Joint National Committe-7Recommendations

Noel.M.Isaac

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.

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

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.

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 associated with reductions in SBP ranging from 8-14 mm Hg, and can help reduce and control weight and sodium intake.

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.

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:

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

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.

• 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.

• 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.

• 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

• 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

• 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

• 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.

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

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.