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PRESENATATION BY
DR MISBAHUL FERDOUS MBBS(USTC)
FMD (USTC)
PGT (CARDIOLOGY) NICVD.DHAKA
PUBLICATION- 1 (ORIGINAL ARTICLE) METABOLIC SYNDROME AND ACUTE ST ELEVATION MI IN
HOSPITAL OUTCOME.
PUBLISHED IN B.H.J. JANUARY-2008
MD (CARDIOLOGY), COURSE SHANDONG UNIVERSITY, CHINA.
Hypertension
Rise of blood pressure above the normal level is called hypertension.
Types:1. Primary or essential hypertension. 2. Secondary hypertension.
Korotkoff, 1905
Ref: Davidson’s Principles & Practice of Medicine 20th P-609
Management of Hypertension A.General management.
B.Antihypertensive Drug therapy.
a) General Treatment
(Non Pharmacological treatment)
Life style modification:
REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 26
Investigations of Hypertension Basic test for initial evaluation a) Always included:
1. Urine for: Protein, blood, glucose
2. Haematocrit
3. Serum electrolytes- specially POTASSIUM
4. Blood urea & serum creatinine
5. ECG
6. Plasma cholesterol
Basic test for initial evaluation
b) Usually included depending on cost & other factors:1. Microscopic analysis 2. WBC 3. Blood / plasma glucose
- Fasting Blood glucose level- 2 HPP blood glucose level
4. Serum – Total cholesterol, HDL, LDL, Triglycerides
5. Serum – calcium, phosphate, uric acid 6. X-ray chest P/A view7. ECG
Investigation of SELECTED PATIENT 1. Ambulatory BP recording
2. Renal ultrasonography
3. Renal angiography
4. Renal isotope scan
5. 24 hours urine assay for creatinine meta morphines and catacholamines on plasma catacolamines if phenochromocytoma suspected.
6. Plasma renin activity & aldesterone
Treatment of hypertension
Prehypertension …Prehypertension … Is Is notnot a disease, a disease,
Is Is notnot “hypertension”, “hypertension”,
Is Is notnot an indication for drug treatment of HTN, an indication for drug treatment of HTN,
Does Does notnot have a BP goal, have a BP goal,
DoesDoes predict a higher risk for developing CV events, predict a higher risk for developing CV events,
DoesDoes predict a higher risk for developing HTN, predict a higher risk for developing HTN,
Should be an incentive to improve lifestyle Should be an incentive to improve lifestyle
practices for prevention of HTN and CVD.practices for prevention of HTN and CVD.
Drug use in Hypertension
Class Drugs / Trade name
DIURETICSA. Thiazide diuretics a. Bendro fluazide
b. Cyclopenthiazide c. Hydrochlorothiazide
B. Loop diuretics a. Bumetanide b. Frusemide
C. Potassium-sparing a. Spironolactone b. Amiloride c. Triamterene
Class Drugs / Trade name Drugs / Trade name
Anti-adrenergic agentsA. β-adreno receptor
antagonist (BBs)Cardio selective • Atenolol• Metaprolol• Acebutolol• Betaxolol• Bisoprolol
Non selective • Propranolol• Oxprenolol • Alprenolol• Timolol • Pindolol
B. α- adreno receptor antagonist
a. Prazosin b. Doxazonicc. Indoramin
C. Non selective adrenergic receptor blocker
a. Phantolamineb. Phenoxy benzamine
Central acting a. Methyldopa b. Clonidine
α/β receptor blockera. Lebetolol
Calcium channel blocker Dihydropyridine Phenyl alkylamine
• Nifidipine • Amlodipine • Nicardipine • Isradipine • Felodipine
• Varapamil • Diltiazem
ACE inhibitor • Captopril • Enalopril• Lisinopril
• Ramipril• Benapril• Fosinopril
Angiotensin II receptor blocker• Losartan • Valsartan
Vasodilator (Direct) • Hydralazine • Minoxidil • Diazoxide
• Na-Nitropruside
REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 27, 28,29
Treatment of hypertension in special situations
1. Hypertension in children and adolescent Life style modification,. if fail
pharmacological therapy should be started
Dosage of antihypertensive medication should be smaller and adjusted very carefully for children.
