Amalina Aminuddin 0820121000 67

Treatment Management

Benefits and principles Benefits ? Principles 1. Improve long term survival and

quality of life2. Promote effective physician-patient

relationship3. Reduce level to 140/90mmHg or less4. Assess cardiovascular risk factors5. Instruct on non-drug treatments and

benefits6. Home BP monitoring for mild

hypertension with no target organ damage

7. Drug therapy given to those with high initial reading, target organ damage or failed non- drug measures

8. Careful selection of drug and appraisal of side effects vs. benefits

9. Avoid drug- related problems10. Aim for steady and graduated control11. Counter problems of patient non-compliance12. Be aware of factors that may contribute to

drug resistance

Patient education Reassurance Clear information Easy to follow instructions Correction of patient’s misconceptions Compliance ?

Non- pharmalogical management

When DBP at initial visit is 90-100mmHg and no organ damage, indicate 3 months without drugs.

Weight reduction Reduce excessive alcohol intake and

smoking Reduction of stress Reduce sodium intake Increase exercise Manage sleep apnoea

Pharmacological therapy

Failed genuine non-pharmalogical trial

SBP 140- 180 or DBP 90 – 110mmHg

Start with a single drug at low dose.

4–6 weeks period for apparent result

If ineffective, consider increasing dose /add another /substitute drug

Use only one drug from any one class at the same time.

Measure the BP at the same time each day.

WHEN TO TREAT : GUIDELINES

1) A or C or D2) If target not reached,

A+C or A +D3) If target not reached,

A+C+D

ACE inhibitor or ARB Calcium-channel

blocker thiazide Diuretic

STARTING REGIMENS

Thiazide diuretic Beta-blocker Calcium-channelblocker

ACE inhibitor

Typical examples

Hydrochlorothiazide12.5 mg dailyIndapamide 1.5 mg or 2.5 mg daily

Atenolol25–50 mg dailyMetoprolol50 mg dailyPropranolol40 mg daily

Amlodipine2.5 mg dailyDiltiazem 180 mg dailyNifedipine 30 mg dailyVerapamil 120–180 mg daily

Captopril6.25 mg bdEnalapril5 mg dailyARBIrbesartan150 mg dailyLosartan50 mg daily

Recommended in

•Heart failure (mild)•Older patients

•Anxious patient•Young patients•Angina•Postmyocardial infarction•Migraine

•Asthma•Angina•PVD•Raynaud phenomenon

•Heart failure•PVD•Diabetes•Raynaud

D B C A

Contraindication

•Type 2 diabetics•Hyperuricaemia•Kidney failure

•Asthma COPD•History of wheeze•Heart failure•Heart block

•Heart block •Heart failure (verapamil, diltiazem)

•Bilateral kidney artery stenosis•Pregnancy•Hyperkalaemia

Precautions

•Hypokalaemia•Thiazides + ACE inhibitors•Kidney failure

•Use with verapamil, ,NSAIDs,in smokers

•With b blockers and digoxin CCF

•Chronic kidney Disease• K-sparing diuretics and NSAIDs

Important side effects

•Rashes•Hypokalaemia•Hyponatraemia•Hyperuricaemia•Hyperglycaemia

•Fatigue•Insomnia•Bronchospasm•Cold extremities

•Headache•Flushing•Ankle oedema•Palpitations

• Cough• Dysgeusia• Hyperkalaemi

a• First dose

hypotension• Angioedema

Management

Mild hypertension Persistent SBP 140-159 or DBP between

90 -99 mmHg, without target organ damage.

Start lifestyle changes then, assess 5 year absolute CV riskRisk ( %) Management • Low

(10)• Maintain lifestyle changes for 6-12

months• Consider drug treatment if >

150/95 mmHg

• Moderate (10-15)

• Maintain lifestyle changes for 3-6 months

• Consider drug treatment if > 140/90 mmHg

• High (>15)

• Maintain lifestyle changes • Begin drug treatment

If BP is well controlled for several months to years, dose or number of drugs can be reduce.

Careful monitoring is mandatory.

