National High Blood Pressure Education Program
`
`Complete Report
`
`The Seventh Report
`of the Joint National
`Committee on
`Prevention,
`Detection,
`Evaluation, and
`Treatment of
`High Blood Pressure
`
`U . S . D E PA R T M E N T O F H E A LT H A N D H U M A N S E R V I C E S
`
`National Institutes of Health
`National Heart, Lung, and Blood Institute
`
`Human Power of N Company
`EX1056
`Page 1 of 104
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`Page 2 of 104
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`Complete Report
`
`The Seventh Report
`of the Joint National
`Committee on
`Prevention,
`Detection,
`Evaluation, and
`Treatment of
`High Blood Pressure
`
`This work was supported entirely by the
`National Heart, Lung, and Blood Institute.
`The Executive Committee, writing teams,
`and reviewers served as volunteers without
`remuneration.
`
`U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
`National Institutes of Health
`National Heart, Lung, and Blood Institute
`National High Blood Pressure Education Program
`
`NIH Publication No. 04-5230
`August 2004
`
`Page 3 of 104
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`

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`Page 4 of 104
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`Page 4 of 104
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`Chair
`Aram V. Chobanian, M.D. (Boston University
`School of Medicine, Boston, MA)
`
`Executive Committee
`George L. Bakris, M.D. (Rush University
`Medical Center, Chicago, IL); Henry R. Black,
`M.D. (Rush University Medical Center,
`Chicago, IL); William C. Cushman, M.D.
`(Veterans Affairs Medical Center, Memphis,
`TN); Lee A. Green, M.D., M.P.H. (University
`of Michigan, Ann Arbor, MI); Joseph L. Izzo,
`Jr., M.D. (State University of New York at
`Buffalo School of Medicine, Buffalo, NY);
`Daniel W. Jones, M.D. (University of Mississippi
`Medical Center, Jackson, MS); Barry J.
`Materson, M.D., M.B.A. (University of Miami,
`Miami, FL); Suzanne Oparil, M.D. (University
`of Alabama at Birmingham, Birmingham, AL);
`Jackson T. Wright, Jr., M.D., Ph.D. (Case
`Western Reserve University, Cleveland, OH)
`
`Executive Secretary
`Edward J. Roccella, Ph.D., M.P.H. (National
`Heart, Lung, and Blood Institute,
`Bethesda, MD)
`
`Financial Disclosures
`Dr. Chobanian has received honoraria for serving
`as a speaker from Monarch, Wyeth, Astra-
`Zeneca, Solvay, and Bristol-Myers Squibb.
`
`Dr. Bakris has received honoraria for serving as a
`speaker from Astra-Zeneca, Abbott, Alteon,
`Biovail, Boerhinger-Ingelheim, Bristol-Myers
`Squibb, Forest, GlaxoSmithKline, Merck,
`Novartis, Sanofi, Sankyo, and Solvay; he has
`received funding/grant support for research pro-
`jects from National Institutes of Health, Astra-
`Zeneca, Abbott, Alteon, Boerhinger-Ingelheim,
`Forest, GlaxoSmithKline, Merck, Novartis,
`Sankyo, and Solvay; he has served as a consul-
`tant/advisor for Astra-Zeneca, Abbott, Alteon,
`Biovail, Boerhinger-Ingelheim, Bristol-Myers
`Squibb, Forest, GlaxoSmithKline, Merck,
`Novartis, Sanofi, Sankyo, and Solvay.
`
`Dr. Black has received honoraria for serving as a
`speaker from Astra-Zeneca, Bristol-Myers Squibb,
`Novartis, Pfizer, Pharmacia, and Wyeth-Ayerst; he
`
`has received funding/grant support for research
`projects from Bristol-Myers Squibb, Boehringer-
`Ingelheim, Merck, Pfizer, and Pharmacia; he has
`served as a consultant/advisor for Abbott, Astra-
`Zeneca, Biovail, Bristol-Myers Squibb,
`GlaxoSmithKline, Merck, Pfizer, and Pharmacia.
