A

REPRINT

FROM

May 21, 2003

The Journal of the American Medical Association

The Seventh Report of the Joint

National Committee on Prevention,

Detection, Evaluation, and Treatment of

High Blood Pressure

The JNC 7 Report

Aram V. Chobanian, MD; George L. Bakris, MO; Henry R. Black, MD;

William C. Cushman. MD; Lee A. Green, MD, MPH; Joseph L. IZlO, Jr, MD;

Daniel W. Jones, MD; Barry J. Materson, MD, MBA; Suzanne Cpari'. MD;

Jackson T. Wright, Jr, MD, PhD; Edward J. Roccella, PhD, MPH; and the National High

Blood Pressure Education Program Coordinating Committee

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.JAMA
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American Medical AssociatiOn

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_ SPECIAL COMMUNICATION CLINICIAN'S CORNER

The Seventh Report of the Joint

National Committee on Prevention,
Detection, Evaluation, and Treatment
of High. Blood Pressure
The JNC 7 Report
Aram V. Chobanian. MD
George L Bakris, MD
He:uJ R. Black, MD
William C. Cushman. MD
Lee A. Green, MD. MPH
Joseph 1.. Izro, Jr, MD
Daniel W. Jones, MD
Barry J. Materson. MD, MBA
Suzanne Oparil. MD \,
Jackson T. Wright, Jr, MD, PhD
Edward J. Roccella, PhD, MPH
and the National High Blood
Pressure Education Program
Coordinating Committee
OR MORE THAN 3 DECADES, ruE
.
"The Seventh Report of the Joint National Committee on Prevention, Oe
tection. Evaluation, and Treatment of High Blood Pressure" provides a new
gUideline for hypertenSion prevention and management The following are
the key messages: (1) In persons older than 50 years. systolic blood pres
sure (BP) of more than 140 mm Hgls a much more imporlantcardiovascular
disease (CVO) risk factor than diastolic BP; (2) The risk of CVO, beginning
at 115/75 mm Hg, doubles with each Increment of 20/1 0 mm Hg; Individu
als who are normotensive at 5S years of age have a 90% lifetime risk for
developing hypertension: (3) Individuals with a systolic BP of 120 to 139
mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as pre
hypertensive and require health-promoting lifestyle modifications to pre
vent CVD; (4) Thiazide-type diuretics should be used in drug treabnent for
most patients with uncomplicated hypertenSion, either alone or combined
with drugs from other classes:Certain high-risk conditions are compelling
Indications for the Initial use of other antihypertensive drug classes (angio
tensin-converting enzyme inhibitors, angiotensin-receptor blockers. P-block

F National Heart. Lung. and ers, calcium channel blockers); (S) Most patients with hypertenSion will re
Blood Institute (NHLBI) bas quire 2 or more antihypertensive medications to achieve goal BP 140190
administered the National mm Hg. or <130/80 mm Hg for patients with diabetes Dr chronic kidney
High Blood Pressure Education disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration
Program (NHBPEP) Coordinating should be given to initiating therapy with 2 agents, 1 of which usually should
Committee, a coalition of 39 major
professional, public, and voluntary
be a thiazide-type diuretic; and (7) The most effective therapy prescribed by
the mos~ careful clinician wJII control hypertension only if patients are mo
organizations and 7 federal agencies.
One important function is to issue tivated. Motivation fmproves when patients have positive experiences with
guidelines and advisories designed La and trust in the cliniCian. Empathy builds trust and is a potent motivator.
increase awareness, prevention, treat Finally, in presenting these guidelines, the committee recognizes that the.
ment, and control of hypertension responsible physician's judgment remains paramount
(high blood pressure [BP]). Since the lAMA 2003;289:2560-2572 wwwJama.com
publication of "The Sixth Report of
the Joint National Committee on the
Prevention, Detection, Evaluation, and ONC VI) released in 1997,1 many AuthorAffilJ.WolI$ and FinaIldal Disclosul1!S an: listed
the end of this article.
Treatment of High Blood Pressure large-scale clinical trials have been at
ft

COlTUpondlng Author and ItI!prInts: Edward J. Roc

published. cella, PhD. MPH, NatioMf Heart. Lung, and Blood In
stitute, NaIionaIIII$Iitutes of HeaIIh, 31 CenlJ:r Dr. MSC
See also pp 2534 and 2573. The decision to appoint a commit 2480, Bethnda. MD 201lS] (e-mtft: foccelllOnih
tee for "The Seventh Repon of theJoint .gov).
2560 JMM., May 21. 200l-Vol2.89, No. 19 (Repri'1ted) e2003 American Medical Association. All rights re5~d.

National Committee on Prevention, De
tection, Evaluation, and Treatment of
High Blood Pressure" ONC 7) was
based on -4 factors: publication of many
new hypertension observational stud
ies and clinical trials; need for a new
clear and concise guideline that would
be useful for clinicians; need to sim
plify the classification ofBP; and a clear
recognition that theJNC reports were
not being used to their maximum ben
efit. ThisJNC report is presented in 2
separate publications: this current suc
cinct practical guide and a more com
prehensive report to be published sepa
rately, which will provide a broader
discussion and justification for the cur
rent recommendations. In presenting
these guidelines, the committee recog
nizes that the responsible physician's
judgment is paramount in managing his
or her patients.
METHODS
Since publication of theJNC VI report,
the NHBPEP Coordinating Committee,
chaired by the director of the NHLBI, has
regularly reviewed and discussed the hy
penension clinical trials at their bian
nual meetings. In many instances, the
principal investigator of the larger stud
ies has presented the infonnation di
rectly to the Coordinating Committee.
The Committee's presentations and re
views are sul1ll1:'lali.zed and posted on the
Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older
BP Systolic
_......
Classification BP,mmHg BP,mmHg
NoonaI <120 and
Prehypertensioo 12()..139 or
- 80-89
Stage 1 hypertension 140-159 or
Stage 2 hypertension 2:160 or
J!\bbl'eWltials: N:;E, angbIensifH:oIWening enzyme; IIAB. angiolerlsir>-receptor ~ BP, blood preswe: CCB, calcium Channel tlIocki!r.
TreaImer1t determined by Ilighest BP ca\egay.
tSe9 TIJIje 8.
t Trea! paIJenIS with cM:lnic kit1nev disease or diabeIes 10 BP goal 01 less IhIIn 1301!!O mm Hg.
i1itial CO!l"bInud therepy $h()Ijd be used cautiously In It'O!l6 at risk tor orthOstatic hypotMsion.
2oo3 American Medical Association. All rights reserved.
THEJNC 7 REPORT
NHLBI Web site.2 In agreeing to com Lected,3.1 which classifies studies in
mission a new report, the director re a process adapted from Last and
quested that the Coordinating Commit Abramson.'
tee members provide in writing a detailed The executive committee melon 6
rationale explaining the necessity to up occasions. 2 of which included meet
date the guidelines and to describe the ings with the entire Coordinating Com
critical issues and concepts to be con mittee. The writing teams also met by
sidered fora new repon. TheJNC 7 chair teleconference and used electronic com
was selected in addition to a 9-member munications to deVelop the report.
executive committee appointed en Twenty-four drafts were created and
tirely from the NHBPEP Coordinating reviewed in a reiterative fashion. At its
Committee membership. The NHBPEP meetings, the executive committee used
Coordinating Committeeserved as mem a modified nominal group process to
bers of 5 writing teams, each of which identify and resolve issues. The NHB-
were co-chaired by 2 executive commit PEP Coordinating Committee reviewed
tee members. the penultimate draft and provided
The concepts identified by the NH written comments to the executive com
BPEP Coordinating Committee mem mittee. In addition, 33 national hyper
bership were used to develop the re tension leaders reviewed and com
port outline. A timeline was developed mented on the document. The NHBPEP
to complete and publish the work in 5 Coordinating Committee approved the
months. Based on the identified criti JNC 7 report.
cal issues and concepts, the executive
committee identified relevant Medical RESULTS
Subject Headings (MeSH) terms and Classification of BP
keywords to further review the scien TABLE 1 provides a classificationofBP
tific literature. These MeSH terms were for adults aged 18 years or older. The
used to generate MEDLlNE searches classification is based on the mean of
that focused on English-language, peer 2 or more properly measured seated BP
reviewed scientific literature fromJanu readings on each on or more office vis
ary 1997 through April 2003. Various its. In contrast with the classification
systems of grading the evidence were provided in the IN C VI report, a new
considered and the classification category designated prehypertension
scheme used in JNC VI and other has been added. and stages 2 and 3
NHBPEP clinical guidelines was se- hypertension have been combined.
Management'
Initial Drug Therapy
Diastolic Ufestyle I
Modiflcation Without Compelling Indlcatlon With Compelling Indlcatlonlt
<80 Encowage
Ves No anthypertensille drug Drug(s) for the compelling
indicated ndiCatiOnst:
9099 Yes Thiazide-type diuretics lor most; Drug(s) for the compelling
may consider ACE inhibitor, i'ld"ations
ARB. !I-blocker, CCB. or Other antihypertensive drugs
combinatlOfl (diuretics. ACE Irhbltor. ARB.
~-blocker. CCB) as needed
2:100 Ves 2-Orug combination for most Drug(s} lor the competing
(usually lhiazide..type diuretic indications
and ACE lnhWor or ARB or Other antJhype.1.l3nsiYe drugs
~-bIocker or CC8) (diuretics, ACE inhibitor. ARB,
p-blockBr. CCB) as needed
(Reprinted) lAMA. May 21. 200J-Vo\2B9. No. 19 :2561
 '"

