Download Treatment Of Hypertension In Special Situation

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:
Primary or essential
hypertension.
2. Secondary hypertension.
1.
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 view
7. ECG
Investigation of SELECTED PATIENT
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
1.
Treatment of hypertension
Prehypertension …

Is not a disease,

Is not “hypertension”,

Is not an indication for drug treatment of HTN,

Does not have a BP goal,

Does predict a higher risk for developing CV events,

Does predict a higher risk for developing HTN,

Should be an incentive to improve lifestyle
practices for prevention of HTN and CVD.
Drug use in Hypertension
Class
Drugs / Trade name
DIURETICS
A. 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 agents
A. β-adreno receptor
antagonist (BBs)
Cardio selective
• Atenolol
• Metaprolol
• Acebutolol
• Betaxolol
• Bisoprolol
B. α- adreno receptor
antagonist
a. Prazosin
b. Doxazonic
c. Indoramin
Non selective
• Propranolol
• Oxprenolol
• Alprenolol
• Timolol
• Pindolol
C. Non selective
a. Phantolamine
adrenergic receptor b. Phenoxy benzamine
blocker
Central acting
a. Methyldopa
b. Clonidine
α/β receptor blocker
a. Lebetolol
Calcium channel blocker
Dihydropyridine
Phenyl alkylamine
•
•
•
•
•
• Varapamil
• Diltiazem
Nifidipine
Amlodipine
Nicardipine
Isradipine
Felodipine
ACE inhibitor
• Captopril
• Enalopril
• Lisinopril
• Ramipril
• Benapril
• Fosinopril
Vasodilator (Direct)
•
•
•
Hydralazine
Minoxidil
Diazoxide
•
Na-Nitropruside
Angiotensin II receptor blocker
•
Losartan
•
Valsartan
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 & βblockers.
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
Non- myocardial infraction
(ii) After MI with presented left ventricular
function.
 (i)

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 20 ]
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
th
[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 hrs
Drugs 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
13.7 million
Controlled
27.4%
36 million
Uncontrolled
72.6%
Global Mortality 2000: Impact of Hypertension and Other Health Risk
Factors
High mortality, developing region
Lower mortality, developing region
Developed region
0
1000 2000 3000 4000 5000 6000 7000 8000
Attributable Mortality
(In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:1347-1360.
Complications of Hypertension:
Hypertension
is a risk factor
TIA, stroke
LVH,
HF,CHD,
Renal failure
Peripheral vascular
disease
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.
Long-Term Antihypertensive Therapy
Significantly Reduces CV Events
Stroke
Myocardial
infarction
Heart failure
0
–10
–20
Average
reduction
in events
(%)
–30
20%-25%
–40
–50
35%-40%
>50%
–60
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.
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 older
persons 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
!
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