National High Blood Pressure
Education Program
NIH Publication
No. 98-4080
November 1997
This set of slides is provided by the
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
Full text of JNC VI may be downloaded from the NHLBI web site.
National High Blood Pressure
Education Program
NIH Publication
No. 98-4080
November 1997
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National High Blood Pressure
Education Program
NIH Publication
No. 98-4080
November 1997
The Sixth Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure
(JNC VI)
Sixth Joint National Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure
Executive Committee:
Sheldon G. Sheps, M.D., Chair
Mayo Clinic and Mayo Foundation and Mayo Medical School
Henry R. Black, M.D., Chair of Chapter 1
Rush-Presbyterian-St. Luke’s Medical Center
Aram V. Chobanian, M.D.
Boston University
Jerome D. Cohen, M.D., Chair of Chapter 2
St. Louis University Health Sciences Center
Harriet P. Dustan, M.D.
University of Vermont College of Medicine
Norman M. Kaplan, M.D., Chair of Chapter 3
University of Texas Southwestern Medical
School
Ray W. Gifford, Jr., M.D.
Cleveland Clinic Foundation
Keith C. Ferdinand, M.D., Chair of Chapter 4
Heartbeats Life Center
Marvin Moser, M.D.
Yale University School of Medicine
slide 5
National High Blood Pressure Education
Program Coordinating Committee
Agency for Health Care Policy
and Research
American Academy of Family
Physicians
American Academy of Insurance
Medicine
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 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, Inc.
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
Association of Black Cardiologists
Citizens for Public Action on High
Blood Pressure and Cholesterol,
Inc.
Council on Geriatric Cardiology
Health Care Financing Administration
Health Resources and Services
Administration
International Society on Hypertension
in Blacks
National Black Nurses’ Association,
Inc.
National Center for Health Statistics,
Centers for Disease Control and
Prevention
National Heart, Lung, and Blood
Institute
National Hypertension Association
National Institute of Diabetes and
Digestive and Kidney Diseases
National Kidney Foundation
National Medical Association
National Optometric Association
National Stroke Association
NHLBI Ad Hoc Committee on Minority
Populations
Society for Nutrition Education
U.S. Department of Veterans’ Affairs
slide 6
JNC VI Table of Contents
1. Introduction
2. Blood Pressure Measurement and
Clinical Evaluation
3. Prevention and Treatment of High Blood
Pressure
4. Special Populations and Situations
slide 7
Purpose of the JNC VI Report
To use evidence-based medicine and
consensus to report on
contemporary approaches to
hypertension prevention and control
for use by primary care clinicians.
slide 8
Progress of the
National High Blood Pressure
Education Program
• Increased awareness, treatment, and
control
• Decreased morbidity and mortality from
stroke and coronary heart disease (CHD)
slide 9
Public Health Challenges for the
National High Blood Pressure
Education Program
• Prevent blood pressure rise with age
• Decrease prevalence
• Increase awareness and detection
• Improve control
• Reduce cardiovascular risks
slide 10
Public Health Challenges for the
National High Blood Pressure
Education Program (continued)
• Recognize importance of controlled
isolated systolic hypertension
• Recognize importance of high-normal
blood pressure
• Reduce demographic variations
• Improve opportunities for treatment
slide 11
Awareness, Treatment, and Control
of High Blood Pressure in Adults*
NHANES II
NHANES III
NHANES III
1976-80
(Phase 1)
1988-91
(Phase 2)
1991-94
Awareness
51%
73%
68.4%
Treatment
31%
55%
53.6%
Control**
10%
29%
27.4%
* Adults age 18 to 74 years with SBP 
140 mm Hg or DBP 
90 mm Hg or taking antihypertensive
medication.
** SBP < 140 mm Hg and DBP < 90 mm Hg.
slide 12
Percent Decline in Age-Adjusted*
Mortality Rates for Stroke by Sex and
Race: United States, 1972-94
0
White men
Percent decline
-10
White women
-20
Black men
-30
Black women
-40
-50
-60
-70
1970
1974
1978
1982
1986
1990
1994
Year
The decline in age-adjusted mortality for stroke in the total population is 59.0%.
