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TREATMENT OF HYPERTENSION
Aim of treatment
1. Relief of symptoms 2. Prevention of complications and target organ damage 3. Improve quality of life 4. Improve mortality
Benefits of Lowering BP: Average Percent Reduction Ø Stroke incidence 35 -‐ 40% Ø Myocardial infarction 20–25% Ø Heart failure 50%
BP Goals
• All be treated to <140/90 mm Hg • Except : diabetes (<85 mm Hg diastolic) • In 80 years age, SBP:140-‐150 mmHg, can go <140 mmHg if the patient is fit and healthy-‐mentally &
physically
Main items of treatment
1. Life style modifications 2. Diagnosis and treatment of the cause in secondary
HTN 3. Drug therapy
4. Treatment in special situations: Ø Elderly Ø Children Ø Diabetics Ø Chronic kidney disease
Lifestyle modification
1. Diet: • Weight reduction • Salt restriction the degree depends on the severity of HTN • High K and Ca intake
2. Exercise and increase physical activity 3. STOP Smoking and alcohol intake 4. Relaxation therapy
When to start drug Rx
Consider BP level and correlate with overall risk: • Cardiovascular risk factors • Overt cardiovascular disease • Asymptomatic organ damage • Diabetes • Chronic kidney disease.
Pharmacological therapy
First line drugs Second line drugs 1. Diuretics especially thiazide 2. ACE Inhibitor & ARBs 3. Calcium channel blockers 4. B-‐Blockers 5. Alfa 2 blockers
1. Centrally acting drugs alfa-‐methyl dopa 2. Direct vasodilators hydralazine, minoxidil 3. Other anti-‐adrenergic drugs reserpine,
guanithidine, alfa 1 blockers 4. Others
Diuretics
Thiazide and thiazide like
Generic name
Trade name
Dose
Chlorothalidone Hygertone 25-‐50mg Hydrochlorothazide Esidrex 25-‐50
Indapamide Natrilex 1.5mg
Loops diuretics
Generic name
Trade name
Dose
Furosmide Lasix 40 – 80 mg Torsemide Examide 5 – 20 mg
K – retaining diuretics
Generic name
Trade name
Dose
Spironolactone Aldactone 25 – 100 mg Amiloride Midamor 5 mg
B-‐Blockers
Generic name
Trade name
Dose
Propranolol Inderal 40-‐320mg Atenolol Tenornin 50-‐100 mg Bisoprolol Concor 5-‐10 mg Carvidelol Dilatrend 25-‐50 mg Metaprolol Betaloc 50-‐100 mg Sotalol Betacor 40-‐80 mg
ACE Inhibitors
Generic name
Trade name
Dose
Captopril Capoten 25-‐150mg Enalapril Ezapril 5-‐40 mg Lisinopril Zestril 10-‐40 mg Ramipril Tritace 2.5-‐10 mg Prindopril Coversyl 5-‐10mg Fosinopril Monopril 10-‐40 mg
Calcium channel blockers
Generic name
Trade name
Dose
Nifidepine Adalate or epilate 10-‐40 mg Amlodopine Norvasc 5-‐20 mg Verapamil Isoptin 80-‐240 mg Deltiezem Altiezem 120-‐240mg
Angiotensin receptor blockers
Generic name
Trade name
Dose
Losartan Cozaar 50-‐100 mg Valsartan Tareg 80-‐320 mg Candisartan Atacand 8-‐32mg Irbesartan Approval 150-‐300mg
Alfa-‐ blockers
Generic name
Trade name
Dose
Prazocin Minipress 6-‐15 mg Doxazocin Cardura 1-‐4 mg
Centrally acting drugs
Generic name
Trade name
Dose
Alfa methyl DOPA Aldomet 500-‐2000 mg Clonidine Catapress 0.2 -‐0.8 mg
ESC guidelines 2013 Treatment and Risk
ESH Guidelines 2013: Drug combinations
Selection of anti-‐HTN drugs
Subclinical organ damage Clinical events LVH ACEI,CA,ARB Stroke Any Asympt. AS CA,ACEI MI BB,ACEI,ARB Microalbuminuria ACEI,ARB Angina BB,CA Renal dysfunction HF D,BB,ACEI,ARB,
Aldo A Conditions AF ARB,ACEI,BB,CA
ISH D,CA ESRD ACEI,ARB,D MS ACEI,ARB,CA PAD CA DM ACEI,ARB LV dysfunction ACEI Pregnancy CA,MD,BB Black D,CA
Treatment algorism
BP Control in Adult ACC 2013
Hypertensive emergencies Definition It is a state of severe HTN that need rapid BP control with parenteral therapy.
Causes
Cardiac Brain Renal Others 1. Acute LVF and
pulmonary edema
2. Acute aortic dissection
3. Acute coronary syndrome
1. Hypertensive encephalopathy
2. Cerebral stroke thrombotic or hemorrhagic
1. Acute renal failure 2. Malignant HTN
1. Eclampsia of pregnancy 2. Postoperative 3. Crises of
pheochromocytoma 4. Drug withdrawal
clonidine, B-‐Blockers 5. Acute intermittent
porphyria
Drugs in HTN emergencies
Drug Dose Onset Side effects Uses Furosemide 20-‐40mg/1-‐2h 2-‐3h Volume depletion With other drugs IV Nitroglycerine 5-‐100 µg /min 2-‐5 min. Headache CAD Na nitroprusside 0.25-‐10 µg/kg Immediate Thiocynate toxicity All case Labetalol 20-‐80mg /10min 5-‐10 Nausea, vomiting HB All except acute HF Diazoxide 5mg/ kg over 15 min 5-‐10 Salt retention Not in CAD, Ao
dissection Esmolol 200-‐500 µg/kg bolus
+ 50-‐300 µg/kg/min 5-‐10 Hypotension Aortic dissection
post-‐operative HTN Hydralazine 20-‐40 mg IM/IV 10-‐30 min Headache, flushing Eclampsia