"
THEJNC 7 REPORT

with hypertension. but the majority will

Table 2. Trends In AWI/l!ness, Treatment, and Control of High 8100d Pressure in Adults With
Hypertension Aged 18 to 74 Years" require 2 or more antihypertensive
National HQa/th and. Nutrition examination SUI'Ve)'$, Weighted %
drugs. 1i1S When physicians faU to pre
scribe lifestyle modifications, adequate
III (Phase 1, III (phase 2, antihypertensive drug doses, or appro
/I (1976-1980) 1988-1991) 1991-1994) 1999-2000
51 73 70 priate drug combinations, inadequate BP
Awareness 68
Treatment 31 55 54 59

control may result.

Controlt 10 29 27 34

Accurate BP Measurement
in the Office
The auscultatory method of BP mea
surement with a properly calibrated and
validated instrument should be used. 16
Patients should be seated quietly for at
Patients with prehypenension are at in this goal (see "Ufestyle Modifica least 5 minutes in a chair rather than on
creased risk for progression to hyper tions" section). an examination table, with feet on the
tension; those in the 130/80 to 139/89 floor and arm supported at heart level.
mm Hg BP range are at twice the risk Benefits of Lowering SP Measurement of BP in the standing po-
to develop hypertension as those with In clinical trials, antihypertensive sition is indicated periodically, espe
lower values. 6 therapy has been associated with 35% cially in those at risk for postural hypo
to 40% mean reductions in stroke in tension. An appropriate-sized cuff (cuff
Cardiovascular Disease Risk cidence; 20% to 25% in myocardial in bladder encircling at least 80% of the
Hypertension affects approximately 50 farction; and more than 50% in HF.1 0 arm) should be used to ensure accu
million individuals in the United States It is estimated that in patients with stage racy. At least 2 measurements should be
and approximately 1 billion individu 1 hypertension (systolic BP, 140-159 made. Systolic BP is the point at which
als worldwide. As the popu,.lation ages. mm Hg andlor diastolic BP. 90-99 the first of 2 or mOre sounds is heard
the prevalence of hypertension will mm Hg) and additional cardiovascu (phase 1) and diastOlic BP is the point
increase even further unless broad and lar risk factors, achieving a sustained before the disappearance of sounds
effectivepreventive measures are imple 12-mm Hg decrease in systolic BP for (phase 5). Physicians should provide to
mented. Recent data from the Framing 10 years will prevent} death for every patients, verbally and in writing. their
ham Heart Study7 suggest that indi 11 patients treated. In the presence of specific BP numbers and BP goals,
viduals who are normotensive at 55 CVD or target-organ damage, only 9 pa
years ofage have a 90% lifetime risk for tients would require this BP reduction Ambulatory BP Monitoring
developing hypertension. to prevent a death,u Ambulatory BP monitoring l7 provides
The relationship between BP and risk information about BP .during daily ac
of cardiovascular disease (CVD) events BP Control Rates tivities and sleep. Ambulatory BP moni
is continuous, consistent, and indepen Hypertension is the most common pri toring is warranted for evaluation of
dent of other r,isk factors. The higher mary diagnosis in the United States ......ith (white-coat) hypertension in the ab
the BP, the greater the chance of myo 35 million office visits as the primary di sence of target-organ injury. It is also
cardial infarction, heartfailure (HF). agnosis. ll Current control rates (sys helpful to assess patients with apparent
stroke, and kidney disease. For indi tolic BP <140 rom Hg and diastolic BP drug resistance, hypotensive symptoms
viduals aged 40 to 70 years, each in <90 mm Hg), although improved, are with antihypertensive medications, epi
crement of 20 mm Hg in systolic BP or still far below the Healthy People 2010 sodic hypertension, and autonomic dys
10 mID 11g in diastolic BP doubles the goal of 50%; 30% are still unaware they function. The ambulatory BP values are
risk of CVD across the entire BP range have hypertension (TABLE 2). In the ma usuallylower than clinic readings. Awake
from llSn5 to 185/115 mm Hg.' jOrity of patients, controlling systolic hy hypertensive individuals have a mean BP
The classification prehypertension, pertension, which is a more important of more than 135/85 mm Hg and dur
introduced in this report (Table 1), rec CVD risk factor than diastolic BP ex ing sleep, more than 120(75 mmHg. The
ognizes this relationship and signals the cept in patients younger than 50 years13 level of BP using ambulatory BP moni
need for increased education of health and occurs much more commonly in toring correlates better rllan office m~
care professionals and the public to de older persons, has been considerably surements with target-organ injury.18
crease BP levels and prevent the devel more difficult than controlling dias Ambulatory BP monitoring also pro- .
opment of hypertension in the general tolic hypertension. Recent clinical trials vides a measure of the percentage ofBP
population. 9 Hypertension preven have demonstrated that effective BP con readings tha t are elevated, the overall BP
tion strategies are available to achieve trol can be achieved in most patients load, and the extent ofBP reduction dur
2562 lAMA. May 21. 200l-Vo! 289. No. 19 (Reprinted) (;12003 American Medical Association. All rights resened.
 THE JNC 7 REPORT

ing sleep. In most individuals, BP de

creases by 10% to 20% during the night;

Box 1. Cardiovascular Risk Facto,,
those in whom such decreases are not
Major Risk Factors
present are at increased risk for cardio..