*Age-adjusted to the 1940 U.S. census population.
slide 13
Percent Decline in Age-Adjusted*
Mortality Rates for CHD by Sex and
Race: United States, 1972-94
Percent decline
0
White men
-10
White women
-20
Black men
Black women
-30
-40
-50
-60
1970
1974
1978
1982
1986
1990
1994
Year
The decline in age-adjusted mortality for CHD in the total population is 53.2%.
*Age-adjusted to the 1940 U.S. census population.
slide 14
Rate per Million Population
Incidence of Reported End-Stage
Renal Disease Therapy, 1982-1995
253*
250
200
150
100
50
1983
1985
*Provisional data.
Adjusted for age, race, and sex.
1987
1989
1991
1993
1995
Year
slide 15
Prevalence of Heart Failure,
by Age, 1976-80 and 1988-91
10%
1988-91
8%
6%
4%
1976-80
2%
0%
30
35
45
55
65
75
80
Age (Years)
slide 16
Summary of Chapter 1
• Hypertension awareness, treatment, and control
rates have increased over the past 3 decades. The
rates of increase have lessened since JNC V.
• Age-adjusted mortality for stroke and CHD
declined during this time but now appear to be
leveling.
• The incidence of end-stage renal disease and the
prevalence of heart failure are increasing.
slide 17
Summary of Chapter 1
(continued)
• Randomized controlled trials provide the best
method of estimating benefit of treatment and
source of information for clinical policy, but
they have limitations.
• Prevention and treatment of hypertension and
target organ disease remain important public
health challenges that must be addressed.
slide 18
Blood Pressure Measurement
• Patients should be seated with back supported and arm
bared and supported.
• Patients should refrain from smoking or ingesting caffeine
for 30 minutes prior to measurement.
• Measurement should begin after at least 5 minutes of rest.
• Appropriate cuff size and calibrated equipment should be
used.
• Both SBP and DBP should be recorded.
• Two or more readings should be averaged.
slide 19
Advantages of Self-Measurement
•
•
•
•
•
Identifies “white-coat hypertension”
Assesses response to medication
Improves adherence to treatment
Potentially reduces costs
Usually provides lower readings than
those recorded in clinic (hypertension is
defined as SBP > 135 or DBP > 85 mm Hg)
slide 20
Ambulatory Measurement
• Ambulatory monitoring can provide:
– readings throughout day during usual activities
– readings during sleep to assess nocturnal
changes
– measures of SBP and DBP load
• Ambulatory readings are usually lower
than in clinic (hypertension is defined as
SBP > 135 or DBP > 85 mm Hg)
slide 21
Classification of Blood Pressure
for Adults
Category
SBP
(mm Hg)
DBP
(mm Hg)
Optimal
< 120
and
< 80
Normal
< 130
and
< 85
High-normal
130-139
or
85-89
Hypertension
Stage 1
Stage 2
Stage 3
140-159
160-179

 180
or
or
or
90-99
100-109
110
When SBP and DBP fall into different categories, use the higher category.
slide 22
Recommendations for Followup
Based on Initial Measurements
Initial Blood Pressure
SBP
DBP
Followup Recommended
< 130
< 85
Recheck in 2 years
130-139
85-89
Recheck in 1 year, give lifestyle advice
140-159
90-99
Confirm within 2 months, give lifestyle
advice
160-179
100-109
 180
 110
Evaluate/refer to care within 1 month
Evaluate/refer to care within 7 days
slide 23
Evaluation Objectives
• To identify known causes
• To assess presence or absence of target
organ damage and cardiovascular disease
• To identify other risk factors or disorders
that may guide treatment
slide 24
Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
• Optional tests
slide 25
Medical History
• Duration and classification of hypertension
• Patient history of cardiovascular disease
• Family history
• Symptoms suggesting causes of
hypertension
• Lifestyle factors
• Current and previous medications
slide 26
Physical Examination
• Blood pressure readings (2 or more)
• Verification in contralateral arm
• Height, weight, and waist circumference
• Funduscopic examination
• Examination of the neck, heart, lungs, abdomen,
and extremities
