Chronic hypertension classification: Difference between revisions

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__NOTOC__
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{{Template:Hypertension}}
{{Chronic hypertension}}


{{CMG}}; '''Assistant Editor-In-Chief:''' Taylor Palmieri
{{CMG}}; '''Assistant Editor-In-Chief:''' [[User:YazanDaaboul|Yazan Daaboul]], [[User:Sergekorjian|Serge Korjian]], {{USAMA}}


==Overview==
==Overview==
[[Blood pressure]] values for adults have been classified in 2004 according to the Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure into normal, prehypertension, stage 1 hypertension and stage 2 hypertension<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>. In Europe, a different classification of blood pressure has been conducted in 2007 by “The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)”<ref name="pmid18327095">{{cite journal| author=Bonny A, Lacombe F, Yitemben M, Discazeaux B, Donetti J, Fahri P et al.| title=The 2007 ESH/ESC guidelines for the management of arterial hypertension. | journal=J Hypertens | year= 2008 | volume= 26 | issue= 4 | pages= 825; author reply 825-6 | pmid=18327095 | doi=10.1097/HJH.0b013e3282f857e7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18327095 }} </ref>. The classification excludes JNC 7’s pre-hypertension category, but includes 3 different grades of hypertension, in contrast to JNC 7’s two-stage classification of hypertension.
In 2004, the Seventh Report of the Joint National Committee (JNC 7) classified blood pressure values into 4 categories: normal, prehypertension, stage I hypertension, and stage II hypertension.<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref> In 2007, the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) classified blood pressure into 7 categories.<ref name="pmid18327095">{{cite journal| author=Bonny A, Lacombe F, Yitemben M, Discazeaux B, Donetti J, Fahri P et al.| title=The 2007 ESH/ESC guidelines for the management of arterial hypertension. | journal=J Hypertens | year= 2008 | volume= 26 | issue= 4 |pages= 825; author reply 825-6 | pmid=18327095 | doi=10.1097/HJH.0b013e3282f857e7 |pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18327095 }} </ref> This classification remained unchanged in the 2013 ESH/ESC classification.<ref name="pmid23817082">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=J Hypertens | year= 2013 | volume= 31 | issue= 7 | pages= 1281-357 | pmid=23817082 | doi=10.1097/01.hjh.0000431740.32696.cc | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23817082 }} </ref> The ESH/ESC classification excludes JNC 7’s pre-hypertension category, but includes 3 different grades of hypertension in contrast to JNC 7’s two-stage classification of hypertension.


==Classification==
==Classification==
===JNC Classification of Severity===
===JNC 8 update on JNC 7 Classification of Blood Pressure===
The ''Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure''<ref name="jnc7">{{
JNC8(2014) proposes no changes in the blood pressure classification given in JNC7(2004). According to the ''Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure''<ref name="jnc7">{{
cite journal
cite journal
|url=http://jama.ama-assn.org/cgi/content/full/289.19.2560v1
|url=http://jama.ama-assn.org/cgi/content/full/289.19.2560v1
Line 19: Line 19:
|pages = 2560-72
|pages = 2560-72
|pmid = 12748199
|pmid = 12748199
}}</ref> has classified blood pressure in the follows:
}}</ref> blood pressure values were classified as follows:
{| class="wikitable" border="1" style="background:FloralWhite"
 
{| border="0" style="border-collapse:collapse; text-align:center; font-size:120%;" cellpadding="5" align="center" width="600px"
|-
| align="center" style="background:#4479BA; color: #FFFFFF;" |Category
| align="center" style="background:#4479BA; color: #FFFFFF;" |Systolic (mmHg)
| align="center" style="background:#4479BA; color: #FFFFFF;" |
| align="center" style="background:#4479BA; color: #FFFFFF;" |Diastolic (mmHg)
|+ align="center" style="background:#4479BA; color: #FFFFFF;" |'''Blood Pressure Classification''' 
|-
|bgcolor="#f3f3f3"|Normal|| < 120 || and ||< 80
|-
|bgcolor="#f3f3f3"|Pre-Hypertension|| 120-139 || or || 80-89
|-
|bgcolor="#f3f3f3"|Stage 1 Hypertension|| 140-159 || or || 90-99
|-
|bgcolor="#f3f3f3"|Stage 2 Hypertension|| >160 || or || <u>></u>100
|}
 
