JNC7(美国最新高血压治疗指南)

ISSN: 1524-4563 Copyright © 2003 American Heart Association. All rights reserved. Print ISSN: 0194-911X. Online 72514 Hypertension is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/01.HYP.0000107251.49515.c2 2003;42;1206-1252; originally published online Dec 1, 2003; Hypertension Education Program Coordinating Committee Jackson T. Wright, Jr, Edward J. Roccella and the National High Blood Pressure Green, Joseph L. Izzo, Jr, Daniel W. Jones, Barry J. Materson, Suzanne Oparil, Aram V. Chobanian, George L. Bakris, Henry R. Black, William C. Cushman, Lee A. Evaluation, and Treatment of High Blood Pressure Seventh Report of the Joint National Committee on Prevention, Detection, http://hyper.ahajournals.org/cgi/content/full/42/6/1206 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://hyper.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Hypertension is online at at VA MED CTR BOISE on November 6, 2009 hyper.ahajournals.orgDownloaded from SEVENTH REPORT OF THE JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION, AND TREATMENT OF HIGH BLOOD PRESSURE Aram V. Chobanian, George L. Bakris, Henry R. Black, William C. Cushman, Lee A. Green, Joseph L. Izzo, Jr, Daniel W. Jones, Barry J. Materson, Suzanne Oparil, Jackson T. Wright, Jr, Edward J. Roccella, and the National High Blood Pressure Education Program Coordinating Committee Abstract—The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120–139 mm Hg or diastolic BP 80–89 mm Hg) 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 that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (�140/90 mm Hg, or �130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician’s judgment remains paramount. (Hypertension. 2003;42:1206–1252.) For more than 3 decades, the National Heart, Lung, andBlood Institute (NHLBI) has administered the National High Blood Pressure Education Program (NHBPEP) Coordi- nating Committee, a coalition of 39 major professional, public, and voluntary organizations and 7 federal agencies. One important function is to issue guidelines and advisories designed to increase awareness, prevention, treatment, and control of hypertension (high blood pressure). Data from the National Health and Nutrition Examination Survey (NHANES) have indicated that 50 million or more Americans have high blood pressure (BP) warranting some form of treatment.1,2 Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals, and approximately 7.1 million deaths per year may be attributable to hypertension.3 The World Health Organization reports that suboptimal BP (�115 mm Hg SBP) is responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease, with little variation by sex. In addition, suboptimal blood pressure is the number one attributable risk for death through- out the world.3 Considerable success has been achieved in the past in meeting the goals of the program. The awareness of hyper- tension has improved from a level of 51% of Americans in the period 1976 to 1980 to 70% in 1999 to 2000 (Table 1). The Received November 5, 2003; revision accepted November 6, 2003. From Boston University School of Medicine (A.V.C.), Boston, Mass; Rush University Medical Center (G.L.B., H.R.B.), Chicago, Ill; Veterans Affairs Medical Center (W.C.C.), Memphis, Tenn; University of Michigan (L.A.G.), Ann Arbor, Mich; State University of New York at Buffalo School of Medicine (J.L.I. Jr.), Buffalo, NY; University of Mississippi Medical Center (D.W.J.), Jackson, Miss; University of Miami (B.J.M.), Miami, Fla; University of Alabama at Birmingham (S.O.), Birmingham, Ala; Case Western Reserve University (J.T.W. Jr.), Cleveland, Ohio; National Heart, Lung, and Blood Institute (E.J.R.), Bethesda, Md. The executive committee, writing teams, and reviewers served as volunteers without remuneration. Members of the National High Blood Pressure Education Program Coordinating Committee are listed in the Appendix. Correspondence to Edward J. Roccella, PhD, Coordinator, National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 31, Room 4A10, 31 Center Drive MSC 2480, Bethesda, MD 20892. E-mail roccelle@nhlbi.nih.gov © 2003 American Heart Association, Inc. Hypertension is available at http://www.hypertensionaha.org DOI: 10.1161/01.HYP.0000107251.49515.c2 1206 JNC 7 – COMPLETE VERSION at VA MED CTR BOISE on November 