• Neurological assessment
slide 27
Laboratory Tests and Other
Diagnostic Procedures
• Determine presence of target organ
damage and other risk factors
• Seek specific causes of hypertension
slide 28
Laboratory Tests Recommended
Before Initiating Therapy
•Urinalysis
•Complete blood count
•Blood chemistry (potassium, sodium, creatinine,
and fasting glucose)
•Lipid profile (total cholesterol and HDL
cholesterol)
•12-lead electrocardiogram
slide 29
Optional Tests and Procedures
•Creatinine clearance
•Microalbuminuria
•24-hour urinary protein
•Serum calcium
•Serum uric acid
•Fasting triglycerides
•LDL cholesterol
•Glycosolated hemoglobin
•Thyroid-stimulating
hormone
•Plasma renin activity/
urinary sodium
determination
•Limited echocardiography
•Ultrasonography
•Measurement of ankle/arm
index
slide 30
Examples of Identifiable
Causes of Hypertension
• Renovascular disease
• Pheochromocytoma
• Renal parenchymal
disease
• Primary aldosteronism
• Polycystic kidneys
• Aortic coarctation
• Cushing syndrome
• Hyperparathyroidism
• Exogenous causes
slide 31
Components of Cardiovascular
Risk in Patients With Hypertension
Major Risk Factors:
• Smoking
• Dyslipidemia
• Diabetes mellitus
• Age older than 60 years
• Sex (men or postmenopausal women)
• Family history of cardiovascular disease
slide 32
Clinical Risk Factors for
Stratification of Patients With
Hypertension
• Heart diseases
• Stroke or transient ischemic attack
• Nephropathy
• Peripheral arterial disease
• Retinopathy
slide 33
Risk Stratification
Risk Group A
 No
risk factors
 No target organ disease/clinical cardiovascular disease


Risk Group B
 At
least one risk factor, not including diabetes
 No target organ disease/clinical cardiovascular disease


Risk Group C
 Target
organ disease/clinical cardiovascular disease
and/or diabetes
 With or without other risk factors

slide 34
Treatment Strategies and
Risk Stratification
Blood Pressure
Stages (mm Hg)
Risk Group A
Risk Group B
Risk Group C
High-normal
(130-139/85-89)
Lifestyle modification
Lifestyle modification
Drug therapy*
Lifestyle modification
Stage 1
(140-159/90-99)
Lifestyle modification
(up to 12 months)
Lifestyle modification
(up to 6 months)**
Drug therapy
Lifestyle modification
Stages 2 and 3
(
160/
100)
Drug therapy
Lifestyle modification
Drug therapy
Lifestyle modification
Drug therapy
Lifestyle modification
*For those with heart failure, renal insufficiency, or diabetes.
**For those with multiple risk factors, clinicians should consider drugs as initial therapy plus lifestyle modifications.
slide 35
Summary of Chapter 2
• Blood pressure classified as optimal, normal,
high-normal, or stages 1, 2, or 3.
• Recommendations for detection, confirmation,
and evaluation remain consistent with those in
the JNC V report.
• In self-monitoring and ambulatory measurement,
hypertension is now defined as SBP >135 mm Hg
and DBP  85 mm Hg.
slide 36
Summary of Chapter 2
(continued)
• New sections discuss genetics and clinical
clues to identifiable causes of hypertension.
• New tables list cardiovascular risk factors and
describe risk stratification.
slide 37
Primary Prevention
• Primary prevention offers an opportunity to interrupt
the costly cycle of managing hypertension.
• A population-wide approach can reduce morbidity
and mortality.
• Most patients with hypertension do not sufficiently
change their lifestyle or adhere to drug therapy
enough to achieve control.
• Blood pressure rise with age is not inevitable.
• Lifestyle modifications have been shown to lower
blood pressure.
slide 38
Goal of Hypertension
Prevention and Management
• To reduce morbidity and mortality by the least
intrusive means possible. This may be
accomplished by achieving and maintaining:
– SBP < 140 mm Hg
– DBP < 90 mm Hg
– controlling other cardiovascular risk factors
slide 39
Add agent from
different class
Substitute drug
from different class
Continue adding agents from other
classes. Consider referral to a
hypertension specialist.
