Ht Nlecture2009


Published on

HTN , 2009/2010 , clinical cases

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Ht Nlecture2009

  1. 1. HTN new Updates Dr Ihab Suliman MBBS,ECFMG(USA),DCBNC(USA), MRCP(UK) Associate Consultant Cardiology Member of the European Working Group on Nuclear Cardiology & Cardiac CT
  2. 2. Case <ul><li>40 years old male , came anxious to the clinic , previous history of drug abuse , before coming to the clinic , had one large CAPPUCINO with extra shot, BP 160/95, a diagnosis of HTN is established if ??????? </li></ul>
  3. 3. <ul><li>1- further 2 readings are 160/95. </li></ul><ul><li>2-there is history of DM. </li></ul><ul><li>3- Cannot officially be made at this time. </li></ul>
  4. 4. <ul><li>3- Cannot officially be made at this time. </li></ul>
  5. 5. HTN Defined <ul><li>Average of 3 or more properly measured Blood Pressure readings over a period of weeks to Months. </li></ul><ul><li>Normal BP is below 120/80. </li></ul><ul><li>Pre-HTN SBP 120-139/80-89 </li></ul><ul><li>Stage 1 140-159/90-99 </li></ul><ul><li>Stage 2 equal or more 160/100 </li></ul><ul><li>JAMA 2003 </li></ul>
  6. 6. Properly Measured <ul><li>Cuff Size </li></ul><ul><li>Bilateral </li></ul><ul><li>Confirm with Manual </li></ul><ul><li>No recent caffeine or Smoking </li></ul>
  7. 7. Hypertension Risk Factors <ul><li>Sodium Intake </li></ul><ul><li>Excess alcohol, Energy drinks. </li></ul><ul><li>Genetic or Racial factors </li></ul><ul><li>Obesity </li></ul><ul><li>Others DM, Lack of excercise </li></ul>
  8. 8. Benefits of HTN Rx <ul><li>Reduced incidence of Stroke (35%-40%). </li></ul><ul><li>Reduced Incidence of MI (20%-25%). </li></ul><ul><li>Reduced Incidence of Heart Failure( 50%) </li></ul>
  9. 9. NNT <ul><li>NNT to prevent one death if SBP is reduced by 12mmHg for 10 years is 11 . </li></ul>
  10. 10. Case <ul><li>55 years old obese Diabetic with Type 2 DM, SBP is consistently above 150 mmHg, the best initial treatment will be ??? </li></ul><ul><li>1-HCTZ 12.5 MG PO DAILY. </li></ul><ul><li>2-TENORMIN 50 MG PODAILY </li></ul><ul><li>3-LISINOPRIL 20 MG PO DAILY </li></ul><ul><li>4-LISINOPRIL 10 MG PODAILY </li></ul>
  11. 11. <ul><li>4-LISINOPRIL 10 MG PODAILY </li></ul><ul><li>You FU the patient by </li></ul><ul><li>A-POTASSIUM </li></ul><ul><li>B-RENIN </li></ul><ul><li>C-CREATININE </li></ul><ul><li>D-ECG </li></ul><ul><li>E— A&C </li></ul><ul><li>F-A,B,C,D </li></ul>
  12. 12. <ul><li>E— A&C </li></ul><ul><li>The patient after starting Lisinopril will be seen after with Basic Screen </li></ul><ul><li>A- one week then 3 monthy </li></ul><ul><li>B- every 3 months </li></ul><ul><li>C- within 3 days then 3months </li></ul>
  13. 13. <ul><li>A- one week then 3 monthy </li></ul>
  14. 14. <ul><li>45 years old male with DM , Prior history of IHD, Last echo report EF 45%, SBP 155, Creatinine 140, potassium 4, started on lisinopril 10 mg po daily, after 3 month on a routine visit SBP 115, creatinine 155, potassium is 4.5 , No chest Pain or SOB, the next step will be ???? </li></ul>