ACE inhibitor & A-II receptor blocker should not be used In pregnant mother
Use of anabolic steroid for body building & smocking strictly prohibited.
b) Hypertension in PREGNANCY
In the 2nd & 3rd trimester, antihypertensive agents often are not indicated unless the Diastolic BP exceeds 100 mm Hg.
If drugs will be methyldopa, Beta-blocker, CCB in order of preference.
Hydralazine (Parenteral) & prazosin may be used.
Should not be used:
ACEi, A-II Receptor blocker, Diuretics, Nitroprusside
c) Hypertension with HORMONE REPLACEMENT THERAPY
Presence of hypertension is not contraindicated for post menopausal estrogen replacement therapy.
frequent FOLLOW UP should be advised .
3. Hypertension with co-existing cardiovascular diseases
a) Hypertension with CCF Diuretics & ACEi are preferable drugs. Contraindications: Ca++ channel blockers & β-
blockers. ACEi used alone or in conjugation with
DIGOXIN or DIURETICS. When ACEi is contraindicated, the
vesodilators combination of HYDRALAZINE and ISOSORBIDE DINITRATE is also effective in this patient.
In one trial A-II receptor blocker (LOSARTAN POTASSIUM) was superior to CAPTROPIL in decrease mortality.
b) Hypertension with coronary artery disease:
Goal BP < 140/ 90 mm Hg β-blocker & Ca++ channel blocker may be
specially useful in patient with HTN & angina pectoris.
ACEi also useful in MI. If β-Blockers are ineffective on contraindicated
VERAPAMIL or DILTIAZEM may be used in following conditions (i) Non- myocardial infraction (ii) After MI with presented left ventricular
function.
c)Hypertension with LVF: All antihypertensive drug can be used except
direct vasodilatation e.g. HYDRALAZINE
In one study treatment with diuretics & an ACEi are better than other drug.
d) Hypertension with BRADYCARDIA: Nifidipine & ACEi are preferable drugs.
Better to avoid β-BLOKERS, VERAPAMIL, DILTIAGEM
4. Hypertension in Diabetes: Goal BP <140 / 80 mm Hg [ref: Davidson’s 20th ]
Goal BP <130 / 80 mm Hg [ref: JNC 7 ]
Life style modification No antihypertensive are contraindicated in
DM ACEi, A-II receptor, Alpha blocker, CCB,
low dose diuretics are preferred choice. Better avoid β-blocker and high dose
diuretics unless special situation. *ACEi →↓69% protein urea in type-I DM
[ref: Davidson’s 20th ]
5. Hypertension in Dyslipidaemia:
Common co-existence & demand aggressive management of both conditions.
High dose THIAZIDES, LOOPS DIURETICS & BETA
BLOCKERS may transiently increase total cholesterol, still has significant reduction CV morbidity & sudden death. So should be used without hesitation.
6. Hypertension with ASTHMA & COPD: Ca++ channel blocker is the preferable
drug. ACEi are safe in most patients with
asthma. A-II receptor blocker may be used if
cough is trouble some problem after using ACEi.
Contraindications:
β-blocker, α-blocker should not be used in patient with asthma except in special circumstances.
7. Hypertension with CVD: BP is actually raised after stroke. Unless end
organ damage in present or malignant HTN is present, elevated BP should not be lowered in acute stage since it will always return towards normal within 24-28 hours.
After 10 days gentle reduction of BP started as a part of secondary prevention strategy of ischemic stroke.
If hemorrhage stroke there is no value in reducing the high BP (except very high) until at least some days after stroke.
8. Hypertension with LIVER DISEASE: ALL Antihypertensive drugs can be used
except METHYLDOPA.
9. Hypertension with GOUT
All hypertensive drugs can be used But all Diuretics can increase serum uric
acid level but rarely induced acute gout. So diuretics should be avoided if possible.