Hypertensiont
vascular events.
Cigarette smoking
Obesity (BMI 2::30)t
Self-measurement of BP
Physical inactivity
Blood pressure self-measurements may
DysUpidemiat
benefit patients by providing infonna
DiabeteS mellitust
tion on response to antihypertensive
Microalbuminuria or estimated GFR <60 mUmin
medication, improving patient adher
Age (>55 years for men, >65 years for women)
ence with therapy, 19 and in evaluating
Family history of premature cardiovascular disease (men <55 years
white-coat hypertension. Individuals
or women 65 years)
with a mean BP of more than 135185
Target-Organ Damage
mm Hg measured at home are gener
Hean
ally considered to be hypertensive.
Left ventricular hypertrophy
Home measurement devices should be
Angina or prior myocardial infarction
checked regularly for accuracy.
Prior coronary rev.ascularization
Han failure
Patient Evaluation
Brain
Stroke or transient ischemic attack
Evaluation of patients with docu
Chronic kidney disease
mented hypertension has 3 objectives:
Peripheral arterial disease
(1) to assess lifestyle and identify other Retinopathy
cardiovascular risk factors or concomi
8M! indiollts body mass index calculated as Weight in kilograms divided by the square of
tant disorders that may affect progno height In mcu:rs; GfR., glomcrular filtration ratc.
sis and guide treatment (~x 1); (2) to tComponulls of tlx metabolic syndrome.
reveal identiflable causes of high BP
(BoX 2); and (3) to assess the presence
or absence of target-organ damage and sis; blood glucose and hematocrit;
CVD. The data needed are acqUired serum potassium, creatinine (or the cor~ Box 2. Identifiable Causes of
through medical history. physical ex responding estimated glomerular fil HypertenSion
amination, routine laboratory tests, and tration rate). and calcium20; and a lipid Sleep apnea
other diagnostic procedures. profile (after a 9- to 12-hour fast) that Drug-induced or drug-related
The physical examination should in includes high-density lipoprotein cho.. (see Box 3)
clude an appropriate measurement ofBP, lesterol, low-density lipoprotein cho Chronic kidney disease
with verification in the contralateral ann; lesterol, and triglycerides. Optional tests Primary aldosteronism
examination of the optic fundi; body include measurement of urinary albu Renovascular disease
mass index calculated as weight in ki min excretion or albumin/creatinine Chronic steroid therapy and
Cushing syndrome
lograms divided by the square ofheight ratio. More extensive testing for iden
Pheochromocytoma
in meters (measurement of waist cir tifiable causes is not indicated gener
Coarctation of the aorta
cumference also may be useful); aus ally unless BP control is not achieved. Thyroid or parathyrOid disease
cultation for carotid, abdominal. and
femoral bruits; palpation of the thyroid Treatment
gland; thorough examination of the heart Goals of Therapy.The ultimate public
and lungs; examination of the abdo health goal of antihypertensive therapy ated with a decrease in CVD compli
men for enlarged kidneys, masses, and is the reduction of cardiovascular and cations. In patients with hypertension
abnormal aortic pulsation; palpation of renal morbidity and mortality. Be with diabetes or renal disease. the BP
the lower extremities for edema and cause most patients with hyperten goal is less than 130180 mm Hg. 2 1.22
pulses; and neurolOgical assessment. sion, especially those aged at least 50 Lifestyle Modifications. Adoption of
years, will reach the diastolic BP goal healthy lifestyles by all individuals is
Laboratory Tests and once systolic BP is at goal, the primary critical for the prevention of high BP and
Other Diagnostic Procedures focus should be on achieVing the sys an indispensable part of the manage
Routine laboratory tests recom tolic BP goal (FIGURE). Treating sys ment of those with hypertension. Ma
mended before initiating therapy in tolic BP and diastolic BP to targets that jor lifestyle modifications shown to
clude an electrocardiogram; unnaly- are less than 140/90 mm Hg is associ- lower BP include weight reduction in
(;)2003 American Medical Association. All rights reserved. (R!!printed) JAMA. May 21, 2003-VoI289, Nu. 19 2563
IHEJNC 7 REPORT

those individuals who are overweight (TABLE. 3).30 lifestyle modifications de of 2 or more lifestyle modifications can

or obesell .l4; adoption of Dietary Ap. crease BF. enhance antihypertensive achieve even better results.

proaches to Stop Hypertension eating drug efficacy, and decrease cardiovas Pharmacologic Treatment. Excel

plan/' which is rich in potassium cular risk. For example, a 1600-mg so lent clinical trial outcome data prove

and caloum16; dietary sodium reduc dium Dietary Approaches to Stop Hy that lowering BP with several classes

tion25 -17 ; physical activi ty 2S.19; and perlension eating plan has effects similar of drugs, including angiotensin

moderation of alcohol consumption to Single drug therapy.25 Combinations converting enzyme (ACE) inhibitors,

angiotensin-receptor blockers (ARBs),

~-blockers. calcium channel blockers
Figure. Algorithm for Treatment of Hypertension (CCBs), and thiazick.-type diuretics, will
all reduce the complications of hyper
Ufe6tyIe McdIIcaIDna
tension. 10.31-37 TABLE -4 and TABLE 5 pro
t
NotIllGoelBP

vide a list of commonly used antihy

{<1401QO tm1 Hg or <1301!1O Irm Hg for lho8e WIth 0iabeteI
pertensive agents.
or Chrtri: KIalBr r.&aeaa!

Thiazide-type diuretics have been the

.1 basis of antihypertensive therapy in most
nIIi&/ Drug CtOcet
I
outcome trials. 37 In these trials, includ
+ f ing the recendy published Antihyper

I Hyperi&l5lon WI1houI

CompeIIro IndIcaIlons

I
I ~Vv1th
~ Indica!Icn
tensive and Upid-Lowering Treatment
to Prevent Heart Attack Trial.lJ diuret
+
Slage 1 HypertlM"lBloo
j
Slage 2 Hyper1ension
l
tlrugt., lor the
ics have been virtually unsurpassed in
preventing the cardiovascular compli
~ BP 140-159 rrm Hg ~BPl;lllOrrmH\lcr
or 0iasIQ&c BP 90-99 rrm Hal DiIIiIklIIc BP ~100 mm Hg)
CompeIng fn:btIon&
(See Table 6)
cations oC hypertension. The exception
ThIazid&-TI/PI !lut!Iics Icr t.'Io&t 2.Qrug CorriWIaliCln lot Most 0Iher ~ensIiIe [)ugI
is the Second Australian National Blood
May ~ AC 1nhIbIIar. ARB.
(\JIIuIiIy ThIazid&-T)'PII OilAtic (DIureIicI, H:;E Irti:iIor. ARB. Pressure trial)6 that reported slightlybet
~BIacIIe<. CCB. or CorJti"IaIion lIflCI ACE rhbIIor elf ARB or ~.BIcck8r. CC8I as NaedId
IlBIoc:kIr or CC'6I ter outcomes in white men with a regi
I I I men that began with an ACE inhibitor
t compared with one starting with a di
Not eI Goal BP
uretic. Diuretics enhance the antihyper