`
`Dr. Carter has served as a consultant/advisor for
`Bristol-Myers Squibb.
`
`Dr. Cushman has received funding/grant support
`for research projects from Astra-Zeneca, Merck,
`Pfizer, Kos, Aventis Pharma, King
`Pharmaceuticals, GlaxoSmithKline, and
`Boehringer-Ingelheim; he has served as a consul-
`tant/advisor for Bristol-Myers Squibb, Sanofi,
`GlaxoSmithKline, Novartis, Pfizer, Solvay,
`Pharmacia, Takeda, Sankyo, Forest, and Biovail.
`
`Dr. Izzo has received honoraria for serving as a
`speaker from Boehringer-Ingelheim, Merck, Pfizer,
`Astra-Zeneca, Solvay, Novartis, Forest, and
`Sankyo; he has received funding/grant support for
`research projects from Boehringer-Ingelheim,
`Merck, Astra-Zeneca, Novartis, GlaxoSmithKline,
`and Biovail; he served as a consultant/advisor for
`Merck, Astra-Zeneca, Novartis, Intercure,
`Sankyo, and Nexcura; he has stock holdings in
`Intercure, Nexcura.
`
`Dr. Jones has served as a consultant/advisor for
`Pfizer, Bristol-Myers Squibb, Merck, Forest, and
`Novartis.
`
`Dr. Manger has served as a consultant/advisor for
`the NHBPEP Coordinating Committee.
`
`Dr. Materson has served as a consultant/advisor
`for Unimed, Merck, GlaxoSmithKline, Novartis,
`Reliant, Tanabe, Bristol-Myers Squibb, Pfizer,
`Pharmacia, Noven, Boehringer-Ingelheim, and
`Solvay.
`
`Dr. Oparil has received funding/grant support for
`research projects from Abbott Laboratories,
`Astra-Zeneca, Aventis, Boehringer-Ingelheim,
`Bristol-Myers Squibb, Eli Lilly, Forest,
`GlaxoSmithKline, Monarch, Novartis [Ciba],
`Merck, Pfizer, Sanofi/BioClin, Schering Plough,
`Schwarz Pharma, Scios Inc, GD Searle, Wyeth-
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
`
`iii
`
`Page 5 of 104
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`

`

`Ayerst, Sankyo, Solvay, and Texas Biotechnology
`Corporation; she has served as a consultant/advi-
`sor for Bristol-Myers Squibb, Merck, Pfizer,
`Sanofi, Novartis, The Salt Institute, and Wyeth-
`Ayerst; she is also on the Board of Directors for
`the Texas Biotechnology Corporation.
`
`Dr. Sowers has received honoraria for serving as a
`speaker from Med Com Vascular Biology
`Working Group and Joslin Clinic Foundation; he
`has received funding/grant support for research
`projects from Novartis and Astra-Zeneca.
`
`Dr. Wright has received honoraria for serving as a
`speaker from Astra, Aventis, Bayer, Bristol-Myers
`Squibb, Forest, Merck, Norvartis, Pfizer, Phoenix
`Pharmaceuticals, GlaxoSmithKline, and
`Solvay/Unimed; he has received funding/grant
`support for research projects from Astra, Aventis,
`Bayer, Biovail, Bristol-Myers Squibb, Forest,
`Merck, Norvartis, Pfizer, Phoenix
`Pharmaceuticals, GlaxoSmithKline, and
`Solvay/Unimed.
`
`National High Blood Pressure Education Program
`Coordinating Committee
`Claude Lenfant, M.D. (National Heart, Lung,
`and Blood Institute, Bethesda, MD); George L.
`Bakris, M.D. (Rush University Medical Center,
`Chicago, IL); Henry R. Black, M.D. (Rush
`University Medical Center, Chicago, IL);
`Vicki Burt, Sc.M., R.N. (National Center for
`Health Statistics, Hyattsville, MD); Barry L.
