This complete version of the updated guidelines for hypertension is written for the health care professional who wants to understand the science behind the new recommendations on high blood pressure. The JNC 7 Complete Report focuses on the new evidence, including a revised treatment algorithm, drug tables, and more. Get this for the health professional or researcher who needs to understand the full scope and significance of the new findings on high blood pressure.
- Publication Date: December 2003 in Hypertension. 2003;42:1206
- Version History:
- JNC 6: published 1997
- JNC 5: published 1992
- JNC 4: published 1988
- JNC 3: published 1984
- JNC 2: published 1980
- JNC 1: published 1976
This complete version of the updated guidelines for hypertension is written for the health care professional who wants to understand the science behind the new recommendations on high blood pressure. The JNC 7 Complete Report focuses on the new evidence, including a revised treatment algorithm, drug tables, and more. Get this for the health professional or researcher who needs to understand the full scope and significance of the new findings on high blood pressure.
- Publication Date: December 2003 in Hypertension. 2003;42:1206
- Version History:
- JNC 6: published 1997
- JNC 5: published 1992
- JNC 4: published 1988
- JNC 3: published 1984
- JNC 2: published 1980
- JNC 1: published 1976
Other Versions
Methodology
The decision to appoint a committee for JNC 7 was based on four factors: the publication of many new hypertension observational studies and clinical trials since the last report was published in 1997; the need for a new, clear, and concise guideline that would be useful to clinicians; the need to simplify the classification of BP; and a clear recognition that the JNC reports did not result in maximum benefit to the public. This JNC report is presented in two separate publications. The initial "Express" version, a succinct practical guide, was published in the May 21, 2003 issue of the Journal of the American Medical Association. The current, more comprehensive report provides a broader discussion and justification for the recommendations made by the committee. As with prior JNC reports, the committee recognizes that the responsible physician's judgment is paramount in managing his or her patients.
Since the publication of the JNC 6 report, the NHBPEP Coordinating Committee, chaired by the director of the NHLBI, has regularly reviewed and discussed studies on hypertension. To conduct this task, the Coordinating Committee is divided into four subcommittees: science base; long-range planning; professional, patient, and public education; and program organization. The subcommittees work together to review the hypertension scientific literature from clinical trials, epidemiology, and behavioral science. In many instances, the principal investigator of the larger studies has presented the information directly to the Coordinating Committee. The committee reviews are summarized and posted on the NHLBI Web site. This ongoing review process keeps the committee apprised of the current state of the science, and the information is also used to develop program plans for future activities, such as continuing education.
During fall 2002, the NHBPEP Coordinating Committee chair solicited opinions regarding the need to update the JNC 6 report. The entire Coordinating Committee provided, in writing, a detailed rationale explaining the necessity for updating JNC 6, outlined critical issues, and provided concepts to be addressed in the new report. Thereafter, the NHBPEP Coordinating Committee chair appointed the JNC 7 chair and an Executive Committee derived from the Coordinating Committee membership. The Coordinating Committee members served on one of five JNC 7 writing teams, which contributed to the writing and review of the document.
The concepts for the new report identified by the NHBPEP Coordinating Committee were used to create the report outline. Based on these critical issues and concepts, the Executive Committee developed relevant medical subject headings (MeSH) terms and keywords to further review the scientific literature. These MeSH terms were used to generate MEDLINE searches that focused on English-language, peer-reviewed, scientific literature from January 1997 through April 2003. Various systems of grading the evidence were considered, and the classification scheme used in JNC 6 and other NHBPEP clinical guidelines was selected. This scheme classifies studies according to a process adapted from Last and Abramson (see Scheme Used for Classification of the Evidence).
In reviewing the exceptionally large body of research literature on hypertension, the Executive Committee focused its deliberations on evidence pertaining to outcomes of importance to patients and with effects of sufficient magnitude to warrant changes in medical practice ("patientoriented evidence that matters," or POEMs). Patient-oriented outcomes include not only mortality but also other outcomes that affect patients' lives and well-being, such as sexual function, ability to maintain family and social roles, ability to work, and ability to carry out daily living activities. These outcomes are strongly affected by nonfatal stroke, HF, CHD, and renal disease; hence, these outcomes were considered along with mortality in the committee's evidencebased deliberations. Studies of physiological endpoints ("disease-oriented evidence," or DOEs) were used to address questions where POEMs were not available.
