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Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
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Hypertension
Hypertension
Hypertension
Hypertension
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Hypertension

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  • 2 nd most common reason for visit All family physicians should be experts at HTN.
  • Transcript

    • 1. HYPERTENSION
    • 2. Hypertension
      • Hypertension is the most common public health problem in developed countries
      • Called Silent Killer
      • No cure is available, but prevention and management decrease the incidence of hypertension and disease sequelae.
      • Definition: Persistently high arterial blood pressure, defined as systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg
    • 3. Hypertension: The Silent Killer Facts & Figures
      • 50 million Americans & 1 billion worldwide affected
      • Most common primary care diagnosis (35 million visits annually)
      • Normotensive at age 55 have 90% lifetime risk of Hypertension
      • Continuous & consistent relationship with CVD
        • Between ages 40-70, starting from 115/75
        • CVD risk doubles with each increment of 20/10
    • 4. Prevalence Prevalence on hypertension by age Age % Hypertension 18~29 4 30~39 11 40~49 21 50~59 44 60~69 54 70~79 64 80 + 65
    • 5. Causes of Hypertension
      • 1- Primary hypertension (90 – 95%)
      • - Essential hypertension
      • 2- Secondary hypertension (5 – 10%)
      • - Renal diseases
      • - Endocrine disease
      • - Steroid excess
      • - Growth hormone excess
      • - Catecholamine excess
      • - Vascular causes
      • - Drugs
    • 6. Hypertension - Guidelines
      • JNC- VII Classification of BP for adults (+18 yrs)
      CATEGORY SBP mm Hg DBP mm Hg Normal <120 & <80 Prehypertension 120-139 or 80-89 Stage-I 140-159 or 90-99 Stage-II >160 or >100
    • 7. VARIOUS TERMS & DEFINITIONS
      • Isolated systolic hypertension
      • SBP greater than 140mm, DBP less than 90mm
      • 65-75 % of elderly hypertensive have ISHT
      • Resistant hypertension
      • It is the failure to reach goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.
      • Uncontrolled hypertension
      • BP above recommended level (treated or untreated)
      • Complicated hypertension
      • Hypertension with co-morbidities
    • 8. Chronic Complications End / Target organ damage Organ Condition Symptoms, signs/events Heart LVH, CAD Angina / MI Artery Atherosclerosis CAD/CVD/PAD Aneurysm Stroke Kidney Nephropathy Microalbuminuria Eye (retina) Retinopathy Blurring of vision Brain CVD TIA/Stroke
    • 9. Prevalence of Cardiovascular Disease
      • Estimated Number of Persons With Cardiovascular Disease in the US
      10 20 30 40 50 60 High BP CAD CHF Stroke Other 50,000,000 12,200,000 4,600,000 4,400,000 2,800,000 Prevalence (millions) BP=blood pressure, CAD=coronary artery disease, CHF=congestive heart failure (24%) American Heart Association® . 2000 Heart and Stroke Statistical Update. 1999
    • 10. Hypertension Risk Factors
      • Modifiable
        • Cigarette smoking
        • Obesity
        • Physical inactivity- sedentary life style
        • Dyslipidemia
        • Diabetes mellitus
        • Microalbuminuria
      • Non - Modifiable
        • Age
        • Family history
        • Sex
    • 11. Hypertension : Symptoms
      • Most of the patients do not complain of any symptoms
      • Symptomatic patients may have one or more of the following symptoms
        • - Headache
        • - Confusion
        • - Severe shortness of breath
        • - Visual disturbances
        • - Nausea and vomiting
    • 12. Hypertension - Management
      • Life style modification:
        • Regular physical exercise
        • Stop smoking
        • Stop alcohol
        • Dietary controls : weight control
          • Restrict salt intake 4-6 gm/day
          • Restrict saturated fats
    • 13. Hypertension - Management Pharmacological management Category Drugs Diuretics Hydrochlorothiazide, Indapamide ACE-Is Enalapril, Perindopril ARBs Olmesartan, Valsartan, Losartan Beta blockers Nebivolol, Atenolol Alpha blockers Terazosin, Prazosin CCB Amlodipine, Diltiazem
    • 14. Hypertension - Management
      • Goals of Therapy
      • The goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality.
      • Most patients with hypertension, reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal.
      • Goal BP <140/90 mmHg : Achieving target BP is associated with a decrease in CVD complications.
      • Goal BP is <130/80 mmHg (patients with HT and diabetes or renal disease)
    • 15. Ideal Antihypertensive Drug
      • Good efficacy
      • Minimal or no serum glucose imbalance
      • Minimal or no electrolyte imbalance
      • Minimal or no lipid profile imbalance
      • Improve quality of life
        • Physical activity, sleep, sexual functions.
      • Dosage compliance
    • 16. The correct Approach to Hypertension
    • 17. JNC 7 Algorithm
    • 18. Anti Hypertensive drug classes The A, B, C, D approach
    • 19. Anti Hypertensive Drug Classes
      • ACEi – Angiotensin converting enzyme inhibitors - let us call them ‘A’
      • ARB – Angiotensin Receptor Blockers – Let us call them also as ‘A’
      • BB – Beta Receptor Blockers – let us call them ‘B’
      • CCB – Calcium channel blockers – let us call them ‘C’
      • Diuretics – let us call them ‘ D ’
    • 20. AB/CD Rule – HT Treatment AGE Younger (< 55) ACEi, Beta-blocker Ca++-blocker, Diuretic) (AB/CD = Dickerson et al. Lancet 353:2008-11;1999 Older (> 55) ACEi / ARB BB A + B A + B + D Diuretic CCB D + C + A D + C I II III III II I Resistant HT / Intolerance Add / substitute alpha blocker Re-consider 2 0 causes  trial of spironolactone IV: V:
    • 21. Drugs for Compelling Indications
    • 22. DIURETICS
      • Mode Of Action:
      • Eliminate excess fluid & NaCl
      • Decrease Na + & water reabsorption
      • Reduce Blood Volume
      Reduce BP
    • 23. DIURETICS
      • Indications:
          • Hypertension
          • Management of CHF
          • Edema due to Renal Dysfunction
      • Side effects:
          • Electrolyte imbalance - Arrhythmias
          • Dyslipidemia
          • Impotence
          • Loss of Libido
    • 24. BETA BLOCKERS
      • Mode of action
        • Block Beta Adrenoreceptors
        • Decrease in CO
        • Decrease in Renin Release from the Kidneys
      Reduce BP
    • 25. BETA BLOCKERS
      • Indications:
          • Hypertension
          • Angina with Myocardial Ischemia
          • Post MI
          • Arrhythmias
          • Heart failure
      • Side effects:
          • Bradycardia
          • Fatigue
          • Bronchospasm
          • Impotence
          • Dyslipidemia
    • 26.
      •  1 blocker
      • Inhibit  1 receptor
      • ↓ Peripheral vascular resistance
      • ↓ Blood pressure
      ALPHA BLOCKER Mechanism of action:
    • 27. ALPHA BLOCKER
      • Indications:
          • Hypertension
      • Side effects:
      • Dizziness
      • Headache
      • Nasal congestion
    • 28. CALCIUM CHANNEL BLOCKERS
      • Mode of action:
          • Interference with Ca ++ uptake in smooth muscles & cardiac muscle
          • Dilation of peripheral arterioles
          • Reduction in PVR
          • Reduction in Afterload
          • No effect on preload
          • Negative inotropic effect
    • 29. CALCIUM CHANNEL BLOCKERS
      • Indications:
        • Hypertension
        • Angina
      • Side effects:
          • Reflex tachycardia
          • Flushing
          • Edema
          • Headache
          • Constipation
          • Hypotension
    • 30. ACE - INHIBITORS
      • Mode of action:
      • Inhibit Angiotensin converting enzyme
      • Decrease formation of angiotensin II
      • Prevent degradation of bradykinin
    • 31. ACE - INHIBITORS
      • Indications:
          • Hypertension
          • Heart failure
          • Post MI
          • Diabetic Nephropathy
      • Adverse effects:
          • Hypotension
          • Hyperkalemia
          • Dry cough
          • Angioedema
          • Rash
    • 32. ANGIOTENSIN-II RECEPTOR INHIBITOR
      • Blocks the AT 1 receptors
      • Cause effective blockage of RAAS
      • Indications:
        • Hypertension
        • Heart failure
        • Post MI
    • 33. Follow-up and Monitoring
      • Patients should return for follow-up and adjustment of medications until the BP goal is reached.
      • More frequent visits for stage 2 HTN or with complicating co morbid conditions.
      • Serum potassium and creatinine monitored 1–2 times per year.
      • After BP at goal and stable, follow-up visits at 3- to 6-month intervals.
      • Co morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.
    • 34. New Features and Key Messages
      • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
      • Certain high-risk conditions are compelling indications for other drug classes.
      • Most patients will require two or more antihypertensive drugs to achieve goal BP.
      • If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a Thiazide-type diuretic.
    • 35. New Features and Key Messages
      • The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.
      • Motivation improves when patients have positive experiences with, and trust in, the clinician.
      • Empathy builds trust and is a potent motivator.
      • The responsible physician’s judgment remains paramount.
    • 36. THANK YOU

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