`Carter, Pharm.D., F.C.C.P. (University of Iowa,
`Iowa City, IA); Francis D. Chesley, Jr., M.D.
`(Agency for Healthcare Research and Quality,
`Rockville, MD); Jerome D. Cohen, M.D. (Saint
`Louis University School of Medicine, St. Louis,
`MO); Pamela J. Colman, D.P.M. (American
`Podiatric Medical Association, Bethesda, MD);
`William C. Cushman, M.D. (Veterans Affairs
`Medical Center, Memphis, TN); Mark J.
`Cziraky, Pharm.D., F.A.H.A. (Health Core, Inc.,
`Newark, DE); John J. Davis, P.A.-C. (American
`Academy of Physician Assistants, Memphis,
`TN); Keith Copelin Ferdinand, M.D., F.A.C.C.
`(Heartbeats Life Center, New Orleans, LA);
`Ray W. Gifford, Jr., M.D., M.S. (Cleveland
`Clinic Foundation, Fountain Hills, AZ);
`Michael Glick, D.M.D. (New Jersey Dental
`
`School, Newark, NJ); Lee A. Green, M.D.,
`M.P.H. (University of Michigan, Ann Arbor,
`MI); Stephen Havas, M.D., M.P.H., M.S.
`(University of Maryland School of Medicine,
`Baltimore, MD); Thomas H. Hostetter, M.D.
`(National Institutes of Diabetes and Digestive
`and Kidney Diseases, Bethesda, MD); Joseph L.
`Izzo, Jr., M.D. (State University of New York
`at Buffalo School of Medicine, Buffalo, NY);
`Daniel W. Jones, M.D. (University of Mississippi
`Medical Center, Jackson, MS); Lynn Kirby,
`R.N., N.P., C.O.H.N. (Sanofi-Synthelabo
`Research, Malvern, PA); Kathryn M. Kolasa,
`Ph.D., R.D., L.D.N. (Brody School of Medicine
`at East Carolina University, Greenville, NC);
`Stuart Linas, M.D. (University of Colorado
`Health Sciences Center, Denver, CO); William
`M. Manger, M.D., Ph.D. (New York University
`Medical Center, New York, NY); Edwin C.
`Marshall, O.D., M.S., M.P.H. (Indiana
`University School of Optometry, Bloomington,
`IN); Barry J. Materson, M.D., M.B.A.
`(University of Miami, Miami, FL); Jay
`Merchant, M.H.A. (Centers for Medicare &
`Medicaid Services, Washington, DC); Nancy
`Houston Miller, R.N., B.S.N. (Stanford
`University School of Medicine, Palo Alto, CA);
`Marvin Moser, M.D. (Yale University School of
`Medicine, Scarsdale, NY); William A. Nickey,
`D.O. (Philadelphia College of Osteopathic
`Medicine, Philadelphia, PA); Suzanne Oparil,
`M.D. (University of Alabama at Birmingham,
`Birmingham, AL); Otelio S. Randall, M.D.,
`F.A.C.C. (Howard University Hospital,
`Washington, DC); James W. Reed, M.D.,
`F.A.C.P., F.A.C.E. (Morehouse School of
`Medicine, Atlanta, GA); Edward J. Roccella,
`Ph.D., M.P.H. (National Heart, Lung, and
`Blood Institute, Bethesda, MD); Lee Shaughnessy
`(National Stroke Association, Englewood, CO);
`Sheldon G. Sheps, M.D. (Mayo Clinic,
`Rochester, MN); David B. Snyder, R.Ph., D.D.S.
`(Health Resources and Services Administration,
`Rockville, MD); James R. Sowers, M.D.,
`F.A.C.P., F.A.C.E. (SUNY Health Science Center
`at Brooklyn, Brooklyn, NY); Leonard M.