. .
I +
Optrntu Doaagaa or /IOd AddIIonIII Dn.Igs I.klllI GoIII BP 1& At::I"iIwe!:I
Consider Condatioo Wlh ~SpedMt
I tensive efficacy of multidrug regimens,
can be useful inachievingBP control, and
are more atrordabIethan other antihy
IlP indicates blood pressure; ACE, a!lgiOtensin-converting enzyme; ARB. angiotensin-receptor blocker; v!d CCS, pertensive agents. Despite these find
calcium channel blader_ ings, diuretics remain underused. )9
Thiazide-type diuretics should be used
as initial therapy for most patients with
Table 3. Lifestyle Modifications to Manage Hypertension-
hypertension, either alone or in combi
Approximate SystoDc BP nation with 1 of the other classes (ACE
Modification Recommendation Reduction, Range
Weight reduction Maintan riom1aI body weight (BMI. 18.5-24.9) 5-20 mm H11Q-kg weight
inhibitors, ARBs, Il-blockers, CCBs)
~ demonstrated to be beneficial in ran
AdOPt DASH eatlng Consume a diet rich h fruits. vegetables, and a..14mmH~ domized controlled outcome trials. The
pIN! Iowfat dairy prock.ds wIttI a reduced list of compelling indications requiring
content of saturated and total fat
Die'.ary sodium Reduce dietary sodium in1ake 10 no more than
the use of other antihypertenslve drugs
reduction 100 mEqIl. i2.4 9 sodII..m Of 6 9 sodium as initial therapy are listed in TABLE 6.
chloride} If a drug is not tolerated or is contrain
Physical actMty Engage h regular aerobic physical actMty dicated, then 1 of the other classes proven
such as brisk ~ (at least 30 minutes
per day. most days 01 the week) to reduce cardiovascular events should .
Moderation of alcohol LimIt consumption to no more than 2 drinks 2-4mm Hg'O be used instead.
consumption per day (1 OZ Of 30 mL ethanol [eg, 24 oz Achieving BP Control in Indi~
beer, 1001 wine. or 3 oz SO-proof
whiskeyD in most men and no more than vidual Patients. Most patients with hy
1 drink per day In women and pertension will require 2 or more anti
rJghter-welgh! persons
hypertensive medications to achieve their
SP goals. 14.1.5 Addition of a second drug
from a different class should be initi
ated when use oC a single drug in ad-
2564 lAMA. Mey 21. 200l-Vo! 289, No. 19 (Reprinted) 1C2003 American Medical Association. AIl rights reserved.
 THEJNC 7 REPORT