Not at Goal Blood Pressure
Inadequate response
but well tolerated
No response or
troublesome side effects
Not at Goal Blood Pressure
Initial Drug Choices
Not at Goal Blood Pressure
Begin or Continue
Lifestyle Modifications
Algorithm forTreatment
of Hypertension
Algorithm for Treatment of
Hypertension (continued)
Begin or Continue Lifestyle Modifications
• Lose weight
• Limit alcohol
• Increase physical
activity
• Reduce Sodium
• Maintain potassium
• Maintain calcium and
magnesium
• Stop smoking
• Reduce saturated fat,
cholesterol
Not at Goal Blood Pressure
slide 41
Algorithm for Treatment of
Hypertension (continued)
Begin or Continue Lifestyle Modifications
Not at Goal Blood Pressure (< 140/90 mm Hg)
lower goals for patients with diabetes or renal disease
Initial Drug Choices
slide 42
Algorithm for Treatment of
Hypertension (continued)
Not at Goal Blood Pressure
Initial Drug Choices
Uncomplicated
Specific Indications
Compelling Indications
– Start at low dose and titrate upward.
– Low-dose combinations may be appropriate.
Not at Goal Blood Pressure
slide 43
Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices*
Uncomplicated
• Diuretics
• -blockers
*Based on randomized controlled trials.
slide 44
Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices*
Compelling Indications
• Heart failure
– ACE inhibitors
– Diuretics
• Myocardial infarction
 -blockers (non-ISA)
– ACE inhibitors (with systolic dysfunction)
• Diabetes mellitus (type 1) with proteinuria
– ACE inhibitors
• Isolated systolic hypertension (older persons)
– Diuretics preferred
– Long-acting dihydropyridine calcium antagonists
*Based on randomized controlled trials.
slide 45
Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices
Specific indications for the following drugs:
• ACE inhibitors
• --blockers
• Angiotensin II receptor
• -blockers
blockers
• -blockers
• Calcium antagonists
• Diuretics
slide 46
Specific Drug Indications
Some antihypertensive drugs may have
favorable effects on comorbid conditions:
• Angina
•Heart failure
– -blockers
–Carvedilol
– Calcium antagonists
–Losartan
• Atrial tachycardia and
fibrillation
– -blockers
•Myocardial infarction
–Diltiazem
–Verapamil
– Nondihydropyridine
calcium antagonists
slide 47
Specific Indications (continued)
Some antihypertensive drugs may have
favorable effects on comorbid conditions:
• Cyclosporine-induced
•Dyslipidemia
hypertension
-blockers
– Calcium antagonists
•Prostatism (benign prostatic
• Diabetes mellitus (1 and 2) hyperplasia)
with proteinuria
-blockers
– ACE inhibitors (preferred) •Renal insufficiency (caution in
– Calcium antagonists
renovascular hypertension and
creatinine  3 mg/dL
• Diabetes mellitus (type 2)
– Low-dose diuretics
[ 265.2 mol/L])
–ACE inhibitors
slide 48
Specific Indications (continued)
Some antihypertensive drugs may have
favorable effects on comorbid conditions:
• Essential tremor
– Noncardioselective -blockers
• Hyperthyroidism
– -blockers
• Migraine
•Osteoporosis
– Thiazides
•Perioperative
hypertension
– -blockers
– Noncardioselective -blockers
– Nondihydropyridine calcium
antagonists
slide 49
Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices
Not at Goal Blood Pressure (< 140/90 mm Hg)
No response or troublesome
side effects
Substitute another drug
from different class
Inadequate response but well
tolerated
Add second agent from
different class (diuretic if
not already used)
Not at Goal Blood Pressure (<140/90 mmHg)
slide 50
Algorithm for Treatment of
Hypertension (continued)
Substitute drug from
different class
Add second agent from
different class
Not at Goal Blood Pressure (< 140/90 mm Hg)
Continue adding agents from other classes.
Consider referral to a hypertension specialist.
slide 51
Add agent from
different class
Substitute drug
from different class
Continue adding agents from other
classes. Consider referral to a
hypertension specialist.
Not at Goal Blood Pressure
Inadequate response
but well tolerated
No response or
troublesome side effects
Not at Goal Blood Pressure
Initial Drug Choices
Not at Goal Blood Pressure
Begin or Continue
Lifestyle Modifications
Algorithm for Treatment
of Hypertension
Lifestyle Modifications
For Prevention and
Management
For Overall and
Cardiovascular Health
• Lose weight if overweight.
• Maintain adequate intake of
calcium and magnesium.
• Limit alcohol intake.
• Increase aerobic physical
activity.
