This is a presentation on JNC 7 guidelines.

1. Joint National Committe-7
Recommendations
Noel.M.Isaac

2. ABSTRACT
In 2003, the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
(JNC) issued its seventh report, which provided guidelines for
the diagnosis and management of this disease. Included in the
guidelines were: a new classification system for hypertension;
recommendations for lifestyle modifications; and recom-
mendations for pharmacologic therapy.

3. CHANGES IN BLOOD PRESSURE CLASSIFICATION
In the JNC 7 guidelines, the 7 categories of blood
Pressure(BP)
defined in JNC 6 were simplified and reduced to 4
categories-
• Normal blood pressure: SBP <120 mm Hg and
diastolic blood pressure (DBP) <80 mm Hg
• Prehypertension: These are patients on the cusp of
developing hypertension. It is defined as a SBP of
120-139 mm Hg or a DBP of 80-89 mm Hg
• Stage I hypertension: SBP 140-159 mm Hg or DBP
90-99 mm Hg
• Stage II hypertension: SBP ≥160 mm Hg or DBP
≥ 100 mm Hg

4. TREATMENT ALGORITHM FOR HYPERTENSION
 In the pre-hypertensive stage:
Lifestyle modifications alone are recommended
 Stage I hypertension:
Lifestyle modifications combined with single-
drug therapy(usually a thiazide-type diuretic) is
recommended.
 Stage II hypertension:
Lifestyle modifications are recommended,
but initial therapy is aggressive, and typically
includes a thiazide type diuretic in combination with
an ACE inhibitor ARB,CCB, or a beta-blocker.

5. LIFE STYLE MODIFICATION
• Weight Reduction
Maintaining a normal body mass index (18.5-24.9 kg/m2)
helps control blood pressure. In fact, SBP can be reduced between 5-
10 mm Hg for every 10 kg of body weight that is lost.
• Diet
The Dietary Approaches to Stop Hypertension (DASH)diet is a plan that
emphasizes eating fruits, vegetables, and low fat dairy products
while discouraging the consumption of saturated and total fats. It is associate
d with reductions in SBP ranging from 8-14 mm Hg, and can help reduce and
control weight and sodium intake.

6. LIFE STYLE MODIFICATION
• Dietary Sodium Intake
Current recommendation is to limit the sodium intake to less than 2.4g per
day which helps in the mean BP reduction by 5/2.7mm Hg.
• Regular physical activity
Regular physical activity must be done atleast 30 min/day or atleast 5 days a
week. This will help reduce the systolic blood pressure(SBP) by 9mm Hg
• Moderate alcohol consumption
JNC 7 defines 2 drinks as 24oz of beer, 10 oz of wine, and 3 oz of 80 proof
whisky. Consumption of 1-2 drinks per day decreases the SBP but greater
than 2 drinks may increase the SBP.

7. Class Drug Usual dose range, mg/day Usual daily frequency*
Diuretics
Loop diuretics Bumetanide
Furosemide
Torsemide
0.5-2
20-80
5-40
2
2
1
Potassium-sparing diuretics Amiloride
Triamterene
5-10
50-100
1-2
1-2
Thiazide and thiazide-like diuretics Chlorthalidone
Hydrochlorothiazide
Indapamide
Metolazone
12.5-25
12.5-50
1.25-2.5
0.5-5
1
1
1
1
ACE Inhibitors Benazepril
Captopril
Enalapril
Fosinopril
Lisinopril
Moexipril
Perindopril
Quinapril
Ramipril
Trandolapril
10-40
25-100
5-40
10-40
10-40
7.5-30
4-8
10-80
2.5-20
1-4
1
2-3
1-2
1
1
1
1
1-2
1
1
ARBs Candesartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan
8-32
150-300
25-100
20-40
20-80
80-320
1
1
1-2
1
1
1
COMMON ANTIHYPERTENSIVE MEDICATIONS AND RECOMMENDED DOSAGES:

8. Aldosterone receptor blockers Eplerenone
Spironolactone
50-100
25-50
1
1
Beta-blockers Atenolol
Bisoprolol
Metoprolol
Nadolol
Propranolol
Carvedilol
25-100
2.5-10
50-100
40-120
40-160
12.5-50
1-2
1
1-2
1
2
2
Calcium channel blockers
Dihydropyridine Amlodipine
Felodipine
Isradipine
Nifedipine (sustained released)
2.5-10
2.5-20
2.5-10
30-60
1
1
2
1-2
Nondihydropyridine Diltiazem (extended release)
Verapamil (ER)
180-420
120-360
1
1
Alpha-blockers Doxazosin
Prazosin
Terazosin
1-16
2-20
1-20
1
2-3
1
Direct vasodilators Hydralazine
Minoxidil
25-100
2.5-80
2-3
1-2

9. COMPELLING INDICATIONS
• Diabetes Mellitus
ACEI/ARBs reduces the risk of progression of DM, and its having reno-
protective activity. ACEI/ARBs can overt diabetic nephropathy and are
therefore considered to be the first line of therapy
Thiazide diuretics, β-blockers or CCBs can be used as an sequential add on
therapy for controlling the blood pressure.

10. • Chronic Kidney Disease
Initially presents with microalbuminuria-( 30-299mg of albumin in 24hr urine
culture)- which progresses over several years to kidney failure. ACEI/ ARBs
along with diuretics reduces this progression to complete renal failure and
hence used as a first line of therapy.
In case if
 The GFR is <60ml/min,
 Serum creatinine in females is greater than 1.3mg/dl or greater than
1.5mg/dl in men
 Albuminuria-( >300mg/day),
Then typically 3 or more anti hypertensive would be required.

11. • Acute Coronary Artery Disease
Includes: Unstable angina,
Non-ST segment elevated MI
ST- segment elevated MI
β-blockers decreases the risk of Subsequent MI/ Sudden cardiac
death, therefore considered as first line of therapy.
If there is any presence of AWMI, LVD, or any other condition where BP
lowering is needed then ACEI/ARBs can be given.

12. • Chronic Coronary Artery Disease
Includes: Post MI
Chronic stable angina
Core regimen= β-blockers + ACEI
ACEI improves cardiac functions and reduces the risk of CV events

13. • Add on’s:
 Thiazide diuretics, for additional BP reduction
 Dihydropyridine CCBs, for treating ischemic symptoms for those with
chronic stable angina
 Non Dihydopyridine CCBs, for to those whom β-blockers cant be used

14. • Stroke
ACEI and Thiazide diuretic can reduce the recurrence of stroke in patient
who have had stroke and therefore considered the first line of therapy

15. • Left Ventricular Dysfunction
ACEI has been found to reduce morbidity and mortality rates in LVD cases
Diuretics is used for the symptomatic treatment of edema
β-blockers has been found to reduce morbidity and mortality rates when
added with ACEI and a Diuretic.
 Standard first line: ACEI + β-blockers + Diuretics.
However only metoprolol, carvedilol and bisoprolol should be used
Add on’s: Aldosterone antagonist.

16. Compelling
indication
Diuretic Beta-
blockers
ACE
inhibitors
ARBs CCB Aldosterone
blockers
Clinical trial supporting
Heart Failure
• • • • • ACC/AHA Heart Failure
Guidelines, COPERNICUS,
SOLVD,ValHEFT, CHARM,
RALES
Post-MI
• • • • ACC/AHA Post MI Guidelines,
Capricorn, SAVE,VALIANT,
EPHESUS
High Coronary
Risk
• • • • • ALLHAT, HOPE, LIFE, EUROPA,
ONTARGET
Chronic Kidney
Disease
• • • NKF HTN Guidelines, REIN,
ROAD, RENAAL
Stroke
• • • ALLHAT, PROGRESS, MOSES,
LIFE
Diabetes
• • IRMA-2, Micro-HOPE
Elderly
• • SHEP, Sys-EURO
CLINICAL TRIAL AND GUIDELINE BASIS FOR COMPELLING INDICATIONS FOR INDIVIDUAL DRUG
CLASSES

17. CONCLUSION
Hypertension is among the most commonly encountered
disorders in the ambulatory setting. The guidelines from the
JNC 7 are practical and easily applied to hypertensive patients.
Compliance with the guidelines will result in improved patient
outcomes.