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Since that time, JNC has repeatedly recommended the use of diuretics. In JNC 5, ACE-I and beta-blockers were added as first-line therapy. In JNC 6, these two classes were removed, and diuretics remained as the sole first-line agent.2zD_H"JNC: The PresentWhat s new in JNC-7? 1. New disease classification of  pre-hypertension 2. Start with 2 drug combo therapy for BP e" 160/100, i.e. Stage 2. 3. Simpler approach to risk stratification - deletion of Stage 3 HTN 4. Committee s fine print comment on choosing first line agent: choice can be based on patient s co-morbid conditions, i.e. compelling indication zZOZZ))w$E  $$)DJNC 7: Controversies Some clinicians are critical of the new recommendations. Not in favor of creating the new disease  pre-hypertension - feel it will cause more anxiety than aid What do you do for someone who is lean and living a healthy lifestyle and has  prehypertension ? No evidence that lifestyle interventions in this population prevents CV disease, though it may slow progression to hypertension. ~9g9ga<  =G!JNC 7: Controversies cont.#Minor concerns regarding combination therapy: If side effects occur, then it may not be clear which agent is responsible and how to adjust therapy. The subset of patients with Stage 2 HTN whose BP could be controlled with monotherapy will not be afforded the opportunity for simpler therapy.N.ZZ.f   ;I#JNC 7: ControversiesMDiuretics overemphasized as first line agent. Guidelines too dependent on the ALLHAT trial. ALLHAT had shown no difference in primary end points of coronary events between diuretics, CCB or ACE-I, but also claimed fewer coronary events in some subsets of patients. Hence, concluding diuretics are the best for everyone as first line. ALLHAT not without flaws: patients were randomized to treatment with a diuretic, CCB or ACE-I without regard for comorbid conditions (i.e., ACE for DM, BB for MI patients) Also, guidelines seem to have ignored trials with evidence of ACE-I superiority in younger patients. Thus, not accounting for the theory of high plasma renin levels as a cause of HTN in this population. To recommend a single drug across-the-board as first line for all patients promotes the absurdity that all hypertension is the same. \ZZ\${d  FFk  b$$((,,,J$JNC 7: The Fine Print Cracking open the door beyond diuretics for first line in a patient without co-morbid conditions Along with promoting a thiazide diuretic for Stage 1 HTN, the committee added this suprising sentence:  May consider ACE-I, ARB, BB, CCB. The  Compelling Indication Category - JNC put emphasis on evidence showing benefits with specific antihypertensive agents for certain medical conditions. Again, taking a small sidestep from the NHLBI dictum of diuretics first. aZZZD)))f  $$#$$')t  )H$$)((),x4    F Treatment: Choosing an agent Role of age and race Younger patients HTN related more frequently to higher plasma renin levels - ACE-I Older patients HTN related to salt - Diuretics African Americans and CCBs Consideration of co-morbid conditions or  compelling indications Side Effect profiles i.e., HCTZ - has high incidence of causing impotence ZZWZ5ZZ)T$0$  $$B))4$  $,TVM%@When the first drug doesn t work ! MJNC 7 pushes for rapid progression to combination therapy before fully exploring monotherapy. This approach is not an issue for those with Stage 2, but for Stage 1. They seem to ignore the understanding that different mechanisms cause HTN in different patients. Others argue it is because of the heterogeneous mechanisms that multiple class of agents are necessary. Alternative approach: if there is a partial response, then increase the dose or add a second agent. If there is no response at all, then try an alternate class. The goal here being to find the simplest way to control BP.vNZ^)>))  ))))Q V' Noncompliance  Estimates of noncompliance with