`Steiner, M.S., O.D. (Eye Group, Oakhurst, NJ);
`Ronald Stout, M.D., M.P.H. (Procter and
`Gamble, Mason, OH); Rita D. Strickland,
`Ed.D., R.N. (New York Institute of Technology,
`
`iv
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
`
`Page 6 of 104
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`

`Springfield Gardens, NY); Carlos Vallbona,
`M.D. (Baylor College of Medicine, Houston,
`TX); Howard S. Weiss, M.D., M.P.H.
`(Georgetown University Medical Center,
`Washington Hospital Center, Walter Reed Army
`Medical Center, Washington, DC); Jack P.
`Whisnant, M.D. (Mayo Clinic and Mayo
`Medical School, Rochester, MN); Laurie
`Willshire, M.P.H., R.N. (American Red Cross,
`Falls Church, VA); Gerald J. Wilson, M.A.,
`M.B.A. (Citizens for Public Action on Blood
`Pressure and Cholesterol, Inc., Potomac, MD);
`Mary Winston, Ed.D., R.D. (American Heart
`Association, Dallas, TX); Jackson T. Wright, Jr.,
`M.D., Ph.D. (Case Western Reserve University,
`Cleveland, OH)
`
`Additional Contributors
`Jan N. Basile, M.D., F.A.C.P. (Veterans
`Administration Hospital, Charleston, SC);
`James I. Cleeman, M.D. (National Heart,
`Lung, and Blood Institute, Bethesda, MD);
`Darla E. Danford, M.P.H, D.Sc. (National
`Heart, Lung, and Blood Institute, Bethesda,
`MD); Richard A. Dart, M.D., F.A.C.P., F.C.C.P.,
`F.A.H.A. (Marshfield Clinic, Marshfield, WI);
`Karen A. Donato, S.M., R.D. (National Heart,
`Lung, and Blood Institute, Bethesda, MD);
`Mark E. Dunlap, M.D. (Louis Stokes Cleveland
`VA Medical Center, Cleveland, OH); Brent M.
`Egan, M.D. (Medical University of South
`Carolina, Charleston, SC); William J. Elliott,
`M.D., Ph.D. (Rush University Medical Center,
`Chicago, IL); Bonita E. Falkner, M.D. (Thomas
`Jefferson University, Philadelphia, PA); John M.
`Flack, M.D., M.P.H. (Wayne State University
`School of Medicine, Detroit, MI); David Lee
`Gordon, M.D. (University of Miami School of
`Medicine, Miami, FL); Philip B. Gorelik, M.D.,
`M.P.H., F.A.C.P. (Rush Medical College,
`Chicago, IL); Mary M. Hand, M.S.P.H., R.N
`(National Heart, Lung, and Blood Institute,
`Bethesda, MD); Linda A. Hershey, M.D., Ph.D.
`(VA WNY Healthcare System, Buffalo, NY);
`Norman M. Kaplan, M.D. (University of Texas
`Southwestern Medical School at Dallas, Dallas,
`TX); Daniel Levy, M.D. (National Heart, Lung,
`and Blood Institute, Framingham, MA);
`James W. Lohr, M.D. (VA WNY Healthcare
`System and SUNY Buffalo, Buffalo, NY);
`
`Vasilios Papademetriou, M.D., F.A.C.P.,
`F.A.C.C. (Veterans Affairs Medical Center,
`Washington, DC); Thomas G. Pickering, M.D.,
`D.Phil. (Mount Sinai Medical Center, New
`York, NY); Ileana L. Piña, M.D., F.A.C.C.
`(University Hospitals of Cleveland, Cleveland,
`OH); L. Michael Prisant, M.D., F.A.C.C.,
`F.A.C.P. (Medical College of Georgia, Augusta,
`GA); Clive Rosendorff, M.D., Ph.D., F.R.C.P.
`(Veterans Affairs Medical Center, Bronx, NY);
`Virend K. Somers, M.D., Ph.D. (Mayo Clinic
`and Mayo Foundation, Rochester, MN); Ray
`Townsend, M.D. (University of Pennsylvania
`School of Medicine, Philadelphia, PA);
`Humberto Vidaillet, M.D. (Marshfield Clinic,
`Marshfield, WI); Donald G. Vidt, M.D.
