Your SlideShare is downloading. ×
0
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Ht Nlecture2009
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Ht Nlecture2009

733

Published on

HTN , 2009/2010 , clinical cases

HTN , 2009/2010 , clinical cases

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
733
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
35
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  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. 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. <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. <ul><li>3- Cannot officially be made at this time. </li></ul>
  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. 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. 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. 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. NNT <ul><li>NNT to prevent one death if SBP is reduced by 12mmHg for 10 years is 11 . </li></ul>
  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. <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. <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. <ul><li>A- one week then 3 monthy </li></ul>
  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. <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. 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. <ul><li>1- Symptoms. </li></ul><ul><li>What are they?????? </li></ul>
  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. <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. <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. 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. 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. <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. <ul><li>1-candesartan </li></ul>
  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. 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. 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. 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. <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. <ul><li>HTN </li></ul>
  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. <ul><li>C- combination of two anti hypertensive agents. </li></ul>
  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. The following are Positive trials? <ul><li>3-HYPVET </li></ul>
  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. <ul><li>1- 90 % or more </li></ul>
  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. <ul><li>B-IV line ,check D-Dimer, High flow oxygen & call ER. </li></ul>
  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. <ul><li>1- Metanalysis of methodologically sound RCTs that have consistent results. </li></ul>
  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. <ul><li>Thiazide Diuertics become first lineRx in Simple uncomplicated HTN. </li></ul>
  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. <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. 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. © 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. <ul><li>Thank you </li></ul>

×