Contraindications: NO DIURETICS
10. Hypertension with PSORIASIS: β-Blocker and ACEi aggravate psoriasis. So
better to avoid them.
11. Hypertension with Scleroedema with Reynaud's phenomenon
NIFIDIPINE and PROSTACYCLINE infusion may occasionally helpful in patient with severe Reynaud's phenomenon.
12. Hypertension with peripheral vascular disease Better to use Ca++ channel blocker &
Vasodilators.
13. Hypertension with Renal parenchymal disease Goal BP 130 / 85 or <125 /75 mm Hg. Unless contraindicated ACEi + Diuretic should be used.
Loop diuretics should be used & potassium sparing diuretics should be avoided.
Thiazide diuretics are not effective with advanced renal insufficiency.
ACEi used with caution if serum creatinine> 3 mg / dl
14. Adjuvant drug therapy
Aspirin: Anti Platelet therapy is a powerful means of reducing cardiovascular risk.
Indications: Age 50 or more, who have well controlled BP and either target organ damage, Diabetes, or a 10 year coronary heart disease- Risk of > 15%
Statins: Treating hyperlipidaemia & also produce a reduction of cardiovascular risk.
Indications: Established vascular disease or hypertension with a high risk of developing coronary heart disease.
15. Hypertensive crises Hypertensive crises A) Emergency B) Urgency
i) Malignant HTN
ii) Accelerated HTN
Goal of reducing BP 160/100 mm of Hg with in 24 hrsDrugs of Choice:
Oral Drugs are better than I/V
Follow up & Monitoring
serum potassium and creatinine monitored 1-2 times per year.
after BP at goal and stable, follow up visits at 3 to 6 months interval. [ref: JNC 7]
Recommendations for Improving Outcomes
Physician
Establish treatment goals
Maintain adherence
Minimize side effects
Patient
Self-Monitor BP
Keep diary of BP therapy
Make life-style changes
Approximately 50 Million Americans Have Hypertension
Uncontrolled72.6%
Controlled27.4%
13.7 million
36 million
Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors
Ezzati et al. Lancet. 2002;360:1347-1360.Ezzati et al. Lancet. 2002;360:1347-1360.Attributable Mortality Attributable Mortality (In thousands; total 55,861,000)(In thousands; total 55,861,000)
High mortality, developing regionHigh mortality, developing region
Lower mortality, developing regionLower mortality, developing region
Developed regionDeveloped region
00 8000800070007000600060005000500040004000300030002000200010001000
High blood pressureHigh blood pressure
TobaccoTobacco
High cholesterolHigh cholesterol
Unsafe sexUnsafe sex
High BMIHigh BMI
Physical inactivityPhysical inactivity
AlcoholAlcohol
Indoor smoke from solid fuelsIndoor smoke from solid fuels
Iron deficiencyIron deficiency
UnderweightUnderweight
TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; HF = heart failure.Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22.
Retinopathy Renal failure
Peripheral vascular disease
Complications of Hypertension:
LVH, HF,CHD,
TIA, stroke
Hypertension Hypertension is a risk factoris a risk factor
35%-40%
20%-25%
>50%
Average reduction in events (%)
–60
–50
–40
–30
–20
–10
0Stroke
Myocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
JNC 7: Appropriate BP Targets
For both CVD and kidney disease, systolic BP is far more important than diastolic BP
Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease)
Only a small fraction of hypertensives are achieving appropriate BP control
Multiple antihypertensive agents are needed for most patients
Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD.
JNC 7: Considerations for olderpersons with hypertension
This population has the lowest rates of BP control and the
greatest absolute benefit with effective therapy.
Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.
More than two-thirds of people over 65 have HTN, i.e. ISH (Isolated systolic hypertension).
I M WORKING IN CARDIAC CATH LAB.
The END!Thank You!
Oh, sorry, not the END, just the beginning!
54
Email: misbahul_ferdous@yahoo.com 26. TAKHDIR.SUGANDHA. R/A ,CHITTAGONG BANGLADESH
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