medical treatment in general: Noncompliance causes 125,000 deaths a year - twice the mortality rate from MVAs 30% of hospital admissions for people over the age of 65 are directly caused by noncompliance. Half of all prescriptions are taken incorrectly, contributing to prolonged or additional illnesses. Noncompliance increases with the number of meds and doses per day; at 4 times a day, only 40% get it right.b>ZZ>)$d$k  $$0U& References Chobanion AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. Weber, MA. The JNC 7 Report: Challenges and Dilemmas in Writing Guidelines. Journal of Clinical Hypertension. 2003;5(4):282-286. Bakris, G. The Implications of JNC 7 for Antihypertensive Treatment Protocols. Medscape. June 30, 2003. Z)))M  ) ))P))  )$$)(()6 9J/#$%&(. / 0 2689:;<=>KNOPQ R!S"T#W$X% ` +T3f3f` +T333FV*` +TNNt^X` +Tff3f>?" dd3??nAd33- ( 3"  3f n?" dd@   @@``PR   3  f` p>(">" Z R  (     fѤ Uw?#" `Ue!  T Click to edit Master title style! !Z   `Ӥ QS?#" `eR  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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HTN is the most common primary diagnosis in the USA with 35 million office visits per year. Framingham Heart Study Individuals who are normotensive at 55 years of age have a 90% lifetime risk of developing HTN Relationship between BP and risk of CVD is continuous, consistent, and independent of other risk factors Only 35% of hypertensive patients on treatment are under control. For those age 40-70, each increased increment of 20 mmHg in systolic BP or 10 mmHg in diastolic BP doubles the risk of CVD across the entire BP range of 115/75 to 185/115. J@  ; ( < > 9 5 E  > w ^"b"  y"m"E  "$$((" 333ffH  0Ԕ ? ̙33y___PPT10Y+D=' = @B +  p k(   X  S 0%Abcm_logo #  C x1?"` mBenefits of Lowering BP -333ff@  C x4N1?"``@   Anti-HTN Therapy associated with: 35  40% mean decrease in stroke 20  25% decrease in MI More than 50% decrease in HFX#  Y #""Y"333ff  C x1?"` `E F Patients with Stage 1 HTN/Additional Risk Factors: Achieving a sustained 12 mmHg decrease in systolic BP for 10 years will prevent 1 death for every 11 pts treatedd4  7 = 4""t"333ff\  C x 1?"`0v^ B The majority of Patients will require 2 or more anti-HTN drugs.*:  C"333ffH  0Ԕ ? ̙33y___PPT10Y+D=' = @B +}   4( CYCCYC 4l 4 C Q)K  ) l 4 C R) K  ) H 4 0Ԕ ? +T3f3f___PPT10i.Yr=+D=' = @B +}   H( ?xobtvcaa Hl H C X)Ue!  ) l H C X)eR ) H H 0Ԕ ? +T3f3f___PPT10i.qsb2+D=' = @B +  K0 c[`(  X  S 0%Abcm_logo %  S ~x 1?"`M iNew BP Classification 3333ff.  # l 1?"`$@,$  0 P Based on the Mean of 2 or more properly measured, seated BP readings. On each of 2 or more office visits New category of pre-hypertension has been added: Identifies patients with increased risk of progression to HTN. Those with BP 130/80  139/89 are at twice the risk Prior Stage 2 and 3 have been combined. G  Y B a "}""  ""333ffH  0Ԕ ? ̙33___PPT10+0ÚD' = @B DD' = @BA?%,( < +O%,( < +D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*+8+0+  + K0 P i(  X  S 0%Abcm_logo !  C xز1?"`  kNew BP Classification 3333ff  C x1?"`DU BP Classification Systolic BP/Diastolic BP Lifestyle Drug Therapy Modifiation Without With Compelling Ind. Compelling Ind.  0      $$((,,a @333ffpB   HD1?\   # l1?"`2 w Normal < 120 and < 80 Encourage Pre Hypertension 120  139 or 80  89 Yes No Drug Indicated Drugs for the Compelling Ind. Stage 1 HTN 140  159 or 90  99 Yes Thiazide for most; Drugs for the may consider ACEI, comp ind. ARB, BB, or CCB as Others as needed first line Stage 2 HTN > 160 or > 100 Yes 2-Drug Combo for Drugs for the most- Usually compelling ind. thiazides AND Other drugs as ACEI, ARB, BB needed or CCB 2V  R   $$((,,0044 88 <<P: <333ffpB   HD1?pB   HD1?pB   HD1?pB  HD1?UUc[  C x 1?"`zT! A* Compelling Indications: Chronic Kidney Disease and Diabetes *B )333ffH  0Ԕ ? ̙33y___PPT10Y+D=' = @B +}   8(  8l 8 C <)K  ) l 8 C t)P ) H 8 0Ԕ ? +T3f3f___PPT10i.VrGD+D=' = @B +}   D( fitotacinoi Dl D C <)Ue!  ) l D C )eR ) H D 0Ԕ ? +T3f3f___PPT10i.jsm+D=' = @B +q   L(  Ll L C )K  ) l L C )K@ ) H L 0Ԕ ? +T3f3f___PPT10i.rsp+D=' = @B +}  ! P(  Pl P C )K\  ) l P C )@K ) H P 0Ԕ ? +T3f3f___PPT10i.wsSy+D=' = @B +  @-(  @ @ C xD1?"` " iTreatment Algorithm (333ff" @ C x01?"`z s lLifestyle Modification 333ff @ C x1?"` d) dNot at Goal BP 333ff  @ C x1?"`! m  jInitial Drug Choices 333ffJ @ C xX(1?"` KI f  HTN without Compelling Factors< 333ff[ @ C x21?"` _l  HTN with Compelling IndicationsL    333ffvB @ ND1?D33vB  @ ND1?33vB  @@ ND1? 3 vB  @ ND1?w   @ C x71?"` ' CStage 1 HTN Thiazides for Most Consider ACEI, ARB, BB, CCB or ComboLD  $   /333ff  @ C xD1?"` k OStage 2 HTN 2-drug combo for most Usually Thiazide and ACEI Or ARB or BB or CCB,P  E*333ff] @ C xdU1?"`   QDrugs for the Compelling Indications Diuretics, ACEI, ARB, BB, CCB as appropriateR R333ff @ C x\X1?"` H dNot at Goal BP 333ffv @ C x`1?"`Y jOptimize Dosages or Add Additional Drugs Until Goal BP is Achieved. Consider Consult with HTN Specialistk k333ffvB @ ND1?v  vB @ ND1?  vB @@ ND1? "3 vB @ ND1?RD cvB @ ND1?vB @@ ND1?fvB @ ND1?0H @ 0Ԕ ? ̙33y___PPT10Y+D=' = @B +.  IA < (  <3 < C x`{1?"` }%Lifestyle Modifications to Manage HTN& &-333ff < C x|1?"`U FModification Recommendation Approximate SBP Reduction, Range|G    333ffpB < HD1?!U! < C x1?"`z   &Weight Reduction Maintain normal body wt 5-20 mmHg/10 kg wt loss (BMI 18.5  24.9)<Y F333ffpB < HD1? U p  < C x1?"` y pAdopt DASH eating Consume a balanced diet with reduced 8  14 mm Hg Plan content of saturated and total fat Dietary sodium Reduce dietary sodium intake to no 2  8 mmHg Restriction more than 100 mEq/L ( 2.4 sodium or 6 sodium chloride) Physical Activity Regular aerobic activity such as 4  9 mm Hg brisk walking at least 30 min/day most days a week EtOH in Moderation Limit consumption to no more than 2 2  4 mmHg drinks per day in men and 1 drink per day in women and smaller people9 1$  .=  h$$(({,,00,333ffpB  < HD1? U pB  < HD1?UpB  < HD1?fH < 0Ԕ ? ̙33y___PPT10Y+D=' = @B +    8C (  8 8 C xԩ1?"`  _ Treatment   3333ff 8 C xw1?"`B$ M Goals of therapy: Decrease risk of CVD and Renal morbidity and mortalityV /   "";"333ff 8 C x1?"` D  ) Primary Focus should be achieving the systolic BP goal Target for Normal Patients: < 140/90 Target in DM/Renal Disease: < 130/80j8 N "7"("%""333ffl 8 Tl1?p 0 ___PPTMac11   |namdtTimes New Roman&Monotype Typography"    |namdtTimes New Roman&Monotype Typography"    |namdtTimes New Roman&Monotype Typography"    |namdtTimes New Roman&Monotype Typography" \___PPT10<4___PPT9tl R Combination Therapy - The 20/10 mm Hg rule: If BP exceeds either of the above targets by at least 20/10 (i.e, 160/100 or 150/90), then 2 drugs should be started Committee recommends a diuretic be one of the agents Diuretics provide a synergistic antihypertensive effect with many other agents Second agent can be ACE, ARB, CCB or BB. % "-"v"6  "O"")"H 8 0Ԕ ? ̙33y___PPT10Y+D=' = @B +q  " @( D'zB@DB @l @ C )Ue!  ) l @ C )eR ) H @ 0Ԕ ? +T3f3f___PPT10i.Yr+D=' = @B +  `(  `& ` C xx1?"`6 pAfrican Americans with HTN -333ff ` # ld1?"`U`  8Minority Populations: Elderly African-Americans (>60 yo) show best responses to monotherapy with Diuretics or CCB, and decreased response with B-Blockers, ACE-Inhibitors, or ARBs compared. Angioedema from ACE-I occurs 2  4 times more frequently in the African-American population8  ""P8 S R333ffv ` NA1? @@H ` 0Ԕ ? ̙33y___PPT10Y+D=' = @B +i    | 0H (  H% H C x1?"` oDrug Treatment Guidelines -333ff H C x 1?"`" YHigh-Risk Aldosterone Conditions Diuretic B-Blocker ACEI ARB CCB Antagonist Heart Failure * * * * * Post-MI * * * High Coronary Disease Risk * * * * Diabetes * * * * * Chronic Kidney Disease * * Recurrent Stroke * * Prevention o=   !B9  +$$((,,00 44 333ffpB H HD1?!pB H HD1?!pB H HD1?!pB H HD1?v !v pB  H HD1? ! pB  H HD1?B!BpB  H HD1?ttpB  H HD1?w w tpB H HD1?ftpB H HD1?tpB H HD1?tpB H HD1?tH H 0Ԕ ? ̙33y___PPT10Y+D=' = @B +   `X(  X" X C xL!1?"