`(Cleveland Clinic Foundation, Cleveland, OH);
`William White, M.D. (The University of
`Connecticut Health Center, Farmington, CT)
`
`Staff
`Joanne Karimbakas, M.S., R.D. (American
`Institutes for Research Health Program,
`Silver Spring, MD)
`
`We appreciate the assistance by: Carol Creech,
`M.I.L.S. and Gabrielle Gessner (American
`Institutes for Research Health Program,
`Silver Spring, MD).
`
`National High Blood Pressure Education Program
`Coordinating Committee Member Organizations
`American Academy of Family Physicians
`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
`Society of Internal Medicine
`American College of Preventive Medicine
`American Dental Association
`American Diabetes Association
`American Dietetic Association
`American Heart Association
`American Hospital Association
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
`
`v
`
`Page 7 of 104
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`

`

`American Medical Association
`American Nurses Association
`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
`American Society of Nephrology
`Association of Black Cardiologists
`Citizens for Public Action on High Blood
`Pressure and Cholesterol, Inc.
`Hypertension Education Foundation, Inc.
`International Society on Hypertension
`in Blacks
`National Black Nurses Association, Inc.
`National Hypertension Association, Inc.
`National Kidney Foundation, Inc.
`National Medical Association
`National Optometric Association
`National Stroke Association
`National Heart, Lung, and Blood Institute
`Ad Hoc Committee on Minority Populations
`Society for Nutrition Education
`The Society of Geriatric Cardiology
`
`Federal Agencies:
`Agency for Health Care Research and Quality
`Centers for Medicare & Medicaid Services
`Department of Veterans Affairs
`Health Resources and Services Administration
`National Center for Health Statistics
`National Heart, Lung, and Blood Institute
`National Institute of Diabetes and Digestive
`and Kidney Diseases
`
`vi
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
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`Page 8 of 104
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`C o n t e n t s
`
`Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
`
`Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
`
`Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
`
`Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
`
`Lifetime Risk of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
`
`Blood Pressure and Cardiovascular Risk. . . . . . . . . . . . . . . . . . . . . . . . . 9
`
`Basis for Reclassification of Blood Pressure . . . . . . . . . . . . . . . . . . . . . 11
`
`Classification of Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
`Cardiovascular Disease Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
`Importance of Systolic Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . 14
`
`Prevention of Hypertension: Public Health Challenges . . . . . . . . . . . . 16
`Community Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
`Calibration, Maintenance, and Use of Blood Pressure Devices. . . . . . 18
`Accurate Blood Pressure Measurement in the Office. . . . . . . . . . . . . . . 18
`Ambulatory Blood Pressure Monitoring. . . . . . . . . . . . . . . . . . . . . . . . 19
`Self-Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
`Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
`Laboratory Tests and Other Diagnostic Procedures . . . . . . . . . . . . . . . 21
`Identifiable Causes of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
`
`Genetics of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
`
`Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
`Blood Pressure Control Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
`Goals of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
`Benefits of Lowering Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . 25
`Lifestyle Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
`Pharmacologic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
`Rationale for Recommendation of Thiazide-Type Diuretics
`as Preferred Initial Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
`Achieving Blood Pressure Control in Individual Patients. . . . . . . . . . . . 30
`Followup and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
`Special Situations in Hypertension Management . . . . . . . . . . . . . . . . 33
`Compelling Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
`Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
`Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
`Diabetes and Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
`Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
`Patients With Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . 38
`Other Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
`Minorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
`Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
`
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`