equate doses fails to achieve the BP goal. tions already in use, tolerability, and de CCBs can be used. l In patients with
When BP is more than 2011 0 mm Hg sired BP targets. In many cases, speciali.'it acute coronary syndromes (unstable an
above goal. consideration should be given consultation may be indicated. gina or myocardial infarction), hyper
to initiating therapy with 2 drugs, ei Ischemic Heart Disease. Ischemic tension should be treated initially with
ther as separate prescriptions or in fIXed heart disease is the most common form f3-blockers and ACE inhibitors,49 with
dose combinations (Figure). The initia of target-organ damage associated with addition of other drugs as needed for
tion of drug therapy with more than 1 hypertension. In patients with hyper SP control. In patients with postmyo
agent may increase the likelihood of tertsion and stable angina pectoris, cardial infarction, ACE inhibitors,
achieving the BP goal in a more timely the first drug of choice is usually a f3-blockers. and aldosterone antago
fashion, but particular caution is ad f3-blocker; alternatively, long-acting nists have proven to be most benefi-
vised in those at risk for orthostatic hy
potension, such as patients with diabe Table 4. Oral Antihypertensive Drugs
tes, autonomic dysfunction. and some
Uaual Dose, Dally
older persons. Use of generic drugs or Class Drug (Trade Name) Range,mgld Frequency
combination drugs should be consid ChlorOlhiazide (Oiuril) 125-500
ered to reduce prescription costs. Chlorthalidone (gene!ic) 12.5-25
Follow-up and Monitoring. Once an Hydrochlorothiazide 12.5-50
tihypertensive drug therapy is initi (Microzide. HydroOlURIWt
Polythiazide (Aenese) 2-4
ated, most patients should return for
Indapamide (lozoI)t 1.25-2.5
follow-up and adjustment of medica
Metolazone (Mykrox) 0.510
tions at approximately monthly inter
Metolazone (ZaroxoIyn) 2.5-5
vals until the BP goal is reached. More
Loop diuretics Bumetanlde (Bumax)t 0.5-2 2
frequent visits will be necessary for pa
Furosemide (Lasixlt 20-80 2
tients with stage 2 hypertension or with
Torsemide (DemacIexIt 2.5-10
complicating comorbid conditions. Se
PoIassium-sparing diursIics Arrlloride (Midaroorlt 5-10 12
rum potassium and creaqnine should
Triamteftne (Oyrenluml 50-100 12
be monitored at least 1 to"2 times per
Aldosterone-receptor blockers Eplerenone Onspra) 50-100 1-2
year. flO After SP is at goal and stable, fol
Spironolactone (Aldactone)t 25-50 12
low-up visits can usually be at 3- to p-8Iockers AtenoIoI {Tenormin)t 25-100
6-month intervals. Comorbidities, such Betaxolol {Kenone)t 5-20
as HF, as.<;ociated diseases, such as dia BisoproIoI (Zebeta}t 2.5-10
betes, and the need for laboratory tests Metoprolol (Lopressor)f 50-100 1-2
influence the frequency of visits. Other Metoproloi extended release 50-100
cardiovascular risk factors should be (ToprolXL)
treated to their respective goals, 'and to Nadolol (Corgard)t 40-120
bacco avoidance should be promoted PropraOOol ~nderaI}t 40-160 2
Vigorously. Low-dose aspirin therapy Propranolol long-acting 60-180
(IndemllA)t
should be considered only when SP is
Timololl8loaUen}t 20-40 2
controlled, because the risk of hemor
!I-Blockers with intmsic Acabutolol (Seclra/)t 2OQ-SOO 2
rhagic stroke is increased in patients sympathomimetic activity PenbutolOl (levatol) 10-40
with uncontrolled hypertension. 61
Pindolol (generic) 10-'\0 2
Combined ",. and ~-bIockers CarvediioI (Coreg) 12.550 2
Special Considerations
LabetaIoI (I\IOImOCIyne. 200-800 2
The patient with hypertension and cer Trandate)t
tain comorbidities reqUires special at ACE inhibitors Benazepril (lotensil}t 10-40 1-2
tention and follow-up by the clinician. Captoplil (Capoten}t 25100 2
Compelling Indications. Table 6 de Enalaprt (Vasoteclt 2.5-40 1-2
scribes compelling indications that re Fosil'lO\Xi (Monoprll) 10-40
quire certain antihypertensive drug Lisinoprfl (F'riniW. Zestrlllt 10-40
classes for high-risk conditions. The drug Mooxipf~ (Univasc) 7,5-30
selections for these compelling indica Perindoj:ri (Aceon) 4-8 1-2
tions are based on favorable outcome Ouinapril (AccupriQ 10-40
data from clinical trials. Combination of Ramipri (AltsCe) 2.5-20 1
;.;.;:;.;=....'-"-.;.;;..;;.."--------:-----1--
agents may be reqUited. Other manage Trandolapril (Mavik) 14
ment considerations include medica
Q2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21. 2003-VoI289. No. 19 25"
 THEJNC 7 REPORT
cial.~'2,S3.6l Intensive lipid manage
ment and aspirin therapy are also
indicated.
Heart Failure. Heart failure, in the
form of systolic or diastolic ventricu
lar dysfunction;results primarily from
systolic hypertension and ischemic
heart disease. Fastidious BP and cho
lesterol control are the primary pre
ventive measures for those at high risk
Cor HF.'IO In asymptomatic individuals
with demon.strable ventriOllar dysfunc
tion, ACE inhibitors and j3-blockers are
. recommended.,l.61 For those with
Table 4. Oral Antihypertensive Drugs (conU
Class
Angiotensin II antagonists
Ca/clum channel
bIockers-non-dihydropyridineS.
Calcium channel
bIocl<en!-dihydtopyridines
a,-Blockers
Central a2-agonisls and other
centrally acting drugs
Direct vasodilators
AllbnMetlon: ACE. angiotensin-converting ~
-DosIIg9$ may 'V9Iy !rom \hose listed rt the Pt1yI:;icisns' Desk F/l!lfetence.-...tich may be COIl:UIed for additional n..
IomIaIion.
tAn! OO>N Q" WIll soon become 8IItdabIe In gene!lc prepareIions.
VI O.1-!Tli1 dose may be ~ fNf1f'/ olher day to achIeIIe ttis dosage.
2566 JAMA. lI.ay 21, 2003-Vol 289. No. 19 (Reprinted)
symptomatic ventricular dysfunction or favorably affect the progression of dia
end-stage heart disease, ACE inhibi betic nephropathy and reduce albu
tors, ~-blockers, ARBs, and aldoste minuria,".56 and ARBs have been shown
rone blockers are recommended along to reduce progression to macroalbu
with loop diuretics.<tO...4/I minuria. 56,,7
Diabetic Hypertension. Combina.. Chronic Kidney Disease. In pa
tions of 2 or more drugs are usually tients with cmonic kidney disease, de
needed to achieve the target BP goal or fined by either (l)reduced excretory
less than 130180 mm Hg.:l.l,ll Thiazide .function with an estimated glomerular
diuretics, Il-blockers, ACE inhibitors, filtration rate of less than 60 mL/min per
ARBs, and CCBs are beneficial in re 1.73 ml (corresponding approximately
ducing CVD and Sl1'Oke incidence in pa-. to a creatinine of > 1.5 mg/dL [> 132.6
tients with diabetes. 33,,",63 The ACE in pmoVL] in men or > L3mg1dL [> 114.9
hibitor- or ARB-based treatments pmoVLJ in women)lD or (2) the pres
ence of albuminuria (>300 mgld or 200
mg albumin per grain of creatinine),
therapeutic goals are to slow deteriora
Usual Ooae, Dally
Drug (Trade Name) Range. mg/d Frequency tion of renal function and prevent CVD.
Candesartan V"-tacand} 8-32 1 Hypertension appears in the majority of
Eprosartan (T6Yetan) 400-800 1-2 these patients and they should receive
Irbesartan V"-vapro) 150-300 1 aggressive BP management, often with
Losar1an (Cozaar) 25-100 1-2 3 or more drugs to reach target BP val
Olmesartan (Benicar) 20-40 ues ofless than 1301B0 mm Hg.:59,6i
Telmisartan (Micardis) 20-80 The ACE inhibitors and ARBs have
Valsartan (Diovan) 80-320 demonstrated favorable effects on the
Diltiazem extended release 180-420 progression of diabetic and nondia
(Cardizem CD,
DUacor XR, Tiazoolt
betic renal disease."S!I6i A limited in
Diltiazem extended release 120540 crease in serum creatinine of as much
(Cartlizem lAj as 35% above baseline with ACE in
VerapamI irmlediate release 60-320 2 hibitors or ARBs is acceptable and not
(Galan, IsoptIn)t a reason to withhold treatment unless
Verapam1Iong-actlng 120-360 1-2
(Calan SR, lsoptin SAlt
hyperkalemia develops.6:S With ad
Verapami-coer(Covera HS, 120-360
vanced renal disease (estimated glo
Verelan PM) merular filtration rate <30 mUmin per
AmIodipine (Norvasc) 2.5-10 1 1.73 ml, corresponding to a serum cre
FeIodiplne (PIeodil) 2.5-20 atinine of 2.5-3.0 mgldL [221-265
1
lsradipine (Dynaoiro OR) 2.5-10 2 llmoVL]), increasing doses of loop di
Nicardiplne sustained release 60120 2 uretics are usually needed in combina
(Gardena SA)
tion with other drug classes.
Nifedipine brig-acting (AdaIat ee, 30-60
Procatdia Xl) Cerebrovascular Disease. The risks
Nlsoldlpine (SUarj 1Q-4() and benefits of acute lowering ofBP dur
Doxazosin ICardura) 1-16 ing an acute stroke are still unclear; con
Prazosin (Mlnipress)t 2-20 23 trol ofBP at intermediate levels (approxi
Terazosln (Hymn) 120 1-2 mately 1601100 mm Hg) is appropriate
CIonicfine (Catapraslt 0.10.8 2 until the condition bas stabilized or im
CIonidine patch (CaIapres TIS) 0.1-{t3 1 weekly proved. ReC1lITen~ stroke rates are low
Methy1dopa (AIdornetl't 250-1000 2 ered by the combination of an ACE in
ReserpIne (generic) 0.05-0.25 1; hibitor and thiazide-type diuretic. J '
Guanlaclne (generic) 0.5-2 1 Other Special Situations. Minority
Hydralazine IApresoIinelt 25-100 2 Populatians. Blood pressure control rates
MIIlOXidiI (Looilen)t 2.5-60 1-2 vary in minority populations and are
lowest in Mexican Americans and Na
tive Americans. 1 In general, the treat
ment of hypertension is similar for all
demographic groups, but socioeco
02003 American Medical Association. AU rights reserved.
 THEJNC 7 REPORT