  15. 15. <ul><li>A- DIC Lisinopril & Start Amlor . </li></ul><ul><li>B- refer to cardiology. </li></ul><ul><li>C-No change & B </li></ul><ul><li>D- DIC lisinopril & start ARBs </li></ul><ul><li>E- Start Aliskiren </li></ul>
  16. 16. Hypertensive Urgency & Emergency <ul><li>What is the difference ??? </li></ul><ul><li>1- Symptoms. </li></ul><ul><li>2- Degree of Systolic BP. </li></ul><ul><li>3- Degree of Diastolic BP </li></ul>
  17. 17. <ul><li>1- Symptoms. </li></ul><ul><li>What are they?????? </li></ul>
  18. 18. Hypertensive Emergency Sx <ul><li>Headache </li></ul><ul><li>Neurolological SX </li></ul><ul><li>Chest Pain </li></ul><ul><li>Anuria </li></ul>
  19. 19. <ul><li>Difference between Hypertensive Urgency & Emergency </li></ul><ul><li>Hypertensive Emergency Is any Significantly SBP with sx. </li></ul><ul><li>Hypertensive Urgency is BP above 230/120 without sx </li></ul>
  20. 20. <ul><li>Difference between Hypertensive Urgency & Emergency </li></ul><ul><li>Hypertensive Emergency Is any Significantly SBP with sx Treatment start immediately, avoid sublingual Nifedipine. Refer to ER </li></ul><ul><li>Hypertensive Urgency is BP above 230/120 without sx, BP should come down to target within 24-48 Hours </li></ul>
  21. 21. Algorithm for Treatment of Hypertension (JNC 7) JAMA, May 2003 Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications With Compelling Indications Stage 2 Hypertension 2-drug combination for most Stage 1 Hypertension Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination Without Compelling Indications
  22. 22. Case <ul><li>60 years old university teacher is working in university of london , he is married with children , not diabetic , not asthmatic , migrated from Nigeria, labeled as first stage of HTN, SBP 150, according to UK guidelines for HTN , the first line will be ? </li></ul><ul><li>1-BB </li></ul><ul><li>2-CCB </li></ul><ul><li>3-Hydralazine </li></ul>
  23. 23. <ul><li>2-CCB </li></ul><ul><li>His Colleague who is a an englishman is 50 years old , visits the same doctor for the same clinical problem, he has history of asthma, he is likely to get ?? </li></ul><ul><li>1-candesartan </li></ul><ul><li>2-BB </li></ul><ul><li>3-lisinopril </li></ul>
  24. 24. <ul><li>1-candesartan </li></ul>
  25. 25. Choosing drugs for patients newly diagnosed with hypertension BHS Guidelines (June 2006) Younger than 55 years 55 years or older Or black patients of any age A C or D A+C or A+D A+C+D <ul><li>Add </li></ul><ul><li>further diuretic therapy </li></ul><ul><li>Or alpha blocker </li></ul><ul><li>Or Beta Blocker </li></ul><ul><li>Consider seeking specialist advice </li></ul>Abbreviations: A: ACE-I (or ARB if ACE intolerant) C: CCB D: thiazide type diuretic Step 1 Step 2 Step 3 Step 4
  26. 26. Hypertension and Diabetes Recommendations of the American Diabetic Association <ul><li>Treat to BP <130/80 mmHg </li></ul><ul><li>All patients with diabetes and hypertension should be treated with a regimen that includes either an ACEi or an ARB . </li></ul><ul><li>If needed to achieve blood pressure targets, a thiazide diuretic should be added. </li></ul>American Diabetes Association. Diabetes Care. 2005; 28 (Suppl 1): S10 – S17.
  27. 27. Conditions favoring the use of ARBs <ul><li>Type 2 diabetic nephropathy </li></ul><ul><li>Diabetic microalbuminuria </li></ul><ul><li>Proteinuria </li></ul><ul><li>Left ventricular hypertrpphy </li></ul><ul><li>ACE-I induced cough </li></ul>
  28. 28. Case 1 <ul><li>45 years old Female discharged from Cardiac Unit last months after establishing diagnosis of CHF with normal coronaries , EF 15%, on ASA, BB, Lasix 40mg BID , Zestril 20 mg, Statin. </li></ul><ul><li>SBP before admission to cardiology was 200 mmHg </li></ul>
  29. 29. <ul><li>What is the cause of her cardiomyopathy? </li></ul><ul><li>1-Viral </li></ul><ul><li>2-idiopathic </li></ul><ul><li>3-Postpartum </li></ul><ul><li>4-HTN </li></ul>
  30. 30. <ul><li>HTN </li></ul>
  31. 31. <ul><li>70 years old female with no prior active cardiac problems, Informed in a private clinic about being Hypertensive, 3 separate visits, SBP 160-170 ,what is the next step?? </li></ul><ul><li>A-life style modfication. </li></ul><ul><li>B-single agent anti hypertensive </li></ul><ul><li>C- combination of two anti hypertensive agents. </li></ul><ul><li>D- a diagnosis of HTN cannot be made at this time. </li></ul>
  32. 32. <ul><li>C- combination of two anti hypertensive agents. </li></ul>
  33. 33. The following are Positive trials? <ul><li>1- I-Preseve </li></ul><ul><li>2- GISSI-AF </li></ul><ul><li>3- HYPVET </li></ul>
  34. 34. The following are Positive trials? <ul><li>3-HYPVET </li></ul>
  35. 35. Prevalence of HTN <ul><li>Prevalence of HTN above the age of 55 years in general population is </li></ul><ul><li>1- 90 % or more </li></ul><ul><li>2- 60% or more </li></ul><ul><li>3- 30% or more </li></ul>
  36. 36. <ul><li>1- 90 % or more </li></ul>
  37. 37. Case <ul><li>22 years old lady with para 5, H/O Pregnancy induced HTN, seen one week after the delivery of twins by C/S, she is SOB , anxious & little bit sweaty , PaO2sat 92%, the best step in mangement will be???? </li></ul><ul><li>A- give propranolol 10 mg po stat. </li></ul><ul><li>B-IV line ,check D-Dimer, High flow oxygen & call ER. </li></ul><ul><li>C-Midazolam 2 mg , ECG stat. </li></ul>
  38. 38. <ul><li>B-IV line ,check D-Dimer, High flow oxygen & call ER. </li></ul>
  39. 39. Scientific evidence <ul><li>Regarding studies of population The strongest Scientific evidence comes from ?? </li></ul><ul><li>1- Metanalysis of methodologically sound RCTs that have consistent results. </li></ul><ul><li>2-Single RCTs. </li></ul><ul><li>3-Observational studies analysed by Experts. </li></ul>
  40. 40. <ul><li>1- Metanalysis of methodologically sound RCTs that have consistent results. </li></ul>
  41. 41. ALLHAT study <ul><li>The following is true about ALLHAT ?? </li></ul><ul><li>The largest trial in Hypertensive patients with mild to moderate renal Impairement. </li></ul><ul><li>Thiazide Diuertics become first lineRx in Simple uncomplicated HTN. </li></ul><ul><li>ACEIs cardiovascular mortality was better than Diuretics. </li></ul>
  42. 42. <ul><li>Thiazide Diuertics become first lineRx in Simple uncomplicated HTN. </li></ul>
  43. 43. HERs The Heart & estrogen Replacement therapy study <ul><li>The following is wrong about HERs?? </li></ul><ul><li>1-It is example of an observational trial . </li></ul><ul><li>2- Reversed decades of thoughts on cardiovascular effects of hormone therapy. </li></ul><ul><li>3-Published in 1998 </li></ul><ul><li>4- It is an example of RCT. </li></ul>
  44. 44. <ul><li>ARBs e.g Candesartan , can be used as first line antihypertensive Line , they are characterized by all the following except?? </li></ul><ul><li>1- Renal protection </li></ul><ul><li>2-better tolerated than ACEI </li></ul><ul><li>3-Increased incidence of DM </li></ul>
  45. 45. Development of new diabetes – CHARM study 0 10 20 30 40 50 60 70 80 No. of cases developing new Diabetes Control candesartan 40% p =0.005 Lancet, 2003
  46. 46. © 2008, American Heart Association. All rights reserved. <ul><li>Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes. </li></ul><ul><li>Ideally, 1 of the 3 agents should be a diuretic & all agents should be prescribed at optimal dose amounts. </li></ul>Resistant Hypertension
  47. 47. <ul><li>Thank you </li></ul>