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Ht Nlecture2009

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HTN , 2009/2010 , clinical cases

HTN , 2009/2010 , clinical cases

Published in: Health & Medicine

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  • 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
    • 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 ???????
  • 3.
    • 1- further 2 readings are 160/95.
    • 2-there is history of DM.
    • 3- Cannot officially be made at this time.
  • 4.
    • 3- Cannot officially be made at this time.
  • 5. 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
  • 6. Properly Measured
    • Cuff Size
    • Bilateral
    • Confirm with Manual
    • No recent caffeine or Smoking
  • 7. Hypertension Risk Factors
    • Sodium Intake
    • Excess alcohol, Energy drinks.
    • Genetic or Racial factors
    • Obesity
    • Others DM, Lack of excercise
  • 8. Benefits of HTN Rx
    • Reduced incidence of Stroke (35%-40%).
    • Reduced Incidence of MI (20%-25%).
    • Reduced Incidence of Heart Failure( 50%)
  • 9. NNT
    • NNT to prevent one death if SBP is reduced by 12mmHg for 10 years is 11 .
  • 10. 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
  • 11.
    • 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
  • 12.
    • 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
  • 13.
    • A- one week then 3 monthy
  • 14.
    • 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 ????
  • 15.
    • A- DIC Lisinopril & Start Amlor .
    • B- refer to cardiology.
    • C-No change & B
    • D- DIC lisinopril & start ARBs
    • E- Start Aliskiren
  • 16. Hypertensive Urgency & Emergency
    • What is the difference ???
    • 1- Symptoms.
    • 2- Degree of Systolic BP.
    • 3- Degree of Diastolic BP
  • 17.
    • 1- Symptoms.
    • What are they??????
  • 18. Hypertensive Emergency Sx
    • Headache
    • Neurolological SX
    • Chest Pain
    • Anuria
  • 19.
    • Difference between Hypertensive Urgency & Emergency
    • Hypertensive Emergency Is any Significantly SBP with sx.
    • Hypertensive Urgency is BP above 230/120 without sx
  • 20.
    • 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
  • 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
    • 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
  • 23.
    • 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
  • 24.
    • 1-candesartan
  • 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
    • 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
  • 26. 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.
  • 27. Conditions favoring the use of ARBs
    • Type 2 diabetic nephropathy
    • Diabetic microalbuminuria
    • Proteinuria
    • Left ventricular hypertrpphy
    • ACE-I induced cough
  • 28. 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
  • 29.
    • What is the cause of her cardiomyopathy?
    • 1-Viral
    • 2-idiopathic
    • 3-Postpartum
    • 4-HTN
  • 30.
    • HTN
  • 31.
    • 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.
  • 32.
    • C- combination of two anti hypertensive agents.
  • 33. The following are Positive trials?
    • 1- I-Preseve
    • 2- GISSI-AF
    • 3- HYPVET
  • 34. The following are Positive trials?
    • 3-HYPVET
  • 35. 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
  • 36.
    • 1- 90 % or more
  • 37. 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.
  • 38.
    • B-IV line ,check D-Dimer, High flow oxygen & call ER.
  • 39. 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.
  • 40.
    • 1- Metanalysis of methodologically sound RCTs that have consistent results.
  • 41. 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.
  • 42.
    • Thiazide Diuertics become first lineRx in Simple uncomplicated HTN.
  • 43. 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.
  • 44.
    • 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
  • 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.
    • 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
  • 47.
    • Thank you

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