===ESH/ESC Classification of Blood Pressure===
In Europe, a different classification of blood pressure was introduced in 2007 by ''The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)''. According to the 2013 Guidelines for the Management of Arterial Hypertension, blood pressure values were classified as follows:
<ref name="pmid18327095">{{cite journal| author=Bonny A, Lacombe F, Yitemben M, Discazeaux B, Donetti J, Fahri P et al.| title=The 2007 ESH/ESC guidelines for the management of arterial hypertension. | journal=J Hypertens | year= 2008 | volume= 26 | issue= 4 | pages= 825; author reply 825-6 | pmid=18327095 | doi=10.1097/HJH.0b013e3282f857e7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18327095  }} </ref>
 
{| border="0" style="border-collapse:collapse; text-align:center; font-size:120%;" cellpadding="5" align="center" width="600px"
|-
| align="center" style="background:#4479BA; color: #FFFFFF;" |Category
| align="center" style="background:#4479BA; color: #FFFFFF;" |Systolic (mmHg)
| align="center" style="background:#4479BA; color: #FFFFFF;" |
| align="center" style="background:#4479BA; color: #FFFFFF;" |Diastolic (mmHg)
|+ align="center" style="background:#4479BA; color: #FFFFFF;" |'''Blood Pressure Classification'''
|-
|bgcolor="#f3f3f3"|Optimal|| < 120 || and ||< 80
|-
|bgcolor="#f3f3f3"|Normal|| 120-129 || and/or || 80-84
|-
|bgcolor="#f3f3f3"|High Normal|| 130-139 || and/or || 85-89
|-
|bgcolor="#f3f3f3"|Grade 1 Hypertension|| 140-159 || and/or || 90-99
|-
|bgcolor="#f3f3f3"|Grade 2 Hypertension|| 160-179 || and/or || 100-109
|-
|bgcolor="#f3f3f3"|Grade 3 Hypertension|| ≥ 180 || and/or || ≥110
|-
|bgcolor="#f3f3f3"|Isolated Systolic Hypertension|| ≥140 || and || <90
|-
|}
 
===2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults (JNC 8) --''' DO NOT EDIT'''===
{| align=center
|-
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+ align="center" style="background:#4479BA; color: #FFFFFF;" |'''Comparison of Current Recommendations With JNC 7 Guidelines'''
|-
| align="center" style="background:#DCDCDC;" | '''Topic'''
! colspan="3" align="center" style="background:#DCDCDC;" | JNC 7
! colspan="4" align="center" style="background:#DCDCDC;" |2014 Hypertension Guideline (JNC8)
|-
|align="left" style="background:#DCDCDC;"|'''Methodology'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" | Nonsystematic literature review by expert committee including a
range of study designs
 
Recommendations based on consensus
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" | Critical questions and review criteria defined by expert panel with
input from methodology team
 
Initial systematic review by methodologists restricted to RCT
 
evidence
 
Subsequent review of RCT evidence and recommendations by the
 
panel according to a standardized protocol
|-
|-
| '''Blood Pressure Classification''' || '''Systolic''' (mm Hg) || || '''Diastolic''' (mm Hg)
|align="left" style="background:#DCDCDC;"|'''Definitions'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Defined hypertension and prehypertension
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Definitions of hypertension and prehypertension not addressed,
but thresholds for pharmacologic treatment were defined
|-
|-
| '''Normal''' || < 120 || and ||< 80
|align="left" style="background:#DCDCDC;"|'''Treatment goals'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" | Separate treatment goals defined for “uncomplicated” hypertension
and for subsets with various comorbid conditions
 
(diabetes and CKD)
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" | Similar treatment goals defined for all hypertensive populations
except when evidence review supports different goals for a particular
 
subpopulation
|-
|-
| '''Pre-Hypertension''' || 120-139 || or || 80-89
|align="left" style="background:#DCDCDC;"|'''Lifestyle recommendations'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Recommended lifestyle modifications based on literature review and
expert opinion
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Lifestyle modifications recommended by endorsing the evidencebased
Recommendations of the Lifestyle Work Group
|-
|-
| '''Stage 1 Hypertension''' || 140-159 || or || 90-99
|align="left" style="background:#DCDCDC;"|'''Drug therapy'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Recommended 5 classes to be considered as initial therapy but recommended
thiazide-type diuretics as initial therapy for most patients
 
without compelling indication for another class
 
Specified particular antihypertensive medication classes for patients
 
with compelling indications, ie, diabetes, CKD, heart failure, myocardial
 
infarction, stroke, and high CVD risk
 
Included a comprehensive table of oral antihypertensive drugs including
 
names and usual dose ranges
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" | Recommended selection among 4 specific medication classes (ACEI
or ARB, CCB or diuretics) and doses based on RCT evidence
 