nomic factors and lifestyle may be im
portant barriers to BP control in some
minority patients. The prevalence, se
verity, and impact of hypertension are
increased in blacks, who also demon
strate somewhat reduced UP responses
to monotherapy with \3-blockers, ACE
inhibitors, or ARBs compared with di
uretics or CCBs. These differential re
sponses are largely eliminated by drug
combinations that include adequate
doses of a diuretic. Angiotensin
converting enzyme inhibitor-induced
angioedema occurs 2 to 4 times more fre
quenuy in black patients with hyper
tension than in other groups.))
Obesity and the Metabolic Syndrome.
Obesity (body mass ind~ 2:30) is an in
creasingly prevalent risk factor for the
development ofhypertension and CVD.
The Adult Treaunent PanelllI guide
line for cholesterol management de
fines the metabolic syndrome as the
presence of 3 or more of the following
conditions: abdominal obesity (waist cir
cumference > 102 em [:>40 in1 in men
or >89 cm {>35 in] in 'women), glu
cose intolerance (fa'iting glucose 2: 110
mgldL [2:6.1 mmollLJ), BP of at least
130185 rom Hg, high triglycendes (2: ISO
mgldL 12:1.70 mmollLJ), or low high
density lipoprotein cholesterol 40
mgldL 1< 1.04 mmoVL] in men or < 50
mgldL [<1.30 mmoVL] in women).66
intensive lifestyle modification should
be pursued in all individuals with the
metabolic syndrome, and appropriate
drug therapy should be instituted for
each of its componenIS as indicated.
Left Ventricular Hypertrophy. Left ven
tricular hypertrophy is an independent
risk factor that increases the risk of sub
sequent CVD. Regression of left ven
tricular hypertrophy occurs with ag
gressive BP management, including
weight loss, sodium restriction, and
treaunent with all classes of an~ihyper
tensive agents except the direct vasodi
lators, hydralazine and minoxidil. 1.67
Peripheral Arterial Disease. Periph
eral arterial disease is equivalent in risk
to ischemic heart disease. Any class of
antihypertemiive drugs can be used in
most patients with peripheral arterial
disease. Other risk factors should be
"'2003 AmeriOln Medical AssoclaUnn. AU rights reserved.
managed aggressively and aspirin
should be used.
Hypertension in OlcU:r Individuals. Hy
pertension occurs in more than two
thirds of individuals after age 65 years. I
This is also the population with the low
Table S. Combination Drugs for Hypertension
Combination Type
ACE inhibitors and CCSS AlTiodipinelbenazepril hydrochloride
ACE inhibitors and ciuretics
Centrally acting drug and diuretic
{)uratic and diletlc
est rates ofBP controL68 Treatment rec
ommendatiorIS for older individuals
with hypertension, including those who
have isolated systolic hypertension,
should follow the same principles out
lined for the general care of hyperten-
FIxed-Dose Combination. mg. Trade Nama
Lolral
(2.5110.5/10,5120. 10120)
EnaIapriI maleatelfelodipine (515) Laxxel
T~ (2/180.11240. Tarka
21240, 41240)
BenazepriVhydrochlotothiazide (516.25. Loteosin HCT
10112.5.20112.5.20125)
Captoprillhydrochlorothiazide (25115. Capozide
25125. 50115. 50125)
EnalaprI maleate/hydrochlorothiazicle Vassrelic
(5112.5. 10125)
Usi1opriiIhydroothiazide (10/12.5, Prinzide
20112.5.20125)
Moexipril HClIhydrochlorothiazide Uniretlc
(7.5112.5. 15/25)
Ouilaprll HCVhydrochlorothiSlic.le AccuretlC
(10112.5. 20112.5. 20125)
Candesartan cilexEltMlydroctiorothiazide Atacand HCT
__~(1~&~1~2.~5~.3~2~/1~2~.5)~______________________
Eprosartan mesylatehlyci'ochlorothiazide Teveten HeT
(6OOI12.5.6CXJI25)
Irbesartan/hydrochloro1hiazide (75112.5, Avalide
~~:?~.3OOI-:-_1_2.-,5),--______________
Losartan potassil.lTlthydrochlorotliazide Hyz.aar
(50112.5.100125)
TelmisartarVhydrochlorothiazide MicardiS Her
(40112.5, 80112.5)
ValsartanlhydrochlorOthiazide (80112.5, OiovanHCT
160112.5)
AtenoIoI/c/lIorthaIi(1one (50125, 1(0125) Tenoretic
Bisoprolol fumaratalhydrochlorolhiaZide Zlac
(2.516.25.516.25,1016.25)
PropranoIoIlMlydrochiorothiazide Inderide
(40125, 80125)
Metoprolol tartratelhydrochiorothiaZide Lopressor HCT
(50125, 100125)
NadoiollbendroflL.rTlethiazicle (40/5,
8015)
011'10l0I maleatelhydrochlorothiazide Timolide
{10125!
MethyldOJ)8l1lydrochlothiazlde Po.Idoril
(250115. 250125. 500130, 500150)
Raserpinelchlorothiazide (0.1251250. Oiupres
0.251500)
Reserpinelhydrochloothiazide Hydropres
(0.125/25,0.125150)
AITiIoride HCVhydrochiorothiazide (5150) Moduretlc
Spironolactonelhydrochlorothiazid9 Aldactone
(25/25. 501501
Triamterenelhydrochlorothiazide
(37.5/25.50125. 75150)
(Reprinted) JAMA. May 21, 200J-Vol 289. No, 19 2567
THEJNC 7 REPORT

sion. In many individuals, lower ini should have their BP checked regu defined as BP that is, on repeated mea
tial drug doses may be indicated to larly. Development ofhypenension is a surement, at the 95th percentile or
avoid symptoms; however, standard reason to consider other forms of con greater adjusted for age, height, andsex.T.I
doses and multiple drugs are needed in . traception. In contrast, hormone replace The fifth Korotkoff sound is used to
the majority of oLder individuals to ment therapy does not raise BP.71 define diastolic BP. Clinicians should be
reach appropriate BP targets. Women with hypertension who be alert to the possibility of identifiable
Postural Hypotension. A decrease in come pregnant should be followed care causes of hypertension in younger chil
standing systolic BP of more than 10 fully because of increased risks to mother dren (ie, kidney disease, coarctation of
mrn Hg, when associated with dizzi and fetus. Methyldopa, ~-blockers, and the aorta). lifestyle interventions are
ness or fainting. is more frequent in vasodilators are preferred medications for strongly recommended, with pharma
older patients with systolic hyperten the safety of the fetus. 72 Angiotensin cologic therapy instituted for higher lev
sion, diabetes, and those taking diuret converting enzyme inhibitors and ARBs els of BP, or if there is insufficient
ics, venodilators (eg, nitrates, a-block should not be used during pregnancy be response to lifestyle modifications. 7"
ers, and sildenafil-hke drugs), and some cause of the potential for fetal defects and Choices of antihypertensive drugs are
psychotropic drugs. Blood pressure in should be avoided in women who are similar in children and adults, but effec
these individuals should also be moni hkely to become pregnant Preeclamp tive doses for children are oIten smaller
tored in the upright position. Caution sia, which occurs after the 20th gesta and should be adjusted carefully. Angio
should be used to avoid volume deple tion week of pregnancy, is character tensin-converting enzyme inhibitors and
tion and excessively rapid dose titra ized by new-onset or worsening ARBs should not be used in pregnant or
tion of antihypenensive drugs. hypertension, albuminuria, and hyper sexually active girls. Uncomplicated
Demrntia. Dementia and cognitive uricemia, sometimes with coagulation hypertension should not be a reason to
impairment occur more commonly in abnormalities. In some patients, pre restrict children from participating in
patients with hypertension. Reduced eclampsia may develop into a hyperten physical activities, particularly because
progression of cognitive impairment sive urgency or emergency and may re long-term exercise may lower BP. Use
may occur with effective antihyperten quire hospitalization, intensive of anabolic steroids should be strongly
sive therapy.69.7D monitoring, early fetal delivery, and par discouraged Vigorous interventions alsQ
Ifypl!rt015ion in WommtOral contra enteral antihypertensive and anticon should be conducted for other existing
ceptives may increase BP and the risk of vulsant therapy.71 modifiable risk factors (eg, smoking).
hypertension increases with duration of Childrrn and Adolescents. In chil Hypertensive Urgenda and Emergen
use. Women taking oral contraceptives dren and adolescents, hypertension is cies. Patients with marked BP eleva-