• Reduce sodium intake.
• Stop smoking.
• Reduce dietary saturated fat
and cholesterol.
• Maintain adequate intake of
potassium.
slide 53
Pharmacologic Treatment
• Decreases cardiovascular morbidity
and mortality based on randomized
controlled trials.
• Protects against stroke, coronary
events, heart failure, progression of
renal disease, progression to more
severe hypertension, and all-cause
mortality.
slide 54
Special Considerations
in Selecting Drug Therapy
• Demographics
• Coexisting diseases and therapies
• Quality of life
• Physiological and biochemical measurements
• Drug interactions
• Economic considerations
slide 55
Drug Therapy
• A low dose of initial drug should be used,
slowly titrating upward.
• Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least 50%
of peak effect remaining at end of 24 hours.
• Combination therapies may provide additional
efficacy with fewer adverse effects.
slide 56
Classes of
Antihypertensive Drugs
• ACE inhibitors
•
•
•
•
•
Adrenergic inhibitors
Angiotensin II receptor blockers
Calcium antagonists
Direct vasodilators
Diuretics
slide 57
Combination Therapies
• -adrenergic blockers and diuretics
• ACE inhibitors and diuretics
• Angiotensin II receptor antagonists and
diuretics
• Calcium antagonists and ACE inhibitors
• Other combinations
slide 58
Followup
• Follow up within 1-2 months after initiating therapy.
• Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications.
• Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose.
• Consider reducing dose and number of agents after
1 year at or below goal.
slide 59
Causes for Inadequate
Response to Drug Therapy
•
•
•
•
•
•
Pseudoresistance
Nonadherence to therapy
Volume overload
Drug-related causes
Associated conditions
Identifiable causes of hypertension
slide 60
Guidelines for Improving
Adherence to Therapy
• Be aware of signs of nonadherence.
• Establish goal of therapy.
• Encourage a positive attitude about achieving goals.
• Educate patients about the disease and therapy.
• Maintain contact with patients.
• Encourage lifestyle modifications.
• Keep care inexpensive and simple.
slide 61
Guidelines for Improving
Adherence to Therapy (continued)
• Integrate therapy into daily routine.
• Prescribe long-acting drugs.
• Adjust therapy to minimize adverse affects.
• Continue to add drugs systematically to meet goal.
• Consider using nurse case management.
• Utilize other health professionals.
• Try a new approach if current regime is inadequate.
slide 62
Hypertensive Emergencies
and Urgencies
• Emergencies require immediate blood pressure
reduction to prevent or limit target organ damage.
• Urgencies benefit from reducing blood pressure
within a few hours.
• Elevated blood pressure alone rarely requires
emergency therapy.
• Fast-acting drugs are available.
slide 63
Drugs Available for
Hypertensive Emergencies
Vasodilators
Adrenergic Inhibitors
•Nitroprusside
•Labetalol
•Nicardipine
•Esmolol
•Fenoldopam
•Phentolamine
•Nitroglycerin
•Enalaprilat
•Hydralazine
slide 64
Summary of Chapter 3
• Modifying lifestyles in populations can have a major
protective effect against high blood pressure and
cardiovascular disease.
• Lowering blood pressure decreases death from stroke,
coronary events, and heart failure; slows progression of
renal failure; prevents progression to more severe
hypertension; and reduces all-cause mortality.
• A diuretic and/or a -blocker should be chosen as initial
therapy unless there are compelling or specific
indications for another drug.
slide 65
Summary of Chapter 3
(continued)
• Management strategies can improve adherence
through the use of multidisciplinary teams.
• The reductions in cardiovascular events
demonstrated in randomized controlled trials have
important implications for managed care
organizations.
• Management of hypertensive emergencies requires
immediate action whereas urgencies benefit from
reducing blood pressure within a few hours.
slide 66
Special Populations
• Racial and ethnic groups
• Children and adolescents
• Women
• Older persons
slide 67
Racial and Ethnic Groups
African Americans
Hispanics
Asian and Pacific Islanders
 Among the highest prevalence
 Early onset
 Delayed treatment

 Generally low prevalence
 Lowest control rate in Mexican Americans

 May be more responsive to treatment than
other groups
American Indians

 Similar prevalence to general population
 High prevalence of diabetes and obesity

slide 68
Children and Adolescents
• Blood pressure at 95th or higher percentile is
considered elevated.