Recommended specific medication classes based on evidence review
 
for racial, CKD, and diabetic subgroups
 
Panel created a table of drugs and doses used in the outcome trials
|-
|-
| '''Stage 2 Hypertension''' || >160 || or || <u>></u>100
|align="left" style="background:#DCDCDC;"|'''Scope of topics'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Addressed multiple issues (blood pressure measurement methods,
patient evaluation components, secondary hypertension, adherence
 
to regimens, resistant hypertension, and hypertension in special
 
populations) based on literature review and expert opinion
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Evidence review of RCTs addressed a limited number of questions,
those judged by the panel to be of highest priority.
|-
|align="left" style="background:#DCDCDC;"|'''Pre-publication review'''
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Reviewed by the National High Blood Pressure Education Program
Coordinating Committee, a coalition of 39 major professional, public,
 
and voluntary organizations and 7 federal agencies
| colspan="4" style="padding: 5px 5px; background: #F5F5F5;" align="left" |Reviewed by experts including those affiliated with professional and
public organizations and federal agencies; no official sponsorship by
 
any organization should be inferred
|-
|}
|}
|}
<small><small>'''Abbreviations:'''


Pre-hypertension is not a disease category; rather, it is a designation chosen to identify individuals at high risk of developing hypertension.  It is not clear if treatment of pre-hypertension would improve outcomes.  In patients with [[diabetes mellitus]] or [[Nephropathy|kidney disease]], a blood pressure > 130/80 mmHg should be considered elevated and may warrant treatment.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; JNC, Joint National Committee;


===Classification of Pathophysiology===
RCT, randomized controlled trial.  
Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes. 
* Over 90% of adult hypertension has no clear cause and is therefore called essential/primary hypertension.  Often, it is part of the [[metabolic syndrome|metabolic "syndrome X"]] in patients with [[insulin resistance]]: it occurs in combination with [[diabetes mellitus]] (type 2), [[combined hyperlipidemia]] and [[central obesity]].<ref name="pmid16719248">{{cite journal | author = Luma GB, Spiotta RT | title = Hypertension in children and adolescents. | journal = Am Fam Physician | volume = 73 | issue = 9 | pages = 1558-68 | month = may | year = 2006 | id = PMID 16719248}}</ref>
* [[Secondary hypertension]] is more common in pre-adolescent children, with most cases caused by [[renal disease]].
====Essential Hypertension====
Essential hypertension is the most prevalent type of hypertension type, and affects 90-95% of hypertensive patients. Although there are risk factors for essential hypertension (sedentary lifestyle, [[obesity]], increased salt intake, increased [[alcohol]] intake), by definition there is no other disease state responsible for the occurrence of the elevated blood pressure.


====Secondary Hypertension====
Adopted from 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).<ref name="pmid24352797">{{cite journal| author=James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al.| title=2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal=JAMA | year= 2014 | volume= 311 | issue= 5 | pages= 507-20 | pmid=24352797 | doi=10.1001/jama.2013.284427 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24352797  }} </ref></small></small>
Secondary hypertension results from an identifiable cause. Recognition of secondary hypertension is critical since the management is different than primary or essential hypertension and involves treatment of the underlying cause of the elevated blood pressure. Underlying disorders that account for secondary hypertension include:


==References==
==References==

Latest revision as of 20:09, 17 May 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Yazan Daaboul, Serge Korjian, Usama Talib, BSc, MD [2]

Overview

In 2004, the Seventh Report of the Joint National Committee (JNC 7) classified blood pressure values into 4 categories: normal, prehypertension, stage I hypertension, and stage II hypertension.[1] In 2007, the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) classified blood pressure into 7 categories.[2] This classification remained unchanged in the 2013 ESH/ESC classification.[3] The ESH/ESC classification excludes JNC 7’s pre-hypertension category, but includes 3 different grades of hypertension in contrast to JNC 7’s two-stage classification of hypertension.