6, 2009 hyper.ahajournals.orgDownloaded from percentage of patients with hypertension receiving treatment has increased from 31% to 59% in the same period, and the percentage of persons with high BP controlled to below 140/90 mm Hg has increased from 10% to 34%. Between 1960 and 1991, median systolic BP (SBP) for individuals 60 to 74 years old declined by approximately 16 mm Hg (Figure 1). These changes have been associated with highly favorable trends in the morbidity and mortality attributed to hyperten- sion. Since 1972, age-adjusted death rates from stroke and coronary heart disease (CHD) have declined by approxi- mately 60% and 50%, respectively (Figures 2 and 3). These benefits have occurred independent of gender, age, race, or socioeconomic status. Within the last 2 decades, better treatment of hypertension has been associated with a consid- erable reduction in the hospital case-fatality rate for heart failure (HF) (Figure 4). This information suggests that there have been substantial improvements. However, these improvements have not been extended to the total population. Current control rates for hypertension in the United States are clearly unacceptable. Approximately 30% of adults are still unaware of their hypertension, more than 40% of individuals with hypertension are not on treat- ment, and two thirds of hypertensive patients are not being controlled to BP levels less than 140/90 mm Hg (Table 1). Furthermore, the rates of decline of deaths from CHD and stroke have slowed in the past decade. In addition, the prevalence and hospitalization rates of HF, wherein the majority of patients have hypertension before developing heart failure, have continued to increase (Figures 5 and 6). Moreover, there is an increasing trend in end-stage renal disease (ESRD) by primary diagnosis. Hypertension is sec- ond only to diabetes as the most common antecedent for this condition (Figure 7). Undiagnosed, untreated, and uncon- trolled hypertension clearly places a substantial strain on the health care delivery system. Methods The decision to appoint a committee for The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) was based on 4 factors: the publication of many new hypertension observational studies and clinical trials since the last report was published in 19974; the need for a new clear and concise guideline that would be useful to clinicians; the need to simplify the classification of BP; and a clear recognition that the JNC reports did not result in maximum benefit to the public. This JNC report is presented in 2 separate publications. The initial “Express” version, a succinct practical guide, was published in the May 21, 2003, issue of the Journal of the American Medical Association.5 The current, more comprehensive report provides a broader discussion and justification for the recommenda- tions made by the committee. As with prior JNC reports, the Figure 1. Smoothed weighted frequency distribution, median, and 90th percentile of SBP for ages 60 to 74 years, United States, 1960 to 1991. Source: Burt et al. Hypertension 1995;26:60–69. Erratum in: Hypertension 1996;27:1192. Figure 2. Percentage decline in age-adjusted mortality rates for stroke by gender and race: United States, 1970 to 2000. Source: Prepared by T. Thom, National Heart, Lung, and Blood Institute from Vital Statistics of the United States, National Cen- ter for Health Statistics. Death rates are age-adjusted to the 2000 US census population. Figure 3. Percentage decline in age-adjusted mortality rates for CHD by gender and race: United States, 1970 to 2000. Source: Prepared by T. Thom, National Heart, Lung, and Blood Institute from Vital Statistics of the United States, National Center for Health Statistics. Death rates are age-adjusted to the 2000 US census population. TABLE 1. Trends in Awareness, Treatment, and Control of High Blood Pressure 1976–2000 National Health and Nutrition Examination Survey, % 1976–80257 1988–91257 1991–944 1999–20005 Awareness 51 73 68 70 Treatment 31 55 54 59 Control* 10 29 27 34 Percentage of adults aged 18 to 74 years with systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication. *SBP below 140 mm Hg and DBP below 90 mm Hg and on antihypertensive medication. Chobanian et al JNC 7 – COMPLETE REPORT 1207 at VA MED CTR BOISE on November 6, 2009 