• Lifestyle modifications should be recommended.
• Drug therapy should be prescribed for higher levels
of blood pressure.
• Attempts should be made to determine other causes
of high blood pressure and other cardiovascular risk
factors.
slide 69
95th Percentile of Blood Pressure by
Selected Ages and Height in Girls
SBP/DBP (mm Hg)
Age
50th Percentile for
Height
75th Percentile for
Height
1
104/58
105/59
6
111/73
112/73
12
123/80
124/81
17
129/84
130/85
slide 70
95th Percentile of Blood Pressure by
Selected Ages and Height in Boys
SBP/DBP (mm Hg)
Age
50th Percentile for
Height
75th Percentile for
Height
1
102/57
104/58
6
114/74
115/75
12
123/81
125/82
17
136/87
138/88
slide 71
Women
• Clinical trials have not demonstrated
significant differences between men and
women in treatment response and outcomes.
• Some women using oral contraceptives may
have significant increases in blood pressure.
• High blood pressure in not a contraindication
to hormone replacement therapy.
slide 72
Pregnant Women
• Chronic hypertension is high blood pressure present
before pregnancy or diagnosed before 20th week of
gestation.
• Preeclampsia is increased blood pressure that occurs
in pregnancy (generally after the 20th week) and is
accompanied by edema, proteinuria, or both.
• ACE inhibitors and angiotensin II receptor blockers
are contraindicated for pregnant women.
• Methyldopa is recommended for women diagnosed
during pregnancy.
slide 73
Antihypertensive Drugs
Used in Pregnancy
These agents* may be used with chronic hypertension
(DBP > 100 mm Hg) or acute hypertension (DBP > 105 mm Hg).
Central -agonists
Methyldopa is the drug of choice.
-blockers and
--blockers
Atenolol, metoprolol, and labetalol appear safe
and effective in late pregnancy.
Calcium antagonists
Potential synergism with magnesium sulfate may
lead to precipitous hypotension.
*Limited or no controlled trials in pregnant women.
slide 74
Antihypertensive Drugs
Used in Pregnancy (continued)
These agents* may be used with chronic hypertension (DBP > 100 mm Hg) or acute
hypertension (DBP > 105).
Diuretics
Diuretics are recommended for chronic hypertension if
prescribed before gestation, but they are not recommended
for preeclampsia.
Direct
vasodilators
Hydralazine is the parenteral drug of choice based on its long
history of safety and efficacy.
*Limited or no controlled trials in pregnant women.
ACE inhibitors and angiotensin II receptor blockers are contraindicated.
slide 75
Older Persons
• Hypertension is common.
• SBP is better predictor of events than DBP.
• Pseudohypertension and “white-coat hypertension”
may indicate need for readings outside office.
• Primary hypertension is most common cause, but
common identifiable causes (e.g., renovascular
hypertension) should be considered.
slide 76
Older Persons (continued)
• Therapy should begin with lifestyle
modifications.
• Starting doses for drug therapy should be lower
than those used in younger adults.
• Goal of therapy is the same (< 140/90 mm Hg)
although an interim goal of SBP < 160 mm Hg
may be necessary.
slide 77
Special Situations
• Cardiovascular
diseases
• Renal disease
• Diabetes mellitus
• Dyslipidemia
• Sleep apnea
• Bronchial asthma
• Gout
• Surgery
• Various chemical
agents
slide 78
Cardiovascular Diseases
• Cerebrovascular disease
– Indication for treatment, except immediately
after ischemic cerebral infarction
• Coronary artery disease
– Benefits of therapy well established
• Left ventricular hypertrophy
– Antihypertensive agents (except direct
vasodilators) indicated
– Reduced weight and decreased sodium intake
beneficial
slide 79
Cardiovascular Diseases (continued)
• Cardiac failure
– ACE inhibitors, especially with digoxin or
diuretics, shown to prevent subsequent heart
failure
• Peripheral arterial disease
– Limited or no data available
slide 80
Renal Disease
• Hypertension may result from renal disease that
reduces functioning nephrons.
• Evidence shows a clear relationship between high
blood pressure and end-stage renal disease.
