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Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
Htn the silent killer25 4-2013
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Htn the silent killer25 4-2013

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  • Slide 6: The slide illustrates the importance of hypertension in relationship to other risks for premature death. The data is from a study of the World Health Organization that found that hypertension is the leading risk for death in women and the second leading risk for death in men in countries like Canada.
  • NOTES FOR PRESENTERS: Key points to raise: Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state. Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Routine periodic screening for high blood pressure is now commonplace in the UK as part of National Service Frameworks for cardiovascular disease prevention. Consequently, the diagnosis, treatment and follow-up of people with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and approximately £1billion in drug costs in 2006.
  • The design was splited in 2 steps : ∗ Firstly, the run in phase to evaluate the efficacy and safety of PRETERAX in a large group of patients. => all participants entered in a preliminary 6-week open run-in phase, during which they received one tablet daily of PRETERAX. ∗ after this preliminary period, patients were randomly assigned to two treatments by a factorial design with 4 arms : => 2 arms “ blood pressure control” : patients received PRETERAX during the first 3 months and were up titrated to BIPRETERAX, or they received the PLACEBO. => 2 arms “intensive blood glucose control” : patients received intensive DIAMICRON MR-based glucose control regimen of up to 4 tablets daily or the regular guideline-based glucose control therapy. Added comments : I’d like to make the “ optimal therapy” clear. This means that patients received a drugs therapy and they were also managed according to the local recommendations.
  • HYVET is an international study, with a strong recruitment of Caucasians in Europe, of Asians in China, and also of North Africans in Tunisia. To enter the study, the patients have to be aged 80 or more, with a SBP >160 mm Hg. Exclusion criteria were orthostatic hypotension, and patients could not be residents in a nursing home at entry, meaning that they do not require the regular input of qualified nurses. They also must be able to stand up and walk.
  • The main finding of HYVET was unexpected, since it’s at odds with results of previous trials (which did not use Natrilix SR as study treatment). Natrilix SR therapy significantly reduced total mortality by 21%. This major finding caused the early stop of the trial.
  • Hypertension is a common comorbidity of diabetes that affects the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity Hypertension is a major risk factor for both CVD and microvascular complications In type 1 diabetes, hypertension is often the result of underlying nephropathy, while in type 2 diabetes it usually coexists with other cardiometabolic risk factors This slide and the following five slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 1 of 6 – Screening and Diagnosis Blood pressure should be measured at every routine visit Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day (B) Reference American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(suppl 1):S28-S29.
  • This set of six slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 3 of 6 – Treatment (Slide 1 of 4) Patients with a blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure (B) Patients with confirmed blood pressure ≥140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals (B) Reference American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(suppl 1):S29.
  • This set of six slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 4 of 6 – Treatment (Slide 2 of 4) Lifestyle therapy for elevated blood pressure consists of weight loss if overweight, DASH-style dietary pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity (B) Reference American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(suppl 1):S29.
  • This set of six slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 5 of 6 – Treatment (Slide 3 of 4) Pharmacologic therapy for patients with diabetes and hypertension should be paired with a regimen that included either an ACE inhibitor or an angiotensin II receptor blocker (ARB); if one class is not tolerated, the other should be substituted Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets (B) Administer one or more antihypertensive medications at bedtime (A) Reference American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(suppl 1):S29.
  • This set of six slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 6 of 6 – Treatment (Slide 4 of 4) If ACE inhibitors, angiotensin II receptor blockers (ARBs), or diuretics are used, serum creatine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored (E) In pregnant women with diabetes and chronic hypertension, blood pressure target goals of 110-129/65-79 mmHg are suggested in the interest of long-term maternal health and minimizing impaired fetal growth ACE inhibitors and angiotensin II receptor blockers (ARBs) are contraindicated during pregnancy (E) Reference American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(suppl 1):S29.
  • Transcript

    • 1. HTNThe Silent KillerNew Data about ACEIat least 12 % of world total mortalityADA 2013 guidelinesBHS 2011 guidelinesDr Ihab SulimanDr Ihab SulimanConsultant CardiologistConsultant Cardiologist25-4-201325-4-2013
    • 2. Leading risks forpremature death35421CholesterolCholesterolAlcoholAlcoholTobacco UseTobacco UseHYPERTENSIONHYPERTENSIONOverweightOverweight(World Health Organization 2002)
    • 3. HTN: KEY CONTRIBUTOR TO DIABETESHTN: KEY CONTRIBUTOR TO DIABETESCOMPLICATIONSCOMPLICATIONSFramingham Study: DM ⊕ HTN vs DM aloneRelative RiskofComplicationTotal mortality ↑ 72%CVD events ↑ 57%• HTN → 44% of deaths and 41% of CVD events in DM!‒ ↑ risk of nephropathy/retinopathy/neuropathy 60-100%Hypertension 2011; 57:891 Lancet 2012; 380:601
    • 4. HTN PREVALENCE: GENERALHTN PREVALENCE: GENERAL vsvs DMDMPOPULATIONSPOPULATIONSnorth american data UTAHnorth american data UTAHBP ≥ 140/90General population 30%• Age ≥ 60y 67%• White 29%• Black 41%• Hispanic 26%Persons with DM 67% 76%BP ≥ 130/80------------------ HTN is more than twice as common in DM!JACC 2012; 60:599 Diabetes Care 2011; 34:1597 Am J Med 2009; 122:443Utah State Health Department, 2012
    • 5. BackgroundBackground•EachEach 22 mmHg rise in systolic blood pressuremmHg rise in systolic blood pressureassociated with increased risk of mortality:associated with increased risk of mortality:– 7%7% from heart diseasefrom heart disease– 10%10% from stroke.from stroke.
    • 6. HTN: DOMINANT CONTRIBUTOR TO GLOBALHTN: DOMINANT CONTRIBUTOR TO GLOBALMORTALITYMORTALITYIncreases RR by 2.0-4.0 fold for:Increases RR by 2.0-4.0 fold for:• CAD, stroke, HF, PADCAD, stroke, HF, PAD• Renal failure, AF, dementia,Renal failure, AF, dementia, ↓↓ cognitioncognitionAttributable risk for HTN:Attributable risk for HTN:• StrokeStroke 62%62% • MI• MI 25%25%• CKDCKD 56%56% • Premature death• Premature death 24%24%• HFHF 49%49%Aftermath:Aftermath:• Shortens lifespan 5yShortens lifespan 5y• $93.5 billion/y in U.S.$93.5 billion/y in U.S.CirculationCirculation 2012; 125:e122012; 125:e12 JJ HumHum HypertensionHypertension 2008; 22:632008; 22:63 HypertensionHypertension 2007; 50:10062007; 50:1006
    • 7. Properly MeasuredProperly Measured Cuff SizeCuff Size BilateralBilateral Confirm with ManualConfirm with Manual No recent caffeine or SmokingNo recent caffeine or Smoking
    • 8. How many BP readings?How many BP readings?1.1. 3 – in sinus3 – in