group (0/2 mmhg) Class effect
Life style modification lean prehypertension?
PROGRESS Perindopril Indapamide vs Placebo Against recurrent stroke, n=6105 0 Risk reduction (%) -10-20 -30-28% Strokes -26% Major vascular events Lancet 2001:358:1033-41
New Engl J Med 2000 ;342 HOPE - Primary outcome 0 (%) CV death MI Stroke -10-20 -26-20 -30 All differences p<0.001-32
SBP > 115mmHg DBP > 75mmHg Stroke RR RR IHD Vascular
Seven Countries Study -Implications for Asian-
Risk factors Target organ damageassociated clinical condition LVH Cerebro vascular Stroke Carotid IMT Hemorrhage Creatinine level TIA Heart MI Angina C. Revascularzation CHF Renal disease Diabetic nephropathy Renal failure Vascular Dissection Sx(+) artery disease Hypertensive retinopathy Hm or exudation papilloedema
High High-normal normal
Odds Ratios High-normal 2.13 Normal 1.34 Optimal 1.0 Am J Kidney Dis 2003;41
Odds Ratios High-normal 2.13 Normal 1.34 Optimal 1.0 Am J Kidney Dis 2003;41
National Heart, Lung, and Blood Institute National High Blood Pressure Education Program U.S. Department of Health and Human Services,, 7 (JNC 7), May 2003 National Institutes of Health ational Heart, Lung, and Blood Institute
10 CVD risk high-normal mild hypertension
Blood Pressure Classification BP Classification SBP mmhg DBP mmhg Normal <120 and <80 Prehypertension 120 139 139 or 80 89 89 Stage 1 Hypertension 140 159 159 or 90 99 99 Stage 2 Hypertension >160 or >100100
Hypertension 2000;36 Prehypertension Prehypertension
Prehypertension August 2003 (120/80< <140/90 mmhg) New (disease?) Category in BP Guidelines Strictly speaking, perfectly correct
High Normal Hypertension Framingham Heart Study : 26 F/U hypertension High-normal