hyper.ahajournals.orgDownloaded from committee recognizes that the responsible physician’s judgment is paramount in managing his or her patients. Since the publication of the JNC 6 report, the NHBPEP Coordi- nating Committee, chaired by the director of the NHLBI, has regularly reviewed and discussed studies on hypertension. To con- duct this task, the Coordinating Committee is divided into 4 subcommittees: Science Base; Long Range Planning; Professional, Patient, and Public Education; and Program Organization. The subcommittees work together to review the hypertension scientific literature from clinical trials, epidemiology, and behavioral science. In many instances, the principal investigator of the larger studies has presented the information directly to the Coordinating Committee. The committee reviews are summarized and posted on the NHLBI web site.6 This ongoing review process keeps the committee apprised of the current state of the science, and the information is also used to develop program plans for future activities, such as continuing education. During fall 2002, the NHBPEP Coordinating Committee chair solicited opinions regarding the need to update the JNC 6 report. The entire Coordinating Committee membership provided, in writing, a detailed rationale explaining the necessity for updating JNC 6, outlined critical issues, and provided concepts to be addressed in the new report. Thereafter, the NHBPEP Coordinating Committee chair appointed the JNC 7 chair and an Executive Committee derived from the Coordinating Committee membership. The Coordinating Com- mittee members served on 1 of 5 JNC 7 writing teams, which contributed to the writing and review of the document. The concepts for the new report identified by the NHBPEP Coordinating Committee membership were used to create the report outline. On the basis of these critical issues and concepts, the Executive Committee developed relevant medical subject headings (MeSH) terms and keywords to further review the scientific litera- ture. These MeSH terms were used to generate MEDLINE searches that focused on English-language, peer-reviewed scientific literature from January 1997 through April 2003. Various systems of grading the evidence were considered, and the classification scheme used in JNC 6 and other NHBPEP clinical guidelines was selected.4,7–10 This scheme classifies studies according to a process adapted from Last and Abramson (see the section Scheme Used for Classification of the Evidence).11 In reviewing the exceptionally large body of research literature in hypertension, the Executive Committee focused its deliberations on Figure 5. Prevalence of CHF by race and gender, ages 25 to 74: United States, 1971 to 1974 to 1999 to 2000. Age-adjusted to 2000 US census population. White and African American in 1999 to 2000 excludes Hispanics. Source: National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Disease. Accessed Sep- tember 2003. http://www.nhlbi.nih.gov/resources/docs/cht- book.htm and 1999 to 2000 unpublished data computed by M. Wolz and T. Thom, National Heart, Lung, and Blood Institute. June 2003. Figure 6. Hospitalization rates for congestive heart failure, ages 45 to 64 and 65�: United States, 1971 to 2000. Source: National Heart, Lung, and Blood Institute. Morbidity and Mortal- ity: 2002 Chart Book on Cardiovascular, Lung, and Blood Dis- ease. Chart 3–35. Accessed September 2003. http://www.nhlbi.nih.gov/resources/docs/cht-book.htm. Figure 7. Trends in incident rates of ESRD, by primary diagno- sis (adjusted for age, gender, race). Disease categories were treated as being mutually exclusive. Source: United States Renal Data System. 2002. Figure 1.14. Accessed September, 2003. http://www.usrds.org/slides.htm. Figure 4. Hospital case-fatality rates for congestive heart failure, ages �65 and 65�: United States, 1981 to 2000. Source: National Heart, Lung, and Blood Institute. Morbidity and Mortal- ity: 2002 Chart Book on Cardiovascular, Lung, and Blood Dis- ease. Chart 3–36. Accessed September 2003. http://www.nhlbi.nih.gov/resources/docs/cht-book.htm. 1208 Hypertension December 2003 at VA MED CTR BOISE on November 6, 2009 hyper.ahajournals.orgDownloaded from evidence pertaining to outcomes of importance to patients and with effects of sufficient magnitude to warrant changes in medical practice (“patient oriented evidence that matters” [POEMs]).12,13 Patient-oriented outcomes include not only mortality but also other outcomes that affect patients’ lives and well-being, such as sexual function, ability to maintain family and social roles, ability to work, and ability to carry out activities of daily living. These outcomes are strongly affected by nonfatal stroke, HF, coronary heart disease, and renal disease; hence, these outcomes were considered along with mortality in the committee’s evidence-based deliberations. Studies of physiological end points (disease-oriented evidence [DOEs]) were used to address questions where POEMs were not available. The Coordinating Committee began the process of developing the JNC 7 Express report in December 2002, and the report was submitted to the Journal of the American Medical Association in April 2003. It was published in an electronic format on May 14, 2003, and in print on May 21, 2003. During this time, the Executive Committee met on 6 occasions, 2 of which included meetings with the entire Coordinating Committee. The writing teams also met by teleconference and used electronic communications to develop the report. Twenty-four drafts were created and reviewed repeatedly. At its meetings, the Executive Committee used a modified nominal group process14 to identify and resolve issues. The NHBPEP Coordinating Committee reviewed the penultimate draft and pro- vided written comments to the Executive Committee. In addition, 33 national hypertension leaders reviewed and commented on the document. The NHBPEP Coordinating Committee approved the JNC 7 Express report. To complete the longer JNC 7 version, the Executive Committee members met via teleconferences and in person and circulated sections of the larger document via e-mail. The sections were assembled and edited by the JNC 7 chair and were circulated among the Coordinating Committee members for review and comment. The JNC 7 chair synthesized the comments, and the longer version was submitted to the journal Hypertension in November, 2003. Lifetime Risk of Hypertension Hypertension is an increasingly important medical and public health issue. The prevalence of hypertension increases with advancing age to the point where more than half of people aged 60 to 69 years old and approximately three-fourths of those aged 70 years and older are affected.1 The age-related rise in SBP is primarily responsible for an increase in both incidence and prevalence of hypertension with increasing age.15 Whereas the short-term absolute risk for hypertension is conveyed effectively by incidence rates, the long-term risk is best summarized by the lifetime risk statistic, which is the probability of developing hypertension during the remaining years of life (either adjusted or unadjusted for competing causes of death). Framingham Heart Study investigators recently reported the lifetime risk of hypertension to be approximately 90% for men and women who were nonhy- pertensive at 55 or 65 years old and survived to age 80 to 85 (Figure 8).16 Even after adjusting for competing mortality, the remaining lifetime risks of hypertension were 86 to 90% in women and 81 to 83% in men. The impressive increase of BP to hypertensive levels with age is also illustrated by data indicating that the 4-year rates Figure 9. Ischemic heart disease (IHD) mortality rate in each decade of age ver- sus usual blood pressure at the start of that decade. Source: Reprinted with per- mission from Elsevier (The Lancet, 2002;360:1903–1913). Figure 8. Residual lifetime risk of hyper- tension in women and men aged 65 years. Cumulative incidence of hyperten- sion in 65-year-old women and men. Data for 65-year-old men in the 1952 to 1975 period are truncated at 15 years since there were few participants in this age category who were followed up beyond this time interval. Source: JAMA 2002;287:1003–1010. Copyright 2002, American Medical Association. All rights reserved. Chobanian et al JNC 7 – COMPLETE REPORT 1209 at VA MED CTR BOISE on November 6, 2009 hyper.ahajournals.orgDownloaded from of progression to hypertension are 50% for those 65 years and older with BP in the 130 to 139/85 to 89 mm Hg range and 26% for those with BP in the 120 to 129/80 to 84 mm Hg range.17 Blood Pressure and Cardiovascular Risk Data from observ