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`Prevelance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
`Age Trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
`Clinical Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
`Clinical Management of the Metabolic Syndrome . . . . . . . . . . . . . . 41
`Lipids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
`Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
`Left Ventricular Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
`Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
`Hypertension in Older People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
`Orthostatic Hypotension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
`Resistant Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
`Cognitive Function and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . 47
`Hypertension in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
`Hypertension in Children and Adolescents. . . . . . . . . . . . . . . . . . . . 53
`Hypertensive Crises: Emergencies and Urgencies . . . . . . . . . . . . . . . 54
`Erectile Dysfunction and Hypertension . . . . . . . . . . . . . . . . . . . . . . 54
`Urinary Outflow Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
`Patients Undergoing Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
`Dental Issues in Hypertensive Individuals . . . . . . . . . . . . . . . . . . . . 56
`Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
`Hypertension and the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
`Renal Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
`Patients With Renovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . 58
`Drugs and Other Agents Affecting Blood Pressure. . . . . . . . . . . . . . . . 59
`Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
`Nonaspirin Nonsteroidal Anti-Inflammatory Drugs . . . . . . . . . . . . . . . 60
`Improving Hypertension Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
`Issues Dealing With Adherence to Regimens . . . . . . . . . . . . . . . . . . . . 61
`What Can the Clinician Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
`Clinical Inertia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
`Role of Other Health Care Professionals . . . . . . . . . . . . . . . . . . . . . . . 62
`Patient Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
`Characterization of Patients Leading to Tailored Therapy . . . . . . . . 63
`Goal Setting and Behavioral Change . . . . . . . . . . . . . . . . . . . . . . . . 63
`Economic Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
`Additional Sources of Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
`Scheme Used for Classification of the Evidence. . . . . . . . . . . . . . . . . . 65
`
`References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
`
`viii
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`L i s t o f Ta b l e s
`
`Ta b l e 1 . Trends in awareness, treatment, and control of high blood
`pressure, 1976–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
`Ta b l e 2. Changes in blood pressure classification . . . . . . . . . . . . . . . . . 11
`Ta b l e 3 . Classification of blood pressure for adults. . . . . . . . . . . . . . . . 12
`Ta b l e 4 . Recommendations for followup based on initial blood
`pressure measurements for adults without acute end
`organ damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
`Ta b l e 5 . Clinical situations in which ambulatory blood pressure
`monitoring may be helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
`Ta b l e 6 . Cardiovascular risk factors. . . . . . . . . . . . . . . . . . . . . . . . . . . 20
`Ta b l e 7 .
`Identifiable causes of hypertension . . . . . . . . . . . . . . . . . . . . . 21
`
`Ta b l e 8 .
`
`Screening tests for identifiable hypertension . . . . . . . . . . . . . . 22
`
`Ta b l e 9 .
`Lifestyle modifications to prevent and manage hypertension . . 26
`Ta b l e 1 0 . Oral antihypertensive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 27
`Ta b l e 1 1 . Combination drugs for hypertension. . . . . . . . . . . . . . . . . . . . 29
`Ta b l e 1 2 . Clinical trial and guideline basis for compelling indications for
`individual drug classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
`Ta b l e 1 3 . Clinical criteria defining the metabolic syndrome in Adult
`Treatment Panel III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
`Ta b l e 1 4 . Estimated prevalence of the metabolic syndrome using the
`Adult Treatment Panel III definition among normal
`weight, overweight, and obese men and women in the
`National Health and Nutrition Examination Survey III . . . . . . 40
`Ta b l e 1 5 . Relative 10-year risk for diabetes, hypertension, heart
`disease, and stroke over the next decade among men
`initially free of disease stratified by baseline body mass index. . . 42
`Ta b l e 1 6 . Lifestyle changes beneficial in reducing weight . . . . . . . . . . . . 42
`Ta b l e 1 7 . Medical therapies of peripheral arterial disease . . . . . . . . . . . . 44
