[Jnc 7 Guidelines For Hypertension Pdf Download
Ainoha Sistek
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This document summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in year 2000. The main topics addressed include the methodology of home blood pressure monitoring, its diagnostic and therapeutic thresholds, its clinical applications in hypertension, with specific reference to special populations, and its applications in research. The final section deals with the problems related to the implementation of these recommendations in clinical practice.
Hypertension represents a major modifiable risk factor for coronary artery disease (CAD), heart failure (HF), stroke, chronic kidney disease (CKD), and dementia.1 Two well-established clinical practice guidelines on hypertension include the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults and the recently published 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension.2,3 This analysis reviews key similarities and differences between these guidelines.
Both guidelines stress the importance of standardized, accurate measurement of blood pressure (BP) and recommend office-based measurements for diagnosis. Although both agree that validated, cuffed devices should be used for BP measurements, the ESH guidelines explicitly recommend against use of cuffless measurement devices. The ESH guidelines point to a lack of standardized validation protocols to test the accuracy of these devices and list concerns about the need for periodic calibration and use of novel predictive technologies to estimate BP.4,5 There is consensus that multiple office BP measurements and BP tracking with either home BP monitoring or ambulatory BP monitoring should be performed before diagnosing hypertension. Compared with the 2018 European Society of Cardiology (ESC)/ESH Guidelines for the Management of Arterial Hypertension, the 2023 ESH guidelines emphasize using out-of-office BP monitoring in addition to traditional in-office measurements to diagnose hypertension.6
Both guidelines recommend that initial therapies include at least one of four major classes: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), thiazide or thiazide-like diuretics, and calcium channel blockers (CCBs). The ESH guidelines continue to include beta-blockers (BBs) as an optional first-line therapy on the basis of randomized controlled trial evidence, whereas the ACC/AHA guideline does not. The guidelines both emphasize use of BBs for patients with a history of ischemic heart disease or HF. The ESH guidelines also recommend consideration of BBs in the treatment of other CV and non-CV conditions, such as atrial fibrillation, hypertension in pregnancy, and hyperthyroidism.9
Both guidelines recommend single-pill combination therapy to reduce pill burden and improve adherence. The ESH guidelines recommend the preferred combination of ACEIs or ARBs with either CCBs or thiazide/thiazide-like diuretics. Whereas the ESH guidelines strongly emphasize initial treatment with a two-drug combination for most patients with hypertension, the ACC/AHA guideline recommends this approach for patients with stage 2 hypertension, those with BP >20/10 mm Hg above their target BP, and Black patients.
The updated ESH guidelines now recommend consideration of renal denervation therapy as an additional or alternative therapy in patients who have uncontrolled resistant hypertension or adverse effects to medications, which is a change from the 2018 ESC/ESH guidelines.3
The 2023 ESH guidelines did not endorse major changes to their primary recommendations; however, the guidelines now align more closely with the 2017 ACC/AHA guideline. Although these guidelines represent a step toward guideline harmonization, key differences remain, including when to initiate therapy.
High blood pressure, also known as hypertension, can lead to serious health problems including heart attack or stroke. Measuring your blood pressure is the only way to know if you have it. Controlling high blood pressure can help prevent major health problems.
In hypertension Stage 1, your health care professional is likely to prescribe lifestyle changes. They may consider adding medication based on your risk of heart disease or stroke and should add medication if you have other conditions such as diabetes, heart failure and kidney disease.
A higher systolic or diastolic reading may be used to diagnose high blood pressure. But the systolic blood pressure tells more about risk factors for heart disease for people over 50. As people get older, their systolic blood pressure usually goes up because:
The 2013 joint European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines recommend that ambulatory blood-pressure monitoring (ABPM) be incorporated into the assessment of cardiovascular risk factors and hypertension. [155, 156]
No evidence was found for a single gold standard protocol for HBPM or ABPM. However, both may be used in conjunction with proper office measurement to make a diagnosis and guide management and treatment options.
Diagnosis based on 2 readings at 2 separate visits; For patients where diagnosis remains uncertain, home blood pressure monitoring (2-3 times a day for 7 days) or 24 hour ambulatory monitoring to confirm diagnosis
In 2017, the ACC/AHA updated their guidelines for the prevention, detection, evaluation, and management of high BP in adults by eliminating the classification of prehypertension and dividing it into two levels, as follows [1, 2] :
NOTE: A group was empaneled to write the Eighth Joint National Committee (JNC 8) guideline, but this effort was discontinued by the National Heart, Lung, and Blood Institute (NHLBI). A paper was published in The Journal of the American Medical Association in 2014 that is generally referred to as "JNC 8," but, officially, there are no JNC 8 guidelines sanctioned by the NHLBI, nor has JNC 8 been endorsed by the AHA, ACC, or many other organizations that endorsed JNC 7. This information is included here owing to the controversy surrounding and interest in the JNC 8.
It is also important to recognize that the SPRINT trial utilized an automatic oscillometric office BP method without human participation, which typically yields an SBP that is 7-10 mm Hg lower than the standard office-based BP used in most studies. [130] This suggests that the lower SBP target in the SPRINT trial may be closer to more moderate targets in other studies, and that stringent SBP targeting of 120 mm Hg in standard clinical practice may increase the rate of adverse events such as hypotension, electrolyte abnormalities, and acute kidney injury. [163, 165]
A large meta-analysis of hypertension studies that tested SBP targets (including the SPRINT trial) demonstrated a reduction in cardiovascular outcomes and overall mortality with an SBP target below 130 mm Hg, although the magnitude of the benefit decreased with BP goals progressively below 150 mm Hg. [166]
Many guidelines exist for the management of hypertension. Two of the most widely used recommendations are the JNC 7 [7] and annually updated guidelines from the American Diabetes Association (ADA). [86]
In 2013, both the JNC 8 and the updated joint guidelines from the European Society of Hypertension/European Society of Cardiology (ESH/ESC) were released. In 2014 and 2015, guidelines were issued by the following organizations:
In 2017, the ACC/AHA as well as the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released guidelines for the prevention, detection, evaluation, and management of high BP in adults [1] and the elderly, [82] respectively.
Orthostatic measurement of BP should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed.
For patients with an SBP >120 mm Hg or DBP >80 mm Hg, lifestyle intervention consists of weight loss if they have overweight or obesity; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern, including reduced sodium and increased potassium intake; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity.
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACEIs, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve BP targets (but not a combination of ACEIs and ARBs).
Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with SBP < 160 mm Hg, DBP < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy.
After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved glomerular filtration rate (GFR) and kidney survival.
Immediate lowering of SBP to lower than 140 mm Hg in adults with spontaneous intracerebral hemorrhage (ICH) who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful.
Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous (IV) tissue plasminogen activator (tPA) should have their BP slowly lowered to below 185/110 mm Hg before thrombolytic therapy is initiated.
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