Clinical Practice Guideline

Hypertension Evaluation and Treatment

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7) was released in May 2003. Premera has adopted the National Heart Lung and Blood Institute’s JNC 7
guideline. The Reference Card from the guideline is attached and the complete guideline text is available online at:
www.nhlbi.nih.gov/guidelines/hypertension/index.htm.

The key focus of JNC’s new guideline is to get patients accurately diagnosed, evaluated and on therapy in a reasonable
amount of time. The diagnosis of “Prehypertension” is characterized by a systolic blood pressure of 120-139 or a diastolic
presure of 80-89. Prehypertension is treated through early interventions. Encouraging life-style changes during this
prehypertensive period sets the stage for initiation of antihypertensive medication should the patient reach stage 1.

The guideline was reviewed and recommended for approval by Premera’s Clinical Quality Advisory Committee. The
Advisory Group’s composition reflects a variety of medical specialties as well as geographic regions served by Premera.
Premera’s Clinical Quality Improvement Committee approved this guideline for the release to participating providers.

Premera reviews and updates clincal practice guidelines at least every two years.

012095 (08-2005)
© 2005 Premera Blue Cross. All Rights Reserved.
This guideline is provided by Premera Blue Cross and Premera Blue Cross Blue Shield of Alaska—Independent Licensees of the Blue Cross Blue Shield Association.
Reference Card from the
Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7)
Evaluation Treatment
Classification of Blood Pressure (BP)* Principles of Hypertension Treatment
Category SBP mmHg DBP mmHg · Treat to BP < 140/90 mmHg or BP < 130/80 mmHg in patients
Normal <120 and <80 with diabetes or chronic kidney disease.
Prehypertension 120-139 or 80-89 · Majority of patients will require two medications to reach goal.
Hypertension, Stage 1 140-159 or 90-99 Algorithm for Treatment of Hypertension
Hypertension, Stage 2 ³160 or ³ 100
*See Blood Pressure Measurement Techniques (reverse side) Lifestyle Modification
Lifestyle Modifications
Key: SBP = systolic blood pressure DBP = diastolic blood pressure

Diagnostic Workup of Hypertension Not at Goal Blood Pressure (<140/90 mmHg)

· Assess risk factors and comorbidities. (<130/80 mmHg for patients with diabetes or chronic kidney disease)
· Reveal identifiable causes of hypertension. See Strategies for Improving Adherence to Therapy

· Assess presence of target organ damage.

· Conduct history and physical examination.
Initial
Initial Drug Choices
· Obtain laboratory tests: urinalysis, blood glucose, hematocrit Drug Choices

and lipid panel, serum potassium, creatinine and calcium.

Optional: urinary albumin/creatinine ratio. Without Compelling With Compelling
· Obtain electrocardiogram. Indications Indications

Assess for Major Cardiovascular Disease (CVD) Risk Factors

· Hypertension · Physical inactivity Stage 1 Hypertension Stage 2 Hypertension
Drug(s) for the
compelling indications
· Obesity (body mass index · Microalbuminuria, estimated (SBP 140-159 or DBP 90- (SBP >160 or DBP >100 See Compelling
³ 30 kg/m2) glomerular filtration rate 99 mmHg) mmHg Indications for Individual
· Dyslipidemia <60 mL/min Thiazide-type diuretics for 2-drug combination for
Drug Classes
· Diabetes Mellitus · Age (>55 for men, >65 for most. May consider ACEI, most (usually thiazide- Other antihypertensive
· Cigarette smoking women) ARB, BB, CCB or type diuretic and ACEI, or drugs (diuretics, ACEI,
· Family history of premature CVD combination. ARB, or BB of CCB). ARB, BB, CCB as
needed.
(men age <55, women age <65)
Assess for Identifiable Causes of Hypertension
· Sleep Apnea · Cushing’s syndrome or steriod Not
NotatatGoal
Goal Blood Pressure
Blood Pressure
· Drug induced/related therapy
· Chronic kidney disease · Pheochromocytoma Optimize dosages or add additonal drugs until goal blood pressure is achieved.
· Primary aldosteronism · Coarctation of aorta Consider consultation with hypertension specialist.
· Renovascular disease · Thyroid/parathyroid disease See Strategies for Improving Adherence to Therapy
Evaluation (cont.) Treatment (cont.)
Blood Pressure Measurement Techniques Principles of Lifestyle Modification
Method Notes · Enourage healthy lifestyles for all individuals.
In-office Two readings, 5 minutes apart, sitting in · Prescribe lifestyle modifications for all patients with
chair. Confirm elevated reading in prehypertension and hypertension.
contralateral arm. · Components of lifestyle modifications include weight reduction,
Ambulatory BP monitoring Indicated for evaluation of “white coat DASH eating plan, dietary sodium reduction, aerobic physical
hypertension.” Absence of 10-20 activity, and moderation of alcohol consumption.
percent BP decrease during sleep may
indicate increased CVD risk.
Lifestyle Modification Recommendations
Patient self-check Provides information on response to Modification Recommendation Avg. SBP Reduction Range=
therapy. May help improve adherence Weight Maintain normal body weight 5-20 mmHg/10 kg
to therapy and is useful for evaluating reduction (body mass index 18.5-24.9
kg/m2).
“white coat hypertension.”
Causes of Resistant Hypertension DASH eating Adopt a diet rich in fruits, 8-14 mmHg
· Improper BP measurement plan vegetables, and lowfat dairy
products with reduced content of
· Excess sodium intake saturated and total fat.
· Inadequate diuretic therapy
· Medication Dietary sodium Reduce dietary sodium intake to 2-8 mmHg
- Inadequate doses reduction £100 mmol per day (2.4 g sodium
- Drug actions and interactions (e.b., nonsteroidal or 6 g sodium chloride).
anti-inflammatory drugs (NSAIDs), illicit drugs,
sympathomimetics, oral contraceptives) Aerobic Regular aerobic physical activity 4-9 mmHg
physical (e.g., brisk walking) at least 30
- Over-the-counter (OTC) drugs and herbal supplements activity minutes per day, most days of the
· Excess alcohol intake week.
· Identifiable causes of hypertension (see reverse side)
Compelling Indications for Individual Drug Classes Moderation of Men: limit to £2 drinks* per day. 2-4 mmHg
alcohol Women and lighter weight
Compelling Indication Initial Therapy Options consumption persons: limit to £1 drink* per
· Heart failure THIAZ, BB, ACEI, ARB, ALDO ANT day.
· Post myocardial infarction BB, ACEI, ALDO ANT
· High CVD risk THIAZ, BB, ACEI, CCB *1 drink = ½ oz or 15 mL ethanol (e.g., 12 oz beer, 5 oz wine, 1.5 oz 80-proof whiskey).
· Diabetes THIAZ, BB, ACEI, ARB, CCB =Effects are dose and time dependent

· Chronic kidney disease ACEI, ARB The National High Blood Pressure Education Program is coordinated by the National Heart, Lung and
· Recurrent stroke prevention THIAZ, ACEI Blood Institute (NHLBI) at the National Institutes of Health. Copies of the JNC report are available on
the NHLBI Web site at www.nhlbi.nih.gov or from the NHLBI Health Information Center, P.O. Box
Key: THIAZ=thiazide diuretic, ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin 30105, Bethesda, MD 20824-0105; Phone: 301-592-8573 or 240-629-3255 (TTY); Fax: 301-592-8563.
receptor blocker, BB=beta blocker, CCB=calcium channel blocker, ALDO ANT-aldosterone antagonist
Source: U. S. Department of Health and Human Services; National Institutes of Health; National Heart,
Strategies for Improving Adherence to Therapy Lung and Blood Insatiate; National High Blood Pressure Education Program. NHLBI is not responsible
· Clinician empathy increases patient trust, motivation, and for any error in this document.

adherence to therapy.
· Physicians should consider their patients’ cultural beliefs and
individual attitudes in formulating therapy. To reorder, call 1-877-638-7827 012979 (02-2004)