`Ta b l e 1 8 . Causes of resistant hypertension . . . . . . . . . . . . . . . . . . . . . . . 47
`Ta b l e 1 9 . Classification of hypertension in pregnancy. . . . . . . . . . . . . . . 50
`Ta b l e 2 0 . Treatment of chronic hypertension in pregnancy . . . . . . . . . . . 51
`Ta b l e 2 1 . Treatment of acute severe hypertension in preeclampsia. . . . . . 52
`Ta b l e 2 2 . The 95th percentile of blood pressure by selected ages, by
`the 50th and 75th height percentiles, and by gender in
`children and adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
`Ta b l e 2 3 . Parenteral drugs for treatment of hypertensive emergencies . . . 55
`Ta b l e 2 4 . Common substances associated with hypertension in humans . . 59
`Ta b l e 2 5 . Provide empathetic reinforcement . . . . . . . . . . . . . . . . . . . . . . 61
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
`
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`Ta b l e 2 6 . Clinician awareness and monitoring . . . . . . . . . . . . . . . . . . . . 61
`Ta b l e 2 7 . Organize care delivery systems . . . . . . . . . . . . . . . . . . . . . . . . 62
`Ta b l e 2 8 . Patient education about treatment . . . . . . . . . . . . . . . . . . . . . 62
`Ta b l e 2 9 . Collaborate with other health professionals . . . . . . . . . . . . . . 62
`Ta b l e 3 0 . Individualize the regimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
`Ta b l e 3 1 . Promote social support systems . . . . . . . . . . . . . . . . . . . . . . . 63
`
`x
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`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
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`Page 12 of 104
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`

`

`L I S T O F F I G U R E S
`
`Fi g u r e 1 .
`
`Fi g u r e 2 .
`
`Smoothed weighted frequency distribution, median, and
`90th percentile of systolic blood pressure for ages
`60–74 years: United States, 1960–1991. . . . . . . . . . . . . . . . . 2
`
`Percent decline in age-adjusted mortality rates for stroke by
`gender and race: United States, 1970–2000 . . . . . . . . . . . . . . 2
`
`Fi g u r e 3 .
`
`Percent decline in age-adjusted mortality rates for coronary
`heart disease by gender and race: United States, 1970–2000. . . 3
`Fi g u r e 4 . Hospital case-fatality rates for congestive heart failure for
`ages younger than 65 years and 65 years and older: United
`States, 1981–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
`
`Fi g u r e 5 .
`
`Prevalence of congestive heart failure by race and gender,
`ages 25–74 years: United States, 1971–74 to 1999–2000 . . . . 4
`Fi g u r e 6 . Hospitalization rates for congestive heart failure, ages 45–64
`years and 65 years and older: United States, 1971–2000 . . . . 5
`Fi g u r e 7 . Trends in incident rates of end-stage renal disease, by
`primary diagnosis (adjusted for age, gender, race) . . . . . . . . . 5
`Fi g u r e 8 . Residual lifetime risk of hypertension in women and
`men aged 65 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
`
`Fi g u r e 9 .
`
`Ischemic heart disease mortality rate in each decade of
`age versus usual blood pressure at the start of that decade . . . 9
`Fi g u r e 1 0 . Stroke mortality rate in each decade of age versus usual
`blood pressure at the start of that decade . . . . . . . . . . . . . . 10
`Fi g u r e 1 1 . Impact of high normal blood pressure on the risk of
`cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
`Fi g u r e 1 2 . Ten-year risk for coronary heart disease by systolic blood
`pressure and presence of other risk factors. . . . . . . . . . . . . . 13
`Fi g u r e 1 3 . Changes in systolic and diastolic blood pressure with age . . 14
`Fi g u r e 1 4 . Difference in coronary heart disease prediction between
`systolic and diastolic blood pressure as a function of age . . . 15
`Fi g u r e 1 5 . Systolic blood pressure distributions . . . . . . . . . . . . . . . . . . 16
`Fi g u r e 1 6 . Algorithm for treatment of hypertension . . . . . . . . . . . . . . . 31
`Fi g u r e 1 7 . Frequency distribution of untreated hypertensive
`individuals by age and hypertension subtype . . . . . . . . . . . . 44
`
`The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
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`xi
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`Page 14 of 104
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`Page 14 of 104
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`

`F o r e w o r d
`
`The complete version of the Seventh Report of
`the Joint National Committee on Prevention,
`Detection, Evaluation, and Treatment of High
`Blood Pressure (JNC7) provides additional scien-
`tific evidence to bolster other JNC 7 products:
`the JNC 7 Express; Facts About the DASH Eating
`Plan; Your Guide to Lowering High Blood
`Pressure; Reference Card from the JNC 7 for
`clinicians; Blood Pressure Wallet Card for patients;
`and Palm application of the JNC 7 recommenda-
`tions. These educational materials are available
`on the NHLBI Web site http://www.nhlbi.nih.gov/.