Classification

JNC 8 update on JNC 7 Classification of Blood Pressure

JNC8(2014) proposes no changes in the blood pressure classification given in JNC7(2004). According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure[4] blood pressure values were classified as follows:

Category Systolic (mmHg) Diastolic (mmHg)
Blood Pressure Classification
Normal < 120 and < 80
Pre-Hypertension 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension >160 or >100

ESH/ESC Classification of Blood Pressure

In Europe, a different classification of blood pressure was introduced in 2007 by The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). According to the 2013 Guidelines for the Management of Arterial Hypertension, blood pressure values were classified as follows: [2]

Category Systolic (mmHg) Diastolic (mmHg)
Blood Pressure Classification
Optimal < 120 and < 80
Normal 120-129 and/or 80-84
High Normal 130-139 and/or 85-89
Grade 1 Hypertension 140-159 and/or 90-99
Grade 2 Hypertension 160-179 and/or 100-109
Grade 3 Hypertension ≥ 180 and/or ≥110
Isolated Systolic Hypertension ≥140 and <90

2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults (JNC 8) -- DO NOT EDIT

Comparison of Current Recommendations With JNC 7 Guidelines
Topic JNC 7 2014 Hypertension Guideline (JNC8)
Methodology Nonsystematic literature review by expert committee including a

range of study designs

Recommendations based on consensus

Critical questions and review criteria defined by expert panel with

input from methodology team

Initial systematic review by methodologists restricted to RCT

evidence

Subsequent review of RCT evidence and recommendations by the

panel according to a standardized protocol

Definitions Defined hypertension and prehypertension Definitions of hypertension and prehypertension not addressed,

but thresholds for pharmacologic treatment were defined

Treatment goals Separate treatment goals defined for “uncomplicated” hypertension

and for subsets with various comorbid conditions

(diabetes and CKD)

Similar treatment goals defined for all hypertensive populations

except when evidence review supports different goals for a particular

subpopulation

Lifestyle recommendations Recommended lifestyle modifications based on literature review and

expert opinion

Lifestyle modifications recommended by endorsing the evidencebased

Recommendations of the Lifestyle Work Group

Drug therapy Recommended 5 classes to be considered as initial therapy but recommended

thiazide-type diuretics as initial therapy for most patients

without compelling indication for another class

Specified particular antihypertensive medication classes for patients

with compelling indications, ie, diabetes, CKD, heart failure, myocardial

infarction, stroke, and high CVD risk

Included a comprehensive table of oral antihypertensive drugs including

names and usual dose ranges

Recommended selection among 4 specific medication classes (ACEI

or ARB, CCB or diuretics) and doses based on RCT evidence

Recommended specific medication classes based on evidence review

for racial, CKD, and diabetic subgroups

Panel created a table of drugs and doses used in the outcome trials

Scope of topics Addressed multiple issues (blood pressure measurement methods,

patient evaluation components, secondary hypertension, adherence

to regimens, resistant hypertension, and hypertension in special

populations) based on literature review and expert opinion

Evidence review of RCTs addressed a limited number of questions,

those judged by the panel to be of highest priority.

Pre-publication review Reviewed by the National High Blood Pressure Education Program

Coordinating Committee, a coalition of 39 major professional, public,

and voluntary organizations and 7 federal agencies

Reviewed by experts including those affiliated with professional and

public organizations and federal agencies; no official sponsorship by

any organization should be inferred

Abbreviations:

ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; JNC, Joint National Committee;

RCT, randomized controlled trial.

Adopted from 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).[5]

References

  1. ↑ Cuddy ML (2005). "Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1)". J Pract Nurs. 55 (4): 17–21, quiz 22-3. PMID 16512265.
  2. ↑ 2.0 2.1 Bonny A, Lacombe F, Yitemben M, Discazeaux B, Donetti J, Fahri P; et al. (2008). "The 2007 ESH/ESC guidelines for the management of arterial hypertension". J Hypertens. 26 (4): 825, author reply 825-6. doi:10.1097/HJH.0b013e3282f857e7. PMID 18327095.
  3. ↑ Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M; et al. (2013). "2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)". J Hypertens. 31 (7): 1281–357. doi:10.1097/01.hjh.0000431740.32696.cc. PMID 23817082.
  4. ↑ Chobanian AV; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289: 2560–72. PMID 12748199.
  5. ↑ James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J; et al. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)". JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797.

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