`UiW lChronic Kidney Disease -333ff8 X C x$D1?"`X ~ Goals: 1) Slow deterioration of renal function 2) Prevent CVD Often need 3 or more drugs Target < 130/80 Drugs: ACE-Inhibitors/ARBs Favorable effects on progression -- Increase in Creatinine of 35% is acceptable Advanced Renal Disease: GFR < 30, CR 2.5  3.0 mg/dl Increased dose of loop diuretics usually needed in combo with other drugsNA m 2  k d",3 333ffH X 0Ԕ ? ̙33y___PPT10Y+D=' = @B +  pd4(  d$ d S ~b1?"`  hSpecial Situations -333ff d C xHd1?"`"4 \LVH: Independent risk factor for subsequent CVD Regression occurs with aggressive BP management -- Weight loss -- Decrease Sodium -- Treat with all classes of anti-hypertensives except direct vasodialators, hydralazine, minoxidil PVD: Equivalent in risk to ischemic heart disease Treatment: Any class of anti-hypertensives, ASA ] ]"b    T 333ffH d 0Ԕ ? ̙33y___PPT10Y+D=' = @B +  K0   h (  h, h S ~1?"`wo pSpecial Situations Continued -333ff h # l@1?"`3!z___PPTMac11TL   |namdtTimes New Roman&Monotype Typography" t___PPT10TL ___PPT9  8HTN in Women OCPs may increase BP --Risks increase with duration of use --Check BPs regularly --Development of HTN Sufficient reason to consider other forms of contraception Pregnancy Methyldopa, B-Blockers, Vasodialators are preferred ACE-Inhibitors/ARBs are contra-indicated in pregnancy and should be avoided in women likely to become pregnant Children HTN defined as BP at 95th percentile or greater when adjusted for age, height, sex -R/O Causes: Kidney Disease, Coarction of the aorta Tx: Lifestyle, reserve drug therapy for higher BP or HTN resistant to lifestyle modification. Drug choice similar for kids but with decreased dose   "" "  """"s"  "$$"tC  333ffH h 0Ԕ ? ̙33y___PPT10Y+D=' = @B +  K0 l,(  l& l C x1?"`(d pAdditional Considerations: 3333ff l C x1?"`X:~ Thiazide Diuretics Slow demineralization in osteoporosis --Use with caution in patients with gout, or h/o significant hyponatremia B-Blockers Treat Atrial Tachycardia/Fibrilation, migraine, thyrotoxicosis (short-term), essential tremor, peri- operative HTN --Avoid in asthma, reactive airway disease, 2nd/3rd degree heart block CCB Treats Raynaud s syndrome, certain arrhythmias Alpha Blockers Treats benign prostatic hypertrophy Aldosterone Antagonists/K-sparing diuretics: Can cause hyperkalemia and should be avoided in patients with K > 5.0 while not on meds N 7"""  " """q  !p <  / F333ffH l 0Ԕ ? ̙33y___PPT10Y+D=' = @B +}  # \(  \l \ C )   ) l \ C )@ ) H \ 0Ԕ ? +T3f3f___PPT10i.{sbr+D=' = @B +X  skt(  t# t C x 1?"`=# mCauses of Resistant HTN -333ff t C x1?"`ff? Improper Measurement Volume Overload and Pseudotolerance Excess Sodium Volume retention from Renal Disease Inadequate Diuretic Therapy Drug-Induced/Other Causes Noncompliance Licorice Inadequate Doses Ephedra Inappropriate Combos ma haung NSAIDS; COX 2 inhibitors Bitter Orange Cocaine, amphetamines, other illicits Obesity Sympathomimetics (decongestants etc.) EtOH OCPs Steroids Erythropoietin Cyclosporine and tacrolimusJ "" "  ")I 3 333ffH t 0Ԕ ? ̙33y___PPT10Y+D=' = @B +}  % ( (3xobtples l  C @ 7Ue!  7 l  C  7eR 7 H  0Ԕ ? +T3f3f___PPT10i.sғf+D=' = @B +     px (  p* p C x1?"` tImproving Hypertension Control -333ff8 p # l)1?"`    Models suggest that even the most effective therapy will only control HTN if the patient is motivated to take meds and to establish and maintain a healthy lifestyle. Motivation improves when patients have positive experiences with their physicians and develop a trusting relationship6@ h w "333ff p # l )1?"` 0|___PPTMac11h`   |namdtTimes New Roman&Monotype Typography"    |namdtTimes New Roman&Monotype Typography" T___PPT104,___PPT9d\  HTN treatment must be patient centered. Drug selection to take into account patient s age, race and special circumstances. 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