Moderate hypertension Try lifestyle

changes Begin drug

treatment if fail If poor initial

response, prescribe2nd drug

Severe hypertension Check for hypertensive

complications May need to be hospitalize CCB with Beta blocker or ACEI

for urgent BP lowering

Hypertensive emergencies

Hypertensive encephalopathy, acute stroke,heart failure, dissecting aortic aneurysm, eclampsia, headache and confusion.

Hospitalised immediately for monitoring and treatment.

Same treatment as severe hypertension. Gradual BP lowering Sodium nitroprusside IV Magnesium sulphate ( eclampsia)

Isolated Systolic Hypertension

Frequently seen in elderly SBP ≥140 mmHg with DBP <90

mmHg Treated as classic hypertension. Commence non-pharmacological

therapy Lower SBP to 140 -160 mmHg

carefully Diuretics, calcium channel

blocking agents and ACE inhibitors.

Refractory Hypertension BP > 140/90mmHg despite maximum

dosage of two drugs for 3-4 months Review possible secondary causes

Drug-related causes: doses too low, inappropriate combinations, effects of other drugs (e.g. antidepressants, adrenal steroids, NSAIDs, oral contraceptives)

Poor compliance with therapy Renovascular hypertension Obesity Excessive alcohol or salt intake Kidney insufficiency and other undiagnosed causes of secondary hypertension Sleep apnoea

Refer to specialist ( no control and no obvious reason)

24-hour ambulatory monitoring.

Routine BP measurement for: Children of hypertensive parents ,those at risk of

secondary hypertension ,children with visual changes, headache, recurrent abdominal pain , and those on corticosteroids

The upper limits of normal BP:

ACEI/ CCB + Diuretics Avoid ACEI in post pubertal girls.

AGE (IN YEARS)

ARTERIAL PRESSURE (MMHG)

14–18 135/9010–13 125/856–9 120/805 or less 110/75

Hypertension In Children

Hypertension in Elderly

Treat isolated systolic hypertension May respond to non-pharmacological treatment.

Reduce dietary sodium Drug dosage—‘start low and go slow’.Treat as younger patient if > 70 years and in good health

Gradual reduction in BP Be aware of drug and drug interactions

GUIDELINES

First-line choice: indapamide /thiazide diuretic (low dose) Add K-sparing diuretic if hypokalaemia

Second line choice: ACE inhibitors or ARB

Other effective drugs (especially for isolated systolic hypertension): β-blockers (low dose) Calcium-channel blockers

SPECIFIC TREATMENT

Diabetes Mellitus Monitor patients for early signs of nephropathy Diabetics with persistent DBP >85 mmHg and

proteinuria need treatment. Treatment

Non-pharmacological treatments First-line choice:

ACE inhibitors or ARBs and calcium-channel blockers Suitable drugs choice:

Prazosin, hydralazine and methyldopa. Caution :Indapamide + ACE inhibitor Monitor proteinuria and kidney function

DBP >80 mmHg in late pregnancy is unacceptable.

Preferred drugs: methyldopa, labetalol,

and β-blockers. Diuretics and ACE

inhibitors should not be used.

Continue same treatment: patients whose BP is under control before surgery

Take parenteral treatment if oral medication affected by surgery

PREGNANCY SURGICAL PATIENTS

Use loop diuretic initially.

Drugs that can be used: β-blockers, Calcium-channel

blockers, Prazosin Methyldopa

Caution :ACE inhibitors

First-line treatment: ACE inhibitors and

diuretics. Other suitable drugs:

hydralazine–nitrate combination

methyldopa. Caution: Calcium-

channel blockers Avoid verapamil and β-

blockers

KIDNEY DISEASE HEART FAILURE

Recommended drugs: β-blockers Calcium antagonists

All except β-blocker

Avoid : Thiazide diuretics, Methyldopa, Reserpine β-blockers

Suitable agents: ACE inhibitors Calcium channel

blockers.

ISCHAEMIC HEART DISEASE ERECTILE DYSFUNCTION

OBSTRUCTIVE PULMONARY DISEASE

Can hypertension be overtreated? Excessive BP reduction can compromise

perfusion in vital organs. Avoid excessive BP reduction in acute

stroke, elderly and head injury. DBP <85 mmHg in ischaemic heart

disease raise the cardiovascular risk

Referance John Murtagh , Murtagh’s General

Practice, 5th edition, 2011, McGraw Hill Australian Pty Ltd.

http://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf