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JNC VII
Diagnostic Workup
Assess risk factors and comorbidities
Reveal identifiable causes of hypertension
Assess presence of target organ damage
Conduct history and physical examination
Obtain laboratory tests: urinalysis, blood
glucose, hematocrit and lipid panel, serum
potassium, creatinine, and calcium
Optional: urinary albumin/creatinine ratio
Obtain electrocardiogram
JNC VII
Assess for Major Cardiovascular
Disease (CVD) Risk Factors
Hypertension
Obesity (body mass index >30 kg/m2)
Dyslipidemia
Diabetes mellitus
Cigarette smoking
Physical inactivity
Microalbuminuria, estimated GFR <60 mL/min
Age (>55 for men, >65 for women)
Family history of premature CVD (men age <55,
women age <65)
JNC VII
Assess for Identifiable Causes of
Hypertension
Sleep apnea
Drug induced/related
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Cushings syndrome or steroid therapy
Pheochromocytoma
Coarctation of aorta
Thyroid/parathyroid disease
JNC VII
Blood Pressure Measurement
Techniques
Method Notes
In-office Two readings, 5 minutes apart, sitting in
chair.
Confirm elevated reading in contralateral
arm.
Ambulatory BP Indicated for evaluation of white coat
monitoring hypertension.
Absence of 1020 percent BP decrease
during sleep may indicate increased CVD risk
Patient self- Provides information on response to therapy.
check May help improve adherence to therapy and
is useful for evaluating white coat
hypertension. JNC VII
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 hypertension (see reverse side)
JNC VII
Compelling indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options
Heart failure THIAZ, BB, ACEI, ARB, ALDO
ANT
Post myocardial BB, ACEI, ALDO ANT
infarction
High CVD risk THIAZ, BB, ACEI, CCB
Diabetes THIAZ, BB, ACEI, ARB, CCB
Chronic kidney disease ACEI, ARB
Recurrent stroke THIAZ, ACEI
prevention
THIAZ = thiazide diuretic, ACEI= angiotensin converting enzyme inhibitor, ARB =
angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker,
ALDO ANT = aldosterone antagonist
JNC VII
Strategies for Improving Adherence
to Therapy
JNC VII
Principles of Hypertension
Treatment
JNC VII
Algorithm for Treatment of
Hypertension
Lifestyle Modifications
Not at Goal
Blood Pressure
JNC VII
Lifestyle Modification
Recommendations
Avg. SBP
Modification Recommendation Reduction
Range
Weight Maintain normal body weight (body mass 520 mmHg/10
reduction index 18.524.9 kg/m2) kg
Adopt a diet rich in fruits, vegetables, and
DASH eating lowfat dairy 814 mmHg
plan products with reduced content of saturated
and total fat
Dietary
Reduce dietary sodium intake to <100 mmol 28 mmHg
sodium
per day (2.4 g sodium or 6 g sodium chloride)
reduction
Aerobic Regular aerobic physical activity (e.g., brisk
49 mmHg
physical walking) at least 30 minutes per day, most
activity days of the week
*Moderation Men:
1 drink = 1/2 oz or limit
15 mL to <2
ethanol drinks*
(e.g., 12 ozper day.
beer, 5 oz wine, 1.5 oz 80-proof whiskey).
24 mmHg
of alcohol
Effects Women
are dose and and lighterDASH
time dependent. weight persons:
= Dietary limit to to Stop Hypertension.
Approaches
consumption <1 drink* per day JNC VII
Hypertension Associated
Cardiovascular Problems/Conditions
JNC VII
Definition :Left Ventricular
Hypertrophy (LVH)
r P T
LV Wall stress
Obstructive epicardial
coronary artery disease
J Clin Hypertens (Greenwich). 2005;7(4):231-238.
Diagnosis :Left Ventricular
Hypertrophy (LVH)
Every year:
> 4 million patients are admitted
with unstable angina and acute MI
> 900,000 patients undergo PTCA
with or without stent
Pathophysiology
Phase 4 Phase 4
Phase 1 Phase 2 VI VI
Phase 5
Angina
No Symptoms Pectoris
Phase 3
VI
Myocardial Ischemia
Presentation
Silent ischemia
Exertion-induced angina
Unstable angina
Acute myocardial infarction
Patient Evaluation
Based on the patients
History / Physical examination
ECG
Unstable angina
Myocardial infarction
Patient Evaluation
History
Ischemic Symptoms Physical Exam
No ST-segment ST-segment
elevation elevation ECG
Acute
Unstable anginaNon-Q MI Q-Wave MI Reperfusion
Management of
Acute Coronary Syndromes (ACS)
Initial Treatment of ACS
STEMI* UA/NSTEMI
2. Hypertension
3. Dilated cardiomyopathy
Pathophysiology of Heart Failure
Neurohormonal and Cytokine Activation in Heart Failure
Vasoconstrictors Vasodilators
Angiotensin II Prostaglandin I2
Norepinephrine Prostaglandin E2
Endothelin BNP, ANP
Vasopressin Nitric Oxide
Natriuretic peptides Proinflammatory Cytokines
ANP, CNP TNF
BNP Interleukin-6
Interferon-
Other factors
? Interleukin-1 & 2
Aldosterone Soluble ILTR 1 & 2
Growth hormone
cortisol
Pathophysiology of Heart Failure
Effect of Sympathetic Activation in Heart Failure
CNS Sympathetic Outflow
Sympathetic Activity to
Cardiac Sympathetic Activity kidneys and vasculature
Disease Progression
Pathophysiology of Heart Failure
Neurohormonal Activation In Heart Failure: Angiotensin
II Effects
Direct Vasoconstriction
Increased Myocardial Contractility
Activation Of The Sympathetic Nervous System
Increase In Vasoconstrictors (Aldosterone,
Vasopressin, Endothelin-1)
Adverse Vascular Remodelling
Increased Myocyte Growth
Vascular Smooth Muscle Growth
Increased Collagen Production
Enhanced Platelet Aggregation Leading To
Thrombogenesis
Pathophysiology of Heart Failure
Deleterious Effects of Aldosterone in Heart Failure
Aldosteron
e
Pathophysiology of Heart Failure
ANP = atrial natriuretic peptide; BNP = B-type or brain natriuretic peptide; CNP = C-type natriuretic
peptide; RAAS = renin-angiotensin-aldosterone system, SNS = sympathetic nervous system
Pathophysiology of Heart Failure
Stages of Heart Failure
At Risk for Heart Failure:
STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
Heart Failure:
STAGE C Past or current symptoms of HF
STAGE D End-stage HF
Medical Management of Heart
Failure
Cardiovascular Medications Useful For Treatment Of Various Stages Of Heart Failure
ACE Inhibitors
Benazepril H - -
Captopril H, DN Post MI HF
Fosinopril H HF
Lisinopril Post MI HF
Moexipril H
Perindopril H, CV Risk
Quinapril H HF
Eprosartan H - -
Irbesartan H, DN - -
Losartan H, DN CV Risk -
Olmesartan H - -
Telmisartan H - -
Aldosterone Antagonists
Eplerenone H Post MI Post MI
Spironolactone H - HF
Medical Management of Heart Failure
Cardiovascular Medications Useful For Treatment Of Various Stages Of Heart Failure
Drug Stage A Stage B Stage C
Beta Blockers
Acebutolol H - -
Atenolol H Post MI -
Betaxolol H -
Bisoprolol H HF
Carteolol H -
Carvedilol H Post MI HF, Post MI
Labetalol H -
Metoprolol Succinate H HF
Metoprolol tartrate H Post MI -
Nadolol H -
Penbutolol H -
Pindolol H -
Propranolol H Post MI -
Timolol H Post MI -
Digoxin - - HF
CV Risk indicates reduction in future cardivascular events;DN, diabetic nephropathy;H, hypertension ; HF, heart failure; Asymptomatic
LVSD, Asymptomatic left ventricular systolic dysfunction; PostMI, reduction in heart failure or other cardiac events following myocardoal
infarction.
Medical Management of Heart Failure
Oral Diuretics Recommended For Use In The Treatment Of Fluid Retention In Chronic Heart Failure
Thiazide Diuretics
Chlorothiazide 250 to 500 mg once or twice 1000 mg 6 to 12 hours
Chlorthalidone 12.5 to 25 mg once 100 mg 24 to 72 hours
Hydrochlorothiazide 25 mg once or twice 200 mg 6 to 12 hours
Indapamide 2.5 once 5 mg 36 hours
Metolazone 2.5 mg once 20 mg 12 to 24 hours
Potassium-sparing diretics
Amiloride 5 mg once 20 mg 24 hours
Spironolactone 12.5 to 25 mg once 50 mg* 2 to 3 days
Triamterene 50 to 75 mg twice 200 mg 7 to 9 hours
Hypertension
Microalbuminuria HDL
cholesterol
Central
obesity Impaired Glucose Tolerance
Type 2 Diabetes
Diabetes Care 1998;21(2):310314.
Williams G, Pickup JC. Handbook of Diabetes. 2nd Edition, Blackwell Science. 1999.
The Metabolic Syndrome and
Associated CVD Risk Factors
Hypertension
Abdominal obesity
Atherosclerosi
Hyperinsulinaemia s
Insulin Diabetes
Resistance
Hypercoagulability
Dyslipidaemia Endothelial
high TGs Dysfunction
small dense LDL
low HDL-C
Insulin Resistance and
Atherosclerosis
Insulin resistance
Clinical diabetes
Accelerated atherosclerosis
Management of Metabolic
Syndrome
Lifestyle treatment
Weight control
Diet
Increased physical activity
(primary therapy for lowering risk factors
and reducing term risk for heart disease)
Treatment of Risk Factors
160
Glomerulonephritis Hypertension Diabetes
120
80
40
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
United States Renal Data System (USRDS) 2000
Annual Data Report WWW.USRDS.ORG
Pathophysiology of Nephropathy
Function Pathology
Proteinuria Glomerulosclerosis
ESRD
Clinical Manifestations of
Nephropathy
Seen when GFR 20 to 35% of normal
Urinary protein excretion > 4gm/day
Fluid retention
Weight gain, peripheral edema, CHF,
pulmonary edema
Uremia
Anorexia, nausea, vomiting, hiccups,
neuromuscular changes, anemia, renal
osteodystrophy
National Kidney Foundation
Algorithm for Achieving Target BP Goals in
Hypertensive Diabetic Patients
BP still not
Blood pressure Start ACE inhibitor
at goal
>130/80 mm Hg titrate upwards
(130/80 mm Hg)
Refer to a
clinical hypertension specialist
*If proteinuria present
(>300 mg per day) non-DHP preferred. Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661
Management of Risk Factors in
Hypertension and Chronic Renal
Disease
Maximal reduction of proteinuria
Dose titration of RAS inhibitors
Therapeutic combinations
Cardiovascular risk management
Reduce CV risk factors
Manage additional risk factors
Anemia
High plasma homocysteine
Thank You