`
`The purpose of JNC reports is to synthesize the
`available scientific evidence and offer guidance
`to busy primary care clinicians. Readers of this
`report should remember that this document is
`intended as a guide, not a mandate. The National
`High Blood Pressure Education Program
`(NHBPEP) recognizes the responsible clinician’s
`judgment regarding the management of patients
`remains paramount. Therefore, JNC documents
`are tools to be adopted and implemented in local
`and individual settings.
`
`In the production of this report, much discussion
`was generated regarding the interpretation of the
`available scientific literature. However, after all of
`the discussions within the JNC 7 Executive
`Committee and the NHBPEP Coordinating
`Committee, as well as the many discussions at
`conferences and scientific meetings conducted in
`the United States and worldwide, the conclusion is
`that best management practice occurs when hyper-
`tension is treated to goal levels and blood pressure
`control is sustained over time. This is irrefutable
`but, unfortunately, hypertension treatment and
`
`control rates worldwide are simply not as good as
`they could be.
`
`By developing this stellar landmark report,
`Dr. Aram Chobanian, the JNC 7 Executive
`Committee, and members of the NHBPEP
`Coordinating Committee, as well as the writers
`and the contributors to this document, have
`addressed the important public health issue of
`improving inadequate blood pressure control.
`Applying JNC 7 recommendations to clinical
`practice will prevent the devastating consequences
`of uncontrolled hypertension. I recommend this
`guideline to clinicians and public health workers
`with the conviction that its contents will indeed
`contribute to the further prevention of premature
`morbidity and mortality. Dr. Chobanian has our
`deep gratitude for leading the effort to develop
`this report in such a timely manner. His brilliant
`leadership is what made the JNC 7 and related
`materials possible. The NHBPEP will release
`other advisories as the scientific evidence becomes
`available.
`
`Barbara M. Alving, M.D.
`Acting Director
`National Heart, Lung, and Blood Institute
`and
`Chair
`National High Blood Pressure Education Program
`Coordinating Committee
`
`Foreword
`
`xiii
`
`Page 15 of 104
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`

`

`A b s t r a c t
`
`The purpose of the Seventh Report of the Joint
`National Committee on Prevention, Detection,
`Evaluation, and Treatment of High Blood
`Pressure (JNC 7) is to provide an evidence-based
`approach to the prevention and management of
`hypertension. The key messages of this report
`are: in those older than age 50, systolic blood
`pressure (SBP) of >140 mmHg is a more impor-
`tant cardiovascular disease (CVD) risk
`factor than diastolic BP (DBP); beginning
`at 115/75 mmHg, CVD risk doubles for each
`increment of 20/10 mmHg; those who are
`normotensive at 55 years of age will have a
`90 percent lifetime risk of developing hyperten-
`sion; prehypertensive individuals (SBP 120–139
`mmHg or DBP 80–89 mmHg) require health-
`promoting lifestyle modifications to prevent the
`progressive rise in blood pressure and CVD; for
`uncomplicated hypertension, thiazide diuretic
`should be used in drug treatment for most,
`either alone or combined with drugs from other
`classes; this report delineates specific
`
`high-risk conditions, which are compelling
`indications for the use of other antihypertensive
`drug classes (angiotensin-converting enzyme
`inhibitors, angiotensin-receptor blo