• Blood pressure should be controlled to < 130/85
mm Hg or lower (< 125/75 mm Hg) in patients
with proteinuria in excess of 1 gram per 24 hours.
• ACE inhibitors work well to control blood pressure
and slow progression of renal failure.
slide 81
Diabetes Mellitus
• Drug therapy should begin along with lifestyle
modifications to reduce blood pressure to
< 130/85 mm Hg.
• ACE inhibitors, -blockers, calcium antagonists, and
low dose-diuretics are preferred.
• Insulin resistance or high peripheral insulin levels may
cause hypertension, which can be treated with lifestyle
changes, insulin-sensitizing agents, vasodilating
antihypertensive drugs, and lipid-lowering agents.
slide 82
Dyslipidemia
• Coexistence of hypertension and dyslipidemia
requires aggressive management.
• Emphasis should be on weight loss; reduced
intake of saturated fat, cholesterol, sodium, and
alcohol; and increased physical activity.
• Lifestyle changes and hypolipidemic agents
should be used to reach appropriate goals.
slide 83
Sleep Apnea
• Obstructive sleep apnea is more common
in patients with hypertension and is
associated with several adverse clinical
consequences.
• Improved hypertension control has been
reported following treatment of sleep
apnea.
slide 84
Bronchial Asthma or Chronic Airway
Disease
• Elevated blood pressure is common in acute
asthma and is possibly related to treatment with
systemic corticosteroids or -agonists.

-blockers and--blockers may exacerbate
asthma.
• ACE inhibitors only rarely induce bronchospasm.
• Over-the-counter medications are generally safe in
limited doses for patients on drug therapy.
slide 85
Gout
• Diuretics can increase serum uric acid
levels.
• Diuretics should be avoided in patients
with gout.
• Diuretic-induced hyperuricemia does
not require treatment in the absence of
gout or urate stones.
slide 86
Patients Undergoing Surgery
• When possible, surgery should be delayed
until blood pressure is < 180/110 mm Hg.
• Those not on prior drug therapy may be best
treated with cardioselective-blockers before
and after surgery.
• Those with controlled blood pressure should
continue medication until surgery and begin
as soon after surgery as possible.
slide 87
Cocaine and Amphetamines
• Cocaine abuse must be considered in patients
presenting to the emergency department with
hypertension-related problems.
• Nitroglycerin is indicated to reverse cocaine-related
coronary vasoconstriction.
• Acute amphetamine toxicity is similar to that of
cocaine but longer in duration.
• Ongoing cocaine abuse does not appear to cause
chronic hypertension.
slide 88
Immunosuppressive Agents
• Immunosuppressive regimens produce
widespread vasoconstriction in both transplant
and nontransplant situations.
• Treatment is based on vasodilation including
dihydropyridine calcium antagonists.
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Erythropoietin
• Erythropoietin often increases blood pressure
in treatment of patients with end-stage renal
disease.
• Management includes optimal volume control,
antihypertensive agents, and reducing
erythopoietin dose or changing method of
administration.
slide 90
Other Chemical Agents
That May Induce Hypertension
• Mineralocorticoids and derivatives
• Anabolic steroids
• Monoamine oxidase inhibitors
• Lead
• Cadmium
• Bromocriptine
slide 91
Summary of Chapter 4
• Racial and ethnic groups are growing segments of our
society. The prevalence of hypertension and control
rates differ across groups. Clinicians should be aware
of social and cultural factors when managing
hypertension.
• Guidelines are provided for management of children
and women with hypertension.
• In older persons, diuretics are preferred and long-acting
dihydropyridine calcium antagonists may be
considered.
slide 92
Summary of Chapter 4
(continued)
• Specific therapy for patients with left ventricular
hypertrophy, coronary artery disease, and heart
failure are outlined.
• Patients with renal insufficiency with greater than
1 g/day of proteinuria should be treated to a goal of
125/75 mm Hg; those with less proteinuria should be
treated to 130/85 mm Hg. ACE inhibitors have
additional renoprotective effects.
• Patients with diabetes should be treated to a therapy
goal of below 130/85 mm Hg.
slide 93
A Population-Wide Strategy
A population-wide strategy to reduce
overall blood pressure by only a few
mm Hg could affect overall
cardiovascular morbidity and mortality
as much as or more than treatment
alone.
slide 94