The Coordinating Committee began the process of developing the JNC 7 Express report in December 2002, and the report was submitted to the Journal of the American Medical Association in April 2003. It was published in an electronic format on May 14, 2003, and in print on May 21, 2003. During this time, the Executive Committee met on six occasions, two of which included meetings with the entire NHBPEP Coordinating Committee. The writing teams also met by teleconference and used electronic communications to develop the report. Twenty-four drafts were created and reviewed repeatedly. At its meetings, the Executive Committee used a modified nominal group process14 to identify and resolve issues. The NHBPEP Coordinating Committee reviewed the penultimate draft and provided written comments to the Executive Committee. In addition, 33 national hypertension leaders reviewed and commented on the document. The NHBPEP Coordinating Committee approved the JNC 7 Express report. To complete the longer JNC 7 version, the Executive Committee members met via teleconferences and in person and circulated sections of the larger document via e-mail. The sections were assembled and edited by the JNC 7 chair and were circulated among the NHBPEP Coordinating Committee members for review and comment. The JNC 7 chair synthesized the comments, and the longer version was submitted to the journal Hypertension in November 2003.
Expert Panel Members
Chair
Aram V. Chobanian, M.D.
Boston University School of Medicine
Boston, MA
Executive Committee
George L. Bakris, M.D.
Rush University Medical Center
Chicago, IL
Henry R. Black, M.D.
Rush University Medical Center
Chicago, IL
William C. Cushman, M.D.
Veterans Affairs Medical Center, Memphis, TN
Lee A. Green, M.D., M.P.H.
University of Michigan
Ann Arbor, MI
Joseph L. Izzo, Jr., M.D.
State University of New York at Buffalo School of Medicine
Buffalo, NY
Daniel W. Jones, M.D.
University of Mississippi Medical Center
Jackson, MS
Barry J. Materson, M.D., M.B.A.
University of Miami, Miami, FL
Suzanne Oparil, M.D.
University of Alabama at Birmingham
Birmingham, AL
Jackson T. Wright, Jr., M.D., Ph.D.
Case Western Reserve University
Cleveland, OH
Executive Secretary
Edward J. Roccella, Ph.D., M.P.H.
National Heart, Lung, and Blood Institute
Bethesda, MD
National High Blood Pressure Education Program Coordinating Committee
Claude Lenfant, M.D.
National Heart, Lung, and Blood Institute
Bethesda, MD
George L. Bakris, M.D.
Rush University Medical Center
Chicago, IL
Henry R. Black, M.D.
Rush University Medical Center
Chicago, IL
Vicki Burt, Sc.M., R.N.
National Center for Health Statistics
Hyattsville, MD
Barry L. Carter, Pharm.D., F.C.C.P.
University of Iowa
Iowa City, IA
Francis D. Chesley, Jr., M.D.
Agency for Healthcare Research and Quality
Rockville, MD
Jerome D. Cohen, M.D.
Saint Louis University School of Medicine
St. Louis, MO
Pamela J. Colman, D.P.M.
American Podiatric Medical Association
Bethesda, MD
William C. Cushman, M.D.
Veterans Affairs Medical Center
Memphis, TN
Mark J. Cziraky, Pharm.D., F.A.H.A.
Health Core, Inc.
Newark, DE
John J. Davis, P.A.-C.
American Academy of Physician Assistants
Memphis, TN
Keith Copelin Ferdinand, M.D., F.A.C.C.
Heartbeats Life Center
New Orleans, LA
Ray W. Gifford, Jr., M.D., M.S.
Cleveland Clinic Foundation
Fountain Hills, AZ
Michael Glick, D.M.D.
New Jersey Dental School
Newark, NJ
Lee A. Green, M.D., M.P.H.
University of Michigan
Ann Arbor, MI
Stephen Havas, M.D., M.P.H., M.S.
University of Maryland School of Medicine
Baltimore, MD
Thomas H. Hostetter, M.D.
National Institutes of Diabetes and Digestive and Kidney Diseases
Bethesda, MD
Joseph L. Izzo, Jr., M.D.
State University of New York at Buffalo School of Medicine
Buffalo, NY
Daniel W. Jones, M.D.
University of Mississippi Medical Center
Jackson, MS
Lynn Kirby, R.N., N.P., C.O.H.N.
Sanofi-Synthelabo Research
Malvern, PA
Kathryn M. Kolasa, Ph.D., R.D., L.D.N.
Brody School of Medicine at East Carolina University
Greenville, NC
Stuart Linas, M.D.
University of Colorado Health Sciences Center
Denver, CO
William M. Manger, M.D., Ph.D.
New York University Medical Center
New York, NY
Edwin C. Marshall, O.D., M.S., M.P.H.
Indiana University School of Optometry
Bloomington, IN
Barry J. Materson, M.D., M.B.A.
University of Miami
Miami, FL
Jay Merchant, M.H.A.
Centers for Medicare & Medicaid Services
Washington, DC
Nancy Houston Miller, R.N., B.S.N.
Stanford University School of Medicine
Palo Alto, CA
Marvin Moser, M.D.
Yale University School of Medicine
Scarsdale, NY
William A. Nickey, D.O.
Philadelphia College of Osteopathic Medicine
Philadelphia, PA
Suzanne Oparil, M.D.
