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Ht Nlecture2009
 

Ht Nlecture2009

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HTN , 2009/2010 , clinical cases

HTN , 2009/2010 , clinical cases

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    Ht Nlecture2009 Ht Nlecture2009 Presentation Transcript

    • 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
    • Case
      • 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 ???????
      • 1- further 2 readings are 160/95.
      • 2-there is history of DM.
      • 3- Cannot officially be made at this time.
      • 3- Cannot officially be made at this time.
    • HTN Defined
      • Average of 3 or more properly measured Blood Pressure readings over a period of weeks to Months.
      • Normal BP is below 120/80.
      • Pre-HTN SBP 120-139/80-89
      • Stage 1 140-159/90-99
      • Stage 2 equal or more 160/100
      • JAMA 2003
    • Properly Measured
      • Cuff Size
      • Bilateral
      • Confirm with Manual
      • No recent caffeine or Smoking
    • Hypertension Risk Factors
      • Sodium Intake
      • Excess alcohol, Energy drinks.
      • Genetic or Racial factors
      • Obesity
      • Others DM, Lack of excercise
    • Benefits of HTN Rx
      • Reduced incidence of Stroke (35%-40%).
      • Reduced Incidence of MI (20%-25%).
      • Reduced Incidence of Heart Failure( 50%)
    • NNT
      • NNT to prevent one death if SBP is reduced by 12mmHg for 10 years is 11 .
    • Case
      • 55 years old obese Diabetic with Type 2 DM, SBP is consistently above 150 mmHg, the best initial treatment will be ???
      • 1-HCTZ 12.5 MG PO DAILY.
      • 2-TENORMIN 50 MG PODAILY
      • 3-LISINOPRIL 20 MG PO DAILY
      • 4-LISINOPRIL 10 MG PODAILY
      • 4-LISINOPRIL 10 MG PODAILY
      • You FU the patient by
      • A-POTASSIUM
      • B-RENIN
      • C-CREATININE
      • D-ECG
      • E— A&C
      • F-A,B,C,D
      • E— A&C
      • The patient after starting Lisinopril will be seen after with Basic Screen
      • A- one week then 3 monthy
      • B- every 3 months
      • C- within 3 days then 3months
      • A- one week then 3 monthy
      • 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 ????
      • A- DIC Lisinopril & Start Amlor .
      • B- refer to cardiology.
      • C-No change & B
      • D- DIC lisinopril & start ARBs
      • E- Start Aliskiren
    • Hypertensive Urgency & Emergency
      • What is the difference ???
      • 1- Symptoms.
      • 2- Degree of Systolic BP.
      • 3- Degree of Diastolic BP
      • 1- Symptoms.
      • What are they??????
    • Hypertensive Emergency Sx
      • Headache
      • Neurolological SX
      • Chest Pain
      • Anuria
      • Difference between Hypertensive Urgency & Emergency
      • Hypertensive Emergency Is any Significantly SBP with sx.
      • Hypertensive Urgency is BP above 230/120 without sx
      • Difference between Hypertensive Urgency & Emergency
      • Hypertensive Emergency Is any Significantly SBP with sx Treatment start immediately, avoid sublingual Nifedipine. Refer to ER
      • Hypertensive Urgency is BP above 230/120 without sx, BP should come down to target within 24-48 Hours
    • 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
    • Case
      • 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 ?
      • 1-BB
      • 2-CCB
      • 3-Hydralazine
      • 2-CCB
      • 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 ??
      • 1-candesartan
      • 2-BB
      • 3-lisinopril
      • 1-candesartan
    • 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
      • Add
      • further diuretic therapy
      • Or alpha blocker
      • Or Beta Blocker
      • Consider seeking specialist advice
      Abbreviations: A: ACE-I (or ARB if ACE intolerant) C: CCB D: thiazide type diuretic Step 1 Step 2 Step 3 Step 4
    • Hypertension and Diabetes Recommendations of the American Diabetic Association
      • Treat to BP <130/80 mmHg
      • All patients with diabetes and hypertension should be treated with a regimen that includes either an ACEi or an ARB .
      • If needed to achieve blood pressure targets, a thiazide diuretic should be added.
      American Diabetes Association. Diabetes Care. 2005; 28 (Suppl 1): S10 – S17.
    • Conditions favoring the use of ARBs
      • Type 2 diabetic nephropathy
      • Diabetic microalbuminuria
      • Proteinuria
      • Left ventricular hypertrpphy
      • ACE-I induced cough
    • Case 1
      • 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.
      • SBP before admission to cardiology was 200 mmHg
      • What is the cause of her cardiomyopathy?
      • 1-Viral
      • 2-idiopathic
      • 3-Postpartum
      • 4-HTN
      • HTN
      • 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??
      • A-life style modfication.
      • B-single agent anti hypertensive
      • C- combination of two anti hypertensive agents.
      • D- a diagnosis of HTN cannot be made at this time.
      • C- combination of two anti hypertensive agents.
    • The following are Positive trials?
      • 1- I-Preseve
      • 2- GISSI-AF
      • 3- HYPVET
    • The following are Positive trials?
      • 3-HYPVET
    • Prevalence of HTN
      • Prevalence of HTN above the age of 55 years in general population is
      • 1- 90 % or more
      • 2- 60% or more
      • 3- 30% or more
      • 1- 90 % or more
    • Case
      • 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????
      • A- give propranolol 10 mg po stat.
      • B-IV line ,check D-Dimer, High flow oxygen & call ER.
      • C-Midazolam 2 mg , ECG stat.
      • B-IV line ,check D-Dimer, High flow oxygen & call ER.
    • Scientific evidence
      • Regarding studies of population The strongest Scientific evidence comes from ??
      • 1- Metanalysis of methodologically sound RCTs that have consistent results.
      • 2-Single RCTs.
      • 3-Observational studies analysed by Experts.
      • 1- Metanalysis of methodologically sound RCTs that have consistent results.
    • ALLHAT study
      • The following is true about ALLHAT ??
      • The largest trial in Hypertensive patients with mild to moderate renal Impairement.
      • Thiazide Diuertics become first lineRx in Simple uncomplicated HTN.
      • ACEIs cardiovascular mortality was better than Diuretics.
      • Thiazide Diuertics become first lineRx in Simple uncomplicated HTN.
    • HERs The Heart & estrogen Replacement therapy study
      • The following is wrong about HERs??
      • 1-It is example of an observational trial .
      • 2- Reversed decades of thoughts on cardiovascular effects of hormone therapy.
      • 3-Published in 1998
      • 4- It is an example of RCT.
      • ARBs e.g Candesartan , can be used as first line antihypertensive Line , they are characterized by all the following except??
      • 1- Renal protection
      • 2-better tolerated than ACEI
      • 3-Increased incidence of DM
    • 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
    • © 2008, American Heart Association. All rights reserved.
      • Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes.
      • Ideally, 1 of the 3 agents should be a diuretic & all agents should be prescribed at optimal dose amounts.
      Resistant Hypertension
      • Thank you