Table 6. Clinic:al Trial and Guideline Basis for Compelling Indications for Individual Drug Classes
Recommended Drugs
High-Risk Cond'rtions I
With Compelling ACE Aldosterone
indication" Diuretic !'I-Blocker Illhibltor ARB CCB Antagonist Clinical Trial Basist
HeM failure ACc/N-IA Heart Failure Guideline,Cl
MEAIT-HF,'1 COPEANICUS,42 CIBtS,42
SOLVD," AlAE. 05 TRACE,4Ii ValHEFT:"
PALESCII
Post-myocardial infarction ACC/N-IA Post-MI Guideline," BHAT,!iO
SAVE,51 Qapricom,52 EPHESUS'"
High coronary disease risk ALLHAT,33 HOPE,lM ANBP2,. UFE,:12
CONVINCE?'
Diabetes NKF-ADA Guideline,21,22 UKPDS,'" AlLHATZI
Chronic kidney disease NKF Guideline, ~ Captopril TriaI,l5 RENAAL,1Il
IONT,S? AEIN,"MSK-
Recurrent stroke p r e v e n t i o n . . PROGRESS3!l
AbbreYIalions: MSt<, AAican American Study of KJdney ~ and Hypertension; NX/#-IA. AmerIcan College c:J CerdioIogy/American Heart AssociatiOn; ACE. angiotBnsh
~ enzyme: AlAE. Acute Inferctlon RamlpcI EfIIcacy: ALl..HAT, AnIlhypartensM! and ~L~ Tleatmen\ 10 Pre\l8l1I Heart At1ack Trial; ANBP2, Second AusIra5an
National Blood f'ressI6B Study; ARB, angioIensin-receptor blocker; SHAT, IIBlocker Heart Mack Trial: cca. calc:iLJ'n chameI blocker; CIBlS, Cen:IIac InsllfICiercy BisoprokX
Study; CONVINCE. Controlled Onset VerepaI'Tj investigation of CardIovascular End Points; COPERNICUS. CarvedIloI Prospective Ra'ldomized ClmAaM SLI'\NaI Study:
EPHESUS, Eplerenone PoslAcuIe MyOCllrdiallnfactiorl Heart F8lIre E1ficec:y and SurvMil Study; HOPE. Hemt CMcomes PrIMIntlon Evaluation Study; 1DNT.1r1tlesara1 DIa
betic NBphropalhyTriaI; llFE. Losartan ~ For Endpoint FIBductlon n Hypertension Study; MERITHF. Me\oprtllol CRIXL Randorn2Bd IntSMllltlon TrVilln Coogestiye
Heart FaIlKe: NKF-AOA. Nallonal KIdney FoI.ndation-American Olabetes Associa1ion; PROGRESS. Perlndopril Protectlon Ag8hs1 RecuTtnI Stroke study; RALES. RendomIzed
Ndactone EvaMition SIudy; RaN, RamiprI E!Iicacy h NepIYopaIhy Study: RENAAL. ReductIon of Endpoints In NorHnsu/ilDependent DIabetes MellItus with the AngiotlInsl'I a
Mtagcnst losartan Study; SAVE. &r.1vaI and ventricular Enlargement Study; SCllVD. Studies or Left Ventricular Dysfunction; TRACE, TrandoIaprtI Cardiac Evaluation Study:
UKPOS. UnIted Kingdom ProspectIve DIabeIes Study; VaIHEFT, Valsa1an Heart FaII\Ke Trta!.
*CompeIing irdcations lor antlhyperllll1SiYe drugs IIf1I based on benefiIs from outcome studies or existing cIiricaI gJt:iellnes: the co~lIing Indication Is managed il parallel wtt"
the blood pra!ISUIB.
tConditions for wtlich cinicallrials demonslrBte benefit c:J specJ!1c classes c:J anlt1ypertansive drugs.

2568 lAMA, May 21. 2003-Vo! 289, No. 19 (Reprinted) Cll003 American Medical Association. All rights rcstned.

lions and acute target-organ damage
(eg, encephalopathy, myocardial in
farction, unstable angina, pulmonary
edema. eclampsia, stroke.. head trauma,
life-threatening arterial bleeding. or aor
tic dissection) require hospitalization
and parenteral drug therapy. I Patients
with markedly elevated BP but with
out acute target-organ damage usually
do not require hospitalization. but they
should receive immediate combina
tion oral antihypettensive therapy. They
should be carefully evaluated and moni
tored for hypertension-induced heart
and kidney damage and for identifi
able causes of hypertension (Box 2).
Additional Considerations in Anti
hypertensive Drug Choices. Antihyper
tensive drugs can have favorable or un
favorable effects on other comorbidities.
Potential Favorable Effects. Thiazide
type diuretics are useful in slowing de
mineralization in osteoporosis. I)-Block
ers can be useful in the treatment of
atrialtachyarrhythmiaslfibrillation. mi
graine. thyrotoxicosis (s~ort-term), es
sential tremor, or perioperative hyper
tension. Calcium channel blockers may
be useful in Raynaud syndrome and cer
tain arrhythmias, and a-blockers may
be useful in prostatism.
Potential Unfavorable Effects. Thia
zide diuretics should be used cau
tiously in patients who have gout or
who have a history of significant hy
ponatremia.j3-Blockers should gener
ally be avoided in individuals who have
asthma, reactive airways disease. or sec
ond- or third-degree heart block. An
giotensin-converting enzyme inhibi
tors and ARBs should not be given to
women likely to become pregnant and
are contraindicated in those who are;
ACE inhibitors should not be used in
individuals with a history of angio
edema. Aldosterone antagonists and po
tassium-sparing diuretics can cause hy
perkalemia and should generally be
avoided in patients who have serum p0
tassium values of more than 5.0 mEqIL
while not taking medications.
Improving Hypertension Control
Adherence to Regimens. Behavioral
models suggest that the most effective
02003 American Mt:diad Associllti(ln. All rights reserved.
THEJNC 7 REPORT
Box 3. Causes of Resistant Hypertension
Improper blood pressure measurement
Volume overload and pseudotolerance
Excess sodium intake
Volume retention from kidney di.sease
Inadequate diuretic therapy
Drug-induced or other causes
Nonadherence
Inadequate doses
Inappropriate combinations
Nonsteroidal anti-inflammatory drugs; cyclooxygenasc 2 inhibitors
Cocaine, amphetamines, other illicit drugs
Sympathomimetics (decongestants. anorectics)
Oral contraceptives
Adrenal steroids
Cyclosporine and tacrolimus
Erythropoietin
[lcorice (including some chewing tobacco)
Selected over-the-counter dietary supplements and medicines (eg, ephedra,
rna baung, bitter orange)
Associated conditions
Obesity
Excess alcohol intake
Identifiable causes of hypertension (see Box 2)
therapy prescribed by the most careful alterations in the plan should be docu
clinician win control hypertension only mented. Blood pressure self,.monitor
if the patient is motivated to take the pre ing can also be useful. Patients' nonad
scribed medication and to establish and herence to therapy is increased by
maintain a health-promoting lifestyle. misunderstanding of the condition or
Motivation improves when patients have treatment, denial of illness because of
positive experiences with and trust in lack of symptoms or perception of drugs
their clinicians. Empathy builds trust as symbols of ill health. lack of patient
and is a potent motivalor. n Patient at involvement in the care plan, or unex
titudes are greatly influenced by cul pected adverse effects of medications.
tural differences. beliefs. and previous The patient should be made to feel rom
experiences with the health care sys fortable in tdling the clinician all ron
tem. 16 These attitudes must be under cerns and fears of unexpected or dis
stood if the clinician is to build trUSt and turbing drug reactions.
increase communication with patients The cost of medications and the
and families. complexity of care (ie, transportarion,
Failure to titrate or combine medica parient difficulty with polypharmacy,
tions, despite knowing the patient is not difficulty in scheduling appointments,
at goal BP, represents clinical inertia and and life's competing demands) are
must be overcome.77 Decision support additional barriers that must be over
systems (ie, electronic and paper), flow come t.O achieve goal BP. All members
sheets. feedback reminders, and involve of the health care team (eg. physi
ment of nurse clinicians and pharma cians, nurse case managers, other
cists can be helpful.78 nurses, phYSician assistants, pharma
The patient and clinician must agree cists, dentists, registered dietitians,
on BP goals. A patient-centered strat optometrists, and podiatrists) must
egy to achieve the goal and an estima work together to influence and rein
tion of the time needed to reach the goal force instructions to improve patients'
are important. '19 When BP is above goal, lifestyles and BP controLIIO
(Reprinted) JAIM, May 21. 2003--Vol 289, No, 19 2569

Orieans. la); Haralambos Gavras. MD (Boston UnI
versity School of Medicine. 8ostcn. Mass>; MartIn Grais.
Me (Feinberg School of Medicine. Northwestem Unl
verslty. Chkago. Ill); WIlla A. Hweh, MD (DaVid Gef
fen School of Medicine, UI1ivenIty of Califomia at los
Angeles); Kenneth A. Jamerson. MD (University of
Miclligan Medical Center. Ann Arbor); Norman M.
Kaplan. MO (University of Texas Southwes1em Medl
ca! Center, Ddas); Theodore A. ICotdIen. MD (Medi
ca! College of Wl5I;OIISin. Milwaukee); Daniel Levy.
MD (National Hurt, lung. and Blood Institute.
Framingham. Mass); Michael A. Moore. MD (Wake
Forest UnIversity School of Medicine and Dan River
Region Cardiovascular Health Initiative Program. Dan
ville. Va); Thomas J. Moore. MD (Boston University
MedIcal Center, Boston. Mass); VasiI!os Papademe
triou, MO (Veterans AdministratiOn Medical Center,
WashinBfoo. DC); Carl J. Pepine. MO (University of
Florida. College of Medicine, GalnesviUe. F\a); Rob
ert A. PhIUips. /IN). PhD (New York University. Lenox
HIli Hospital. New York); Thomas G. Pickering. MD.
DPhii (Mount Sinai Medical Center. New York. NY);
l. Michael Prisant, MD (Medical College of Georgia.
Avgusta); C. VllI1kata5. Ram.MO (UnIven'.ity of Texas
Southwestern Medical Cenler and Texas Blood Pres
sure Instilute. Dallas); Eli!ah Saunders. MD (Unlver
sity of Matyland School of Medldne, Baltimore); Ste
phen C. TextOl. MO (Mayo Clinic, Rodlester, Minn);
Donald G. Vidt. MD (Cleveland Clinic Foundation.
Oeveland. Ohio); Myron H. Weinberger. MD (lndi
ana University School of Medicine. Indianapolis); Paul
K. Whelton. MD, MS<: (Tulane University Health Sci
ences Center. New Orleans. La).
FundinBlSupport:This work was supported entirely
by the National Heart, lung. and Blood Institute. The
executive COInmittee. writing teams, and reviewers
served as volunteers without remuneration.
The NHBPEP CoonIlnatlna Committee Indudes Rep
resentaUves From the following Member Orpn!z.l
tlons: Amerlcan Academy of family Physldans; Ameri
can Academy of Neuroloy: American Academy of
Ophthalmology; Amerlcan N.:M1remt of Physician Assis
tants; American Association of Oupalional Health
Nurses;ArrIe!bn CoIlegeofC4rdiology; Amefican Col
lege of Chest Physicians; American College of Oa:u
pational and Environmental Medidne; American Col
lege of I'hysicianrAmetican SocIety of Internal MediCIne;
American College of Pn!ventIve Medicine; American
Dental AssocIation; American Diabetes Assodation;
American Oietetk: Association; American Heart Asso
ciation; American Ho!ipitaJ As!odation; American Medi
cal Association; American Nurses Association; Ameri
can Optometric AssocIation; American Osteopathic
Association; American Pharmaceutical Association;
Americ.an PodiatricMed1c:a1 AssocIation: AmerIcan Pub
Iii: Health AssocIation; AmerIcan Red Cross; American
Society of Health-System Pharmadsts; American S0cI
ety of Hypertension; AmerIcan Society of Nephrology;
Association of Black Cardiologists; Citizens for Publk
Action on High Blood Pressure and Cholesterol. tnc;
Hypertension Education Foundation. Inc; Interna
tional Societyon Hypertension in Blacks; NatlonalBlack
Nurses Assodatlon. Inc; National Hypertension Asso
Ciation.lnc; Natiol'lal Kidney Foundation. Inc; Nation.ll
Medical Association; National Optometric Assocla
tion; National Stroke Association; NHlBI Ad Hoc COIn'
mitlee on Minority Populations; Society for Nutrition
Education; The Society of Geriatric CardIology. fed
eraI ~ "'tJlfqforHealthare Resean:hand Qual
ity; Centers fcr Medicare and Medicaid Se1vice'!i; Depart.
ment ofVeterllns Affairs; HeaIltt Resources and 5enIIces
Administration; National Cenlef for Health Statistics;
National Heart. Lung. and Blood Institute: NaIIonaIlnsti
Me of Diabetes and OIf:esti~ and Kidney Diseases.
Acknowlqment: We olpptedate the assistance of
Carol Creech. MILS. and Gabrielle Gessner, BS, from
American Institutes for Research Health Program, SiI
ver Spring. Md.
2003 American Medical Association. All rights resened.
THEJNC 7 REPORT
Scheme Used for Classification of the Evidence --I
M Meta-analysis; use of statistical methods to combine the results from clinical I
trials
Ra Randomized controlled trials; also known as experimental studies
Re Retrospective analyses; also known as case-control studies
F Prospective study; also known as cohort studies. including historical or pro
spective follow-up studies
X Cross-sectional survey; also known as prevalence studies
Pr Previous review or pOSition statements
C Clinical interventions (nonnmdomized)
These symbols are appended to the citations in the reference list. The studies that
provided evidence supporting the recommendations of this repon were classified
and reviewed by the staff and the executive committee. The classjfication scheme
is from theJNC VI repon. 1
REFERENCES 14. Cushman WC, Ford CEo Cutter JA. et aI. Success
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