University of Alabama at Birmingham
Birmingham, AL
Otelio S. Randall, M.D., F.A.C.C.
Howard University Hospital
Washington, DC
James W. Reed, M.D., F.A.C.P., F.A.C.E.
Morehouse School of Medicine
Atlanta, GA
Edward J. Roccella, Ph.D., M.P.H.
National Heart, Lung, and Blood Institute
Bethesda, MD
Lee Shaughnessy
National Stroke Association
Englewood, CO
Sheldon G. Sheps, M.D.
Mayo Clinic, Rochester, MN
David B. Snyder, R.Ph., D.D.S.
Health Resources and Services Administration
Rockville, MD
James R. Sowers, M.D., F.A.C.P., F.A.C.E.
SUNY Health Science Center at Brooklyn
Brooklyn, NY
Leonard M. Steiner, M.S., O.D.
Eye Group
Oakhurst, NJ
Ronald Stout, M.D., M.P.H.
Procter and Gamble
Mason, OH
Rita D. Strickland, Ed.D., R.N.
New York Institute of Technology
Springfield Gardens, NY
Carlos Vallbona, M.D.
Baylor College of Medicine
Houston, TX
Howard S. Weiss, M.D., M.P.H.
Georgetown University Medical Center
Washington Hospital Center
Walter Reed Army Medical Center
Washington, DC
Jack P. Whisnant, M.D.
Mayo Clinic and Mayo Medical School
Rochester, MN
Laurie Willshire, M.P.H., R.N.
American Red Cross
Falls Church, VA
Gerald J. Wilson, M.A., M.B.A.
Citizens for Public Action on Blood Pressure and Cholesterol, Inc.
Potomac, MD
Mary Winston, Ed.D., R.D.
American Heart Association
Dallas, TX
Jackson T. Wright, Jr., M.D., Ph.D.
Case Western Reserve University
Cleveland, OH
Additional Contributors
Jan N. Basile, M.D., F.A.C.P.
Veterans Administration Hospital
Charleston, SC
James I. Cleeman, M.D.
National Heart, Lung, and Blood Institute
Bethesda, MD
Darla E. Danford, M.P.H, D.Sc.
National Heart, Lung, and Blood Institute
Bethesda, MD
Richard A. Dart, M.D., F.A.C.P., F.C.C.P., F.A.H.A.
Marshfield Clinic
Marshfield, WI
Karen A. Donato, S.M., R.D.
National Heart, Lung, and Blood Institute
Bethesda, MD
Mark E. Dunlap, M.D.
Louis Stokes Cleveland VA Medical Center
Cleveland, OH
Brent M. Egan, M.D.
Medical University of South Carolina
Charleston, SC
William J. Elliott, M.D., Ph.D.
Rush University Medical Center
Chicago, IL
Bonita E. Falkner, M.D.
Thomas Jefferson University
Philadelphia, PA
John M. Flack, M.D., M.P.H.
Wayne State University School of Medicine
Detroit, MI
David Lee Gordon, M.D.
University of Miami School of Medicine
Miami, FL
Philip B. Gorelik, M.D., M.P.H., F.A.C.P.
Rush Medical College
Chicago, IL
Mary M. Hand, M.S.P.H., R.N
National Heart, Lung, and Blood Institute
Bethesda, MD
Linda A. Hershey, M.D., Ph.D.
VA WNY Healthcare System
Buffalo, NY
Norman M. Kaplan, M.D.
University of Texas Southwestern Medical School at Dallas
Dallas, TX
Daniel Levy, M.D.
National Heart, Lung, and Blood Institute
Framingham, MA
James W. Lohr, M.D.
VA WNY Healthcare System and SUNY Buffalo
Buffalo, NY
Vasilios Papademetriou, M.D., F.A.C.P., F.A.C.C.
Veterans Affairs Medical Center
Washington, DC
Thomas G. Pickering, M.D., D.Phil.
Mount Sinai Medical Center
New York, NY
Ileana L. Piña, M.D., F.A.C.C.
University Hospitals of Cleveland
Cleveland, OH
L. Michael Prisant, M.D., F.A.C.C., F.A.C.P.
Medical College of Georgia
Augusta, GA
Clive Rosendorff, M.D., Ph.D., F.R.C.P.
Veterans Affairs Medical Center
Bronx, NY
Virend K. Somers, M.D., Ph.D.
Mayo Clinic and Mayo Foundation
Rochester, MN
Ray Townsend, M.D.
University of Pennsylvania School of Medicine,
Philadelphia, PA
Humberto Vidaillet, M.D.
Marshfield Clinic
Marshfield, WI
Donald G. Vidt, M.D.
Cleveland Clinic Foundation
Cleveland, OH
William White, M.D.
The University of Connecticut Health Center
Farmington, CT
Expert Reviewers
William B. Applegate, M.D., M.P.H.
Wake Forest University School of Medicine
Winston Salem, NC
Jan N. Basile, M.D., F.A.C.P.
Veterans Administration Hospital
Charleston, SC
Robert Carey, M.D.,
University of Virginia Health System
Charlottesville, VA
Victor Dzau, M.D.
Brigham and Women's Hospital
Boston, MA
Brent M. Egan, M.D.
Medical University of South Carolina
Charleston, SC
Bonita Falkner, M.D.
Jefferson Medical College
Philadelphia, PA
John M. Flack, M.D., M.P.H.
Wayne State University School of Medicine
Detroit, MI
Edward D. Frohlich, M.D.
Ochsner Clinic Foundation
New Orleans, LA
Haralambos Gavras, M.D.
Boston University School of Medicine
Boston, MA
Martin Grais, M.D.
Feinberg School of Medicine, Northwestern University
Chicago, IL
Willa A. Hsueh, M.D.
David Geffen School of Medicine
UCLA Department of Medicine
Los Angeles, CA
Kenneth A. Jamerson, M.D.
University of Michigan Medical Center
Ann Arbor, MI
Norman M. Kaplan, M.D.
University of Texas Southwestern Medical Center
Dallas, TX
Theodore A. Kotchen, M.D.
Medical College of Wisconsin
Milwaukee, WI
Daniel Levy, M.D.
National Heart, Lung, and Blood Institute
Framingham, MA
Michael A. Moore, M.D.
Dan River Region Cardiovascular Health Initiative Program
Danville, VA
Thomas J. Moore, M.D.
Boston University Medical Center
Boston, MA
Vasilios Papademetriou, M.D., F.A.C.P., F.A.C.C.
Veterans Affairs Medical Center
Washington, DC
Carl J. Pepine, M.D.
University of Florida, College of Medicine
Gainesville, FL
Robert A. Phillips, M.D., Ph.D.
New York University, Lenox Hill Hospital
New York, NY
Thomas G. Pickering, M.D., D.Phil.
Mount Sinai Medical Center
New York, NY
L. Michael Prisant, M.D., F.A.C.C., F.A.C.P.
Medical College of Georgia
Augusta, GA
C. Venkata S. Ram, M.D.
University of Texas Southwestern Medical Center and Texas Blood Pressure Institute
Dallas, TX
Elijah Saunders, M.D., F.A.C.C., F.A.C.P.
University of Maryland School of Medicine
Baltimore, MD
Stephen C. Textor, M.D.
Mayo Clinic
Rochester, MN
Donald G. Vidt, M.D.
Cleveland Clinic Foundation
Cleveland, OH
Myron H. Weinberger, M.D.
Indiana University School of Medicine
ndianapolis, IN
Paul K. Whelton, M.D., M.Sc.
Tulane University Health Sciences Center
New Orleans, LA
Conflicts of Interest
Dr. Chobanian has received honoraria for serving as a speaker from Monarch, Wyeth, Astra- Zeneca, Solvay, and Bristol-Myers Squibb.
Dr. Bakris has received honoraria for serving as a speaker from Astra-Zeneca, Abbott, Alteon, Biovail, Boerhinger-Ingelheim, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Merck, Novartis, Sanofi, Sankyo, and Solvay; he has received funding/grant support for research projects from National Institutes of Health, Astra- Zeneca, Abbott, Alteon, Boerhinger-Ingelheim, Forest, GlaxoSmithKline, Merck, Novartis, Sankyo, and Solvay; he has served as a consultant/ advisor for Astra-Zeneca, Abbott, Alteon, Biovail, Boerhinger-Ingelheim, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Merck, Novartis, Sanofi, Sankyo, and Solvay.
Dr. Black has received honoraria for serving as a speaker from Astra-Zeneca, Bristol-Myers Squibb, Novartis, Pfizer, Pharmacia, and Wyeth-Ayerst; he has received funding/grant support for research projects from Bristol-Myers Squibb, Boehringer- Ingelheim, Merck, Pfizer, and Pharmacia; he has served as a consultant/advisor for Abbott, Astra- Zeneca, Biovail, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Pfizer, and Pharmacia.
Dr. Carter has served as a consultant/advisor for Bristol-Myers Squibb.
Dr. Cushman has received funding/grant support for research projects from Astra-Zeneca, Merck, Pfizer, Kos, Aventis Pharma, King Pharmaceuticals, GlaxoSmithKline, and Boehringer-Ingelheim; he has served as a consultant/ advisor for Bristol-Myers Squibb, Sanofi, GlaxoSmithKline, Novartis, Pfizer, Solvay, Pharmacia, Takeda, Sankyo, Forest, and Biovail.
Dr. Izzo has received honoraria for serving as a speaker from Boehringer-Ingelheim, Merck, Pfizer, Astra-Zeneca, Solvay, Novartis, Forest, and Sankyo; he has received funding/grant support for research projects from Boehringer-Ingelheim, Merck, Astra-Zeneca, Novartis, GlaxoSmithKline, and Biovail; he served as a consultant/advisor for Merck, Astra-Zeneca, Novartis, Intercure, Sankyo, and Nexcura; he has stock holdings in Intercure, Nexcura.
Dr. Jones has served as a consultant/advisor for Pfizer, Bristol-Myers Squibb, Merck, Forest, and Novartis.
Dr. Manger has served as a consultant/advisor for the NHBPEP Coordinating Committee.
Dr. Materson has served as a consultant/advisor for Unimed, Merck, GlaxoSmithKline, Novartis, Reliant, Tanabe, Bristol-Myers Squibb, Pfizer, Pharmacia, Noven, Boehringer-Ingelheim, and Solvay.
Dr. Oparil has received funding/grant support for research projects from Abbott Laboratories, Astra-Zeneca, Aventis, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forest, GlaxoSmithKline, Monarch, Novartis [Ciba], Merck, Pfizer, Sanofi/BioClin, Schering Plough, Schwarz Pharma, Scios Inc, GD Searle, Wyeth Ayerst, Sankyo, Solvay, and Texas Biotechnology Corporation; she has served as a consultant/advisor for Bristol-Myers Squibb, Merck, Pfizer, Sanofi, Novartis, The Salt Institute, and Wyeth- Ayerst; she is also on the Board of Directors for the Texas Biotechnology Corporation.
Dr. Sowers has received honoraria for serving as a speaker from Med Com Vascular Biology Working Group and Joslin Clinic Foundation; he has received funding/grant support for research projects from Novartis and Astra-Zeneca.
Dr. Wright has received honoraria for serving as a speaker from Astra, Aventis, Bayer, Bristol-Myers Squibb, Forest, Merck, Norvartis, Pfizer, Phoenix Pharmaceuticals, GlaxoSmithKline, and Solvay/Unimed; he has received funding/grant support for research projects from Astra, Aventis, Bayer, Biovail, Bristol-Myers Squibb, Forest, Merck, Norvartis, Pfizer, Phoenix Pharmaceuticals, GlaxoSmithKline, and Solvay/Unimed.
Text-only Slide Set of the Report
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS Slide Set
Title Page--Department of Health and Human Services
National Institutes of Health
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
I. Introduction
II. Measurement and Evaluation
9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 |
III. Treatment
24 | 25 | 26 | 27 | 28 | 29 | 30 |
IV. Special Considerations
31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 |
V. Improving Hypertension Control
45 | 46 | 47 | 48 | 49 | 50 | 51 | 52 | 53 | 54
SLIDE 1: National Heart, Lung, and Blood Institute National High Blood Pressure Education Program
Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS
SLIDE 2: Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Executive Committee
Aram Chobanian, M.D., Chair Dean?s Office and Department of Medicine Boston University School of Medicine
- George L. Bakris, M.D.
Department of Preventive Medicine
Rush-Presbyterian-St. Luke?s Medical Center - Henry R. Black, M.D.
Department of Preventive Medicine
Rush-Presbyterian-St. Luke?s Medical Center - William C. Cushman, M.D.
Preventive Medicine Section
Veterans Affairs Medical Center - Lee A. Green, M.D.
Department of Family Medicine
University of Michigan - Joseph L. Izzo, Jr., M.D.
Department of Medicine and Pharmacology
SUNY at Buffalo School of Medicine - Daniel W. Jones, M.D.
Department of Medicine and Center for Excellence in Cardiovascular-Renal Research
University of Mississippi Medical Center - Barry J. Materson, M.D.
Department of Medicine U
niversity of Miami School of Medicine - Suzanne Oparil, M.D.
Department of Medicine, Physiology & Biophysics Division of Cardiovascular Disease
University of Alabama - Jackson T. Wright, Jr., M.D.
University Hospitals of Cleveland
Case Western Reserve University - Executive Secretary
Edward J. Roccella, Ph.D, M.P.H.
National Heart, Lung, and Blood Institute
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SLIDE 3: National High Blood Pressure Education Program Coordinating Committee
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Physician Assistants
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Occupational and Environmental Medicine
American College of Physicians
?American Society of Internal Medicine
American College of Preventive Medicine
American Dental Association
American Diabetes Association
American Dietetic Association
American Heart Association
American Hospital Association
American Medical Association
American Nurses Association
American Optometric Association
American Osteopathic Association
American Pharmaceutical Association
American Podiatric Medical Association
American Public Health Association
American Red Cross
American Society of Health-System Pharmacists
American Society of Hypertension
American Society of Nephrology
Association of Black Cardiologists
Citizens for Public Action on High Blood Pressure and Cholesterol, Inc.
Hypertension Education Foundation, Inc.
International Society on Hypertension in Blacks
National Black Nurses Association, Inc.
National Hypertension Association, Inc.
National Kidney Foundation, Inc.
National Medical Association
National Optometric Association
National Stroke Association
NHLBI Ad Hoc Committee on Minority Populations
Society for Nutrition Education
The Society of Geriatric Cardiology
Federal Agencies:
Agency for Healthcare Research and Quality
Centers for Medicare & Medicaid Services
Department of Veterans Affairs
Health Resources and Services Administration
National Center for Health Statistics
National Heart, Lung, and Blood Institute
National Institute of Diabetes and Digestive and Kidney Diseases
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SLIDE 4: JNC 7
- Express?Succinct evidence-based recommendations. Published in JAMA May 21, 2003, and as a Government Printing Office publication.
- Full Report?comprehensive justification and rationale (coming soon).
SLIDE 5: Purpose
Why JNC 7?
- Publication of many new studies.
- Need for a new, clear, and concise guideline useful for clinicians.
- Need to simplify the classification of BP.
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SLIDE 6: New Features and Key Messages
- 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.
SLIDE 7: New Features and Key Messages (Continued)
- Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
- Certain high-risk conditions are compelling indications for other drug classes.
- Most patients will require two or more antihypertensive drugs to achieve goal BP.
- If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.
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SLIDE 8: New Features and Key Messages (Continued)
- 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.
SLIDE 9: BP Measurement and Clinical Evaluation
- Classification of BP
- CVD Risk
- Benefits of Lowering BP
- BP Control Rates
- BP Measurement Techniques
- In-office
- Ambulatory BP Monitoring
- Self-measurement
- Patient Evaluation
- Laboratory Tests and Other Diagnostic Procedures
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SLIDE 10: Blood Pressure Classification
| BP Classification | SBP mmHg | DBP mmHg | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Prehypertension | 120?139 | or | 80?89 |
| Stage 1 Hypertension | 140?159 | or | 90?99 |
| Stage 2 Hypertension | [[nid:845 view_mode=custom_size width=13 height=14]]160 | or | [[nid:845 view_mode=custom_size width=13 height=14]]100 |
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SLIDE 11: CVD Risk
- HTN prevalence ~ 50 million people in the United States.
- The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.
- Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.
- Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.
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SLIDE 12: Benefits of Lowering BP
| Average Percent Reduction | |
|---|---|
| Stroke incidence | 35?40% |
| Myocardial infarction | 35?40% |
| Heart failure | 50% |
SLIDE 13: Benefits of Lowering BP
In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.
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SLIDE 14: BP Control Rates
Trends in awareness, treatment, and control of high blood pressure in adults ages 18?74
| Trends in awareness, treatment, and control of high blood pressure in adults ages 18?74 | ||||
|---|---|---|---|---|
| II 1976?80 |
II (Phase 1) 1988?91 |
II (Phase 2) 1991?94 |
1999?2000 | |
| Awareness | 51 | 73 | 68 | 70 |
| Treatment | 31 | 55 | 54 | 59 |
| Control | 10 | 29 | 27 | 34 |
SLIDE 15: BP Measurement Techniques
| Method | Brief Description |
|---|---|
| In-office | Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. |
| Ambulatory BP monitoring | Indicated for evaluation of ?white-coat? HTN. Absence of 10?20% BP decrease during sleep may indicate increased CVD risk. |
| Self-measurement | Provides information on response to therapy. May help improve adherence to therapy and evaluate ?white-coat? HTN. |
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SLIDE 16: Office BP Measurement
- Use auscultatory method with a properly calibrated and validated instrument.
- Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.
- Appropriate-sized cuff should be used to ensure accuracy.
- At least two measurements should be made.
- Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.
SLIDE 17: Ambulatory BP Monitoring
- ABPM is warranted for evaluation of ?white-coat? HTN in the absence of target organ injury.
- Ambulatory BP values are usually lower than clinic readings.
- Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.
- BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.
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SLIDE 18: Self-Measurement of BP
- Provides information on:
- Response to antihypertensive therapy
- Improving adherence with therapy
- Evaluating white-coat HTN
- Home measurement of >135/85 mmHg is generally considered to be hypertensive.
- Home measurement devices should be checked regularly.
SLIDE 19: Patient Evaluation
Evaluation of patients with documented HTN has three objectives:
- Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.
- Reveal identifiable causes of high BP.
- Assess the presence or absence of target organ damage and CVD.
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SLIDE 20: CVD Risk Factors
- Hypertension*
- Cigarette smoking
- Obesity* (BMI [[nid:845 view_mode=custom_size width=13 height=14]]30 kg/m2)
- 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.
SLIDE 21: Identifiable Causes of Hypertension
- 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
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SLIDE 22: Target Organ Damage
- Heart
- Left ventricular hypertrophy
- Angina or prior myocardial infarction
- Prior coronary revascularization
- Heart failure
- Brain
- Stroke or transient ischemic attack
- Chronic kidney disease
- Peripheral arterial disease
- Retinopathy
SLIDE 23: Laboratory Tests
- Routine Tests
- Electrocardiogram
- Urinalysis
- Blood glucose, and hematocrit
- Serum potassium, creatinine, or the corresponding estimated GFR, and calcium
- Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides
- Optional tests
- Measurement of urinary albumin excretion or albumin/creatinine ratio
- More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
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SLIDE 24: TreatmentOverview
- Goals of therapy
- Lifestyle modification
- Pharmacologic treatment
- Algorithm for treatment of hypertension
- Classification and management of BP for adults
- Followup and monitoring
SLIDE 25: Goals of Therapy
- Reduce CVD and renal morbidity and mortality.
- Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
- Achieve SBP goal especially in persons [[nid:845 view_mode=custom_size width=13 height=14]]50 years of age.
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SLIDE 26: Lifestyle Modification
| Modification | Approximate SBP reduction(range) |
|---|---|
| Weight reduction | 5?20 mmHg/10 kg weight loss |
| Adopt DASH eating plan | 8?14 mmHg |
| Dietary sodium reduction | 2?8 mmHg |
| Physical activity | 4?9 mmHg |
| Moderation of alcohol consumption | 2?4 mmHg |
SLIDE 27: Algorithm for Treatment of Hypertension
| Initial drug therapy | |||||
|---|---|---|---|---|---|
| BP classification | SBP* mmHg | DBP* mHg | Lifestyle modification | Without compelling indication | With compelling indications |
| Normal | <120 | and <80 | Encourage | ||
| Prehypertension | 120?139 | or 80?89 | Yes | No antihypertensive drug indicated. | Drug(s) for compelling indications.*** |
| Stage 1 Hypertension | 140?159 | or 90?99 | Yes | Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. | Drug(s) for the compelling indications.*** Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
| Stage 2 Hypertension | [[nid:845 view_mode=custom_size width=13 height=14]]160 | or [[nid:845 view_mode=custom_size width=13 height=14]]100 | Yes | Two-drug combination for most** (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). | Drug(s) for the compelling indications.*** Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
*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.
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SLIDE 28: Classification and Management of BP for adults
| Initial drug therapy | |||||
|---|---|---|---|---|---|
| BP classification | SBP* mmHg | DBP* mHg | Lifestyle modification | Without compelling indication | With compelling indications |
| Normal | <120 | and <80 | Encourage | ||
| Prehypertension | 120?139 | or 80?89 | Yes | No antihypertensive drug indicated. | Drug(s) for compelling indications.*** |
| Stage 1 Hypertension | 140?159 | or 90?99 | Yes | Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. | Drug(s) for the compelling indications.*** Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
| Stage 2 Hypertension | [[nid:845 view_mode=custom_size width=13 height=14]]160 | or [[nid:845 view_mode=custom_size width=13 height=14]]100 | Yes | Two-drug combination for most** (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). | Drug(s) for the compelling indications.*** Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. |
*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.
SLIDE 29: Followup and Monitoring
- Patients should return for followup and adjustment of medications until the BP goal is reached.
- More frequent visits for stage 2 HTN or with complicating comorbid conditions.
- Serum potassium and creatinine monitored 1?2 times per year.
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SLIDE 30: Followup and Monitoring(continued)
- After BP at goal and stable, followup visits at 3- to 6-month intervals.
- Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.
SLIDE 31: Special Considerations
- Compelling Indications
- Other Special Situations
- Minority populations
- Obesity and the metabolic syndrome
- Left ventricular hypertrophy
- Peripheral arterial disease
- Hypertension in older persons
- Postural hypotension
- Dementia
- Hypertension in women
- Hypertension in children and adolescents
- Hypertension urgencies and emergencies
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SLIDE 32: Compelling Indications for Individual Drug Classes
| Compelling Indication | Initial Therapy Options | Clinical Trial Basis |
|---|---|---|
| Heart failure | THIAZ, BB, ACEI, ARB, ALDO ANT | ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES |
| Postmyocardialinfarction | BB, ACEI, ALDO ANT | ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS |
| High CAD risk | THIAZ, BB, ACE, CCB | ALLHAT, HOPE, ANBP2, LIFE, CONVINCE |
SLIDE 33: Compelling Indications for Individual Drug Classes
| Compelling Indication | Initial Therapy Options | Clinical Trial Basis |
|---|---|---|
| Diabetes | THIAZ, BB, ACE, ARB, CCB | NKF-ADA Guideline, UKPDS, ALLHAT |
| Chronic kidney disease | ACEI, ARB | NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK |
| Recurrent stroke prevention | THIAZ, ACEI | PROGRESS |
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SLIDE 34: Minority Populations
- In general, treatment similar for all demographic groups.
- Socioeconomic factors and lifestyle important barriers to BP control.
- Prevalence, severity of HTN increased in African Americans.
- African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs.
- These differences usually eliminated by adding adequate doses of a diuretic.
SLIDE 35: Left Ventricular Hypertrophy
- LVH is an independent risk factor that increases the risk of CVD.
- Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.
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SLIDE 36: Peripheral Arterial Disease(PAD)
- PAD is equivalent in risk to ischemic heart disease.
- Any class of drugs can be used in most PAD patients.
- Other risk factors should be managed aggressively.
- Aspirin should be used.
SLIDE 37: Hypertension in OlderPersons
- More than two-thirds of people over 65 have HTN.
- This population has the lowest rates of BP control.
- Treatment, including those who with isolated systolic HTN, should follow same principles outlined for general care of HTN.
- Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.
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SLIDE 38: Postural Hypotension
- Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs.
- BP in these individuals should be monitored in the upright position.
- Avoid volume depletion and excessively rapid dose titration of drugs.
SLIDE 39: Dementia
- Dementia and cognitive impairment occur more commonly in people with HTN.
- Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.
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SLIDE 40: Hypertension in Women
- Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.
- Development of HTN?consider other forms of contraception.
- Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.
SLIDE 41: Children and Adolescents
- HTN defined as BP?95th percentile or greater, adjusted for age, height, and gender.
- Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications.
- Drug choices similar in children and adults, but effective doses are often smaller.
- Uncomplicated HTN not a reason to restrict physical activity.
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SLIDE 42: Hypertensive Urgencies and Emergencies
- Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy.
- Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.
SLIDE 43: Additional Considerations in Antihypertensive Drug Choices
Potential favorable effects
- Thiazide-type diuretics useful in slowing demineralization in osteoporosis.
- BBs useful in the treatment of atrial tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN.
- CCBs useful in Raynaud?s syndrome and certain arrhythmias.
- Alpha-blockers useful in prostatism.
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SLIDE 44: Additional Considerations in Antihypertensive Drug Choices
Potential unfavorable effects
- Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia.
- BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or third-degree heart block.
- ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.
- ACEIs should not be used in individuals with a history of angioedema.
- Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.
SLIDE 45: Improving Hypertension Control
- Adherence to regimens
- Resistant hypertension
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SLIDE 46: Strategies for Improving Adherence to Regimens
- Clinician empathy increases patient trust, motivation, and adherence to therapy.
- Physicians should consider their patients? cultural beliefs and individual attitudes in formulating therapy.
SLIDE 47: Causes of Resistant Hypertension
- Improper BP measurement
- Excess sodium intake
- Inadequate diuretic therapy
- Medication
- Inadequate doses
- Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
- Over-the-counter (OTC) drugs and herbal supplements
- Excess alcohol intake
- Identifiable causes of HTN
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SLIDE 48: Public Health Challenges and Community Programs
- Public health approaches (e.g. reducing calories, saturated fat, and salt in processed foods and increasing community/school opportunities for physical activity) can achieve a downward shift in the distribution of a population?s BP, thus potentially reducing morbidity, mortality, and the lifetime risk of an individual?s becoming hypertensive.
- These public health approaches can provide an attractive opportunity to interrupt and prevent the continuing costly cycle of managing HTN and its complications.
SLIDE 49: Population-Based Strategy
SBP Distributions
| % Reduction in Mortality | |||
|---|---|---|---|
| Reduction in SBP mmHg | Stroke | CHD | Total |
| 2 | ?6 | ?4 | ?3 |
| 3 | ?8 | ?5 | ?4 |
| 5 | ?14 | ?9 | ?7 |
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SLIDE 50: Supporting Materials
- Web site www.nhlbi.nih.gov/
- For patients and the general public
- ?Facts About the DASH Eating Plan? (Revised May 2003)
- ?Your Guide to Lowering Blood Pressure?
- For health professionals
- Reference Card
- Slide Show
SLIDE 51: Web sitewww.nhlbi.nih.gov/
- Photo of the JNC 7 Website.
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SLIDE 52: DASH Fact Sheet
- Photo of the DASH Fact Sheet.
SLIDE 53: Your Guide to Lowering Blood Pressure
- Photo of the Your Guide to Lowering Blood Pressure publication.
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SLIDE 54: Reference Card
- Photo of the Reference Card.
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Media Kit
- Press Release
- Conference Speakers Remarks
- Visual Aids
Increased Risk of Heart Disease Death Associated with Prehypertension and Hypertension by Decade of Life
Increased Risk of Stroke Death Associated with Prehypertension and Hypertension by Decade of Life
- Articles
- JAMA Article: — Early Release Article, posted May 14, 2003:
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
- Hypertension Article — Complete Report, Posted March 23, 2004:
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
- JAMA Article: — Early Release Article, posted May 14, 2003: