Classification and Management of Essential Hypertension for Adults
The following table illustrates the JNC 7 recommendations for the initial management of essential hypertension based on the patient’s stage of hypertension and for certain indications.
| Classification and Management of BP for adults | |||||
|---|---|---|---|---|---|
BP Classification |
SBP* (mm Hg) |
DBP* (mm Hg) |
Lifestyle Modifications |
Initial Drug Therapy |
|
Without Compelling Indications |
With Compelling Indications |
||||
Normal |
<120 |
and <80 |
Encourage |
||
Prehypertension (Normal) |
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.^ |
Stage 2 Hypertension |
>160 |
or >100 |
Yes |
Two-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. |
|
*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. |
|||||
Classification and Management of Essential Hypertension for Adults – Lifestyle Modifications
“Adoption of healthy lifestyles by all persons is critical for the prevention of high blood pressure and is an indispensable part of the management of those with hypertension.” – JNC 7 Report on Hypertension, 2003
Lifestyle modifications achieve what objectives? Please take a moment to reflect and consider this question. There are many possible answers.
- Reduce blood pressure
- Enhance anti-hypertensive drug efficacy
- Decrease cardiovascular risks
Lifestyle modifications directly contribute blood pressure reduction:
| Lifestyle modifications directly contribute blood pressure reduction: | |
|---|---|
Lifestyle modification |
Approximate systolic BP reduction range |
Weight Reduction |
5–20 mmHg/10 kg weight loss |
DASH eating plan |
8–14 mmHg |
Dietary Sodium Reduction |
2–8 mmHg |
Physical Activity |
4–9 mmHg |
Moderation of Alcohol Consumption |
2–4 mmHg |
FYI | Specific Recommendations Regarding Lifestyle Modifications
Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2).
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat.
Dietary sodium reduction Reduce dietary sodium intake to no more than 100
mmol per day (2.4 g sodium or 6 g sodium chloride).
Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).
Moderation of alcohol consumption Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight personsThere is more information regarding the DASH eating plan and other exercise and nutrition information in “the library”.
Resources | Nutrition and Exercise Handouts for Patients
Nutrition and Exercise: Healthy Balance for a Health Heart (English and Spanish)
www.Familydoctor.org (American Academy of Family Physicians)
Spice Up Your Life! Eat Less Salt and Sodium (National Heart, Lung, Blood Institute PDF Link)
Your Guide to Lowering Blood Pressure (National Heart, Lung, and Blood Institute PDF Link)
Classification and Management of Essential Hypertension – Drug Therapy for Adults Without Compelling Indications
The initial drug of choice for hypertensive adults without any other compelling indications is the following:
| Classification and Management of BP for adults | |||||
|---|---|---|---|---|---|
BP Classification |
SBP* (mm Hg) |
DBP* (mm Hg) |
Lifestyle Modifications |
Initial Drug Therapy |
|
Without Compelling Indications |
With Compelling Indications |
||||
Normal |
<120 |
and <80 |
Encourage |
||
Prehypertension (Normal) |
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.^ |
Stage 2 Hypertension |
>160 |
or >100 |
Yes |
Two-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. |
| *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. |
|||||
Initial Drug Therapy Without Compelling Indications
Normal and Prehypertension
Normal and prehypertension patients require no medications but lifestyle modifications are encouraged.
Stage 1 Hypertension
For Stage 1 hypertension patients, the first line agent of choice for most is thiazide-type diuretics. Thiazide diuretics:
- have been found have the best reduction in morbidity and mortality in regards to hypertension
- have known benefits and side effect profiles with >70 years of data
- are extremely inexpensive drugs (estimated cost is $5 for a 30 day supply)
If the thiazide diuretic does not optimize the blood pressure, you should continue the thiazide but add another agent from the following classes of antihypertensives: ACE inhibitor, ARBs, beta blockers, or calcium channel blockers. They have all been found to work synergistically with the thiazide diuretic to reduce blood pressure and all have data demonstrating equivalent reduction of morbidity and mortality.
Stage 2 Hypertension
Stage 2 hypertensive patients are rarely controlled on one medication alone. Because of significant evidence, most will require two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). The combination drugs (example: atenolol – hydrochlorothiazide; lisinopril – hydrochlorothiazide, etc.) also reduce pill burden for patients.
Special caution must be exercised in initial combined therapy in those at risk for orthostatic hypotension such as the elderly, diabetic patients, and patients with autonomic dysfunctions (ex. paraplegic patients).
Some providers are reluctant to start combination medications in Stage 2 hypertension patients. If there is a negative side effect, there may be difficulty in pinpointing which is the offending agent in a combination medication. The JNC 7 treatment algorithm is a suggested management guide but should not replace individual clinical judgment or patient preference.
Classification and Management of Essential Hypertension – Drug Therapy for Adults With Compelling Indications
| Classification and Management of BP for adults | |||||
|---|---|---|---|---|---|
BP Classification |
SBP* (mm Hg) |
DBP* (mm Hg) |
Lifestyle Modifications |
Initial Drug Therapy |
|
Without Compelling Indications |
With Compelling Indications |
||||
Normal |
<120 |
and <80 |
Encourage |
||
Prehypertension (Normal) |
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.^ |
Stage 2 Hypertension |
>160 |
or >100 |
Yes |
Two-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. |
| *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. |
|||||
What are the compelling indications? Please take a moment to reflect and consider this question. There are several possible answers.
Congestive heart failure, post myocardial infarction, high coronary artery disease risk, diabetes, chronic renal disease, and recurrent stroke prevention.
The initial drugs of choice for hypertensive adults with specific compelling indications is the following:
| 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 |
Postmyocardial infarction |
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 |
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 |
CHF
Diuretics reduce heart failure; beta blockers reduce cardiac work demand; and ACE inhibitors and ARBs reduce afterload. Low dose aldosterone antagonists reduce morbidity and mortality in CHF but these agents should not be titrated to higher levels (as other BP medications) as they may be associated with negative outcomes.
Diabetes and Renal Disease
ACE inhibitors and ARBs are renal protective in addition to lowering blood pressure which makes these agents ideal first line choices for these conditions. Beta blockers in diabetics, contrary to common teachings, do not mask hypoglycemia and are actually excellent reducers of morbidity and mortality.
What is Prehypertension?
What is prehypertension? (Choose the one best answer)
The correct answer is E. - All of the statements are true. “Because of new data on lifetime risk of hypertension and the impressive increase in the risk of cardiovascular complications associated with levels of BP previously considered to be normal, the JNC 7 report has introduced a new classification that includes the term ‘prehypertension’ “ (JNC 7 Report, 2003). The diagnosis of prehypertension is confirmed when an average of two or more blood pressure measurements on separate visits, or equivalent home blood pressures, reveal a DBP of 80-89 mm Hg or SBP of 120-139 mm Hg. These BP ranges are still considered normal and prehypertension is not a disease category. Prehypertension is a designation chosen to identify individuals at high risk of developing hypertension (50% of prehypertensive patients will eventually develop hypertension). Individuals who are prehypertensive are notcandidates for drug therapy based on their level of BP and should be strongly encouraged to practice lifestyle modification in order to reduce their risk of developing future hypertension. Moreover, individuals with prehypertension, who also have diabetes or kidney disease, should be considered candidates for appropriate drug therapy if a trial of lifestyle modification fails to reduce their BP to 130/80mmHg or less.
FYI | Prehypertension
Vasan RS, Larson MG, Leip EP, Evans JC, O’Donnell CJ, Kannel WB, et al. Impact of high normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7.
Lizka et al. Prehypertension and Cardiovascular Morbidity
Ann Fam Med 2005;3:294-299