Management of Hypertension according to JNC 7

BY SANDAR KYI, MD

Introduction

Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge.In the US: Forty-three million people are estimated to have hypertension

Introduction

Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population

Introduction

Generally, the higher the blood pressure, the greater the risk. Untreated hypertension affects all organ systems and can shorten one's life expectancy by 10 to 20 years.

Introduction

The question is, what are the barriers to the management of hypertension according to JNC 7?.

Hypothesis

It is a hypothesis that barriers to the effective management of patient with uncontrolled hypertension include patient management time constraints, physician practice patterns, drug adverse effects, and patient specific factors such as lack of adherence to therapy, limited access to care, financial barriers related to the cost of medications & lack of knowledge about the seriousness of uncontrolled hypertension.

Methods

Random chart reviews of 200 patients out of 500 charts those are following in FCC of RCRMC for hypertension from 2000-2006.Sex – F:M 157:43Race – Hispanic : Non-Hispanic

115 : 85 Smoker : Non Smoker - 58:142

Inclusion Criteria : pt with pre-hypertension, HTN stage 1,stage 2 according to JNC 7.

Methods

All charts were reviewed following factors: - Demographic factor: age, sex, culture

background, first language -co-morbidity: hypercholesterolemia, IHD,

diabetes outcome of BP treatment:

1. acute coronary event (CP, angina, MI,CHF, bypass surgery)2. stroke (TIA, CVA both ischemic and hemorrhagic)3. BP whether reached goal BP or not

JNC VII report recommendations

Initial therapy based on the JNC VII report recommendations is as follows: Prehypertension (systolic 120-139, diastolic 80-89): No antihypertensive drug is indicated. (f/up BP measure within 1 yr).Stage 1 hypertension (systolic 140-159, diastolic 90-99): Thiazide-type diuretics are recommended for most. ACE inhibitor, angiotensin II receptor blocker (ARB), beta-blocker, calcium channel blocker, or combination may be considered. Stage 2 hypertension (systolic more than 160, diastolic more than 100): Two-drug combination (usually thiazide-type diuretic and ACE inhibitor or ARB or beta-blocker or calcium channel blocker) is recommended for most. For the compelling indications, other antihypertensive drugs (eg, diuretics, ACE inhibitor, ARB, beta-blocker, calcium channel blocker) may be considered as needed.

JNC 7 Reference Card

JNC 7 Reference Card

Number of patients with HTN who f/up in FCC

Number of patients with HTN who did not reach goal BP

Complication in non-compliant patients

Complication in patient whose Dr not following JNC 7

Complication in patients who did not take med: due to SE

Complication in patients who reached goal BP

% of Acute Coronary Event Complication

Numbers of patients with co-morbidity

In pts who reached goal BP - 18 (25%)

In pts who were non-compliant – 34 (52%)

In pts who didn’t take med: due to SE – 10 (32%)

In pts whose Dr not following JNC 7- 15 (47%)

Numbers of patients with co-morbidity

Discussion

Thus, according to this study, patient non-compliant had been identified as one of the main reasons that BP therapy fails.

Drug adverse effects have also been identified as a factor related to physician prescribing pattern of hypertensive medications.

Discussion

Other findings seem to suggest that physicians are familiar with the JNC 7 guidelines for treating HTN but do not implement this knowledge into their everyday practice.

BP is one of the contributing factor to get complication but other co-morbidities (high cholesterol, DM ) can also contribute to complications.

Conclusion

This study clearly demonstrates that positive association between uncontrolled HTN & complication (such

as cardiovascular disease , CVA,).The finding of this study provide useful information for designing effective physician interventions for the management of patients with uncontrolled HTN.

Limitations of Research Study

Small sample sizes with 6yrs duration.

Didn’t review patient cultural background, educational status, BMI, smoking history details, control of diabetic, & control of hypercholesterolemia.

Also not mentioned Duration of Physician time spent with pt. Usage of language interpreter if pt doesn’t speak English as first language.

Recommendation

Further extensive study to include following factors:

patient cultural background, educational status, BMI, smoking history details, control of diabetic & control of hypercholesterolemia.

Duration of Physician time spent with pt. Usage of language interpreter if pt doesn’t speak English as first language.

ReferencesBarriers to Blood Pressure ControlG. Divakara Murthy Archives of Internal Medicine E-medicine HTNSat Sharma, MD, FRCPC, FACP, FCCP, DABSM, Program Director, Associate Professor, Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Manitoba; Site Director of Respiratory Medicine, St Boniface General Hospital The National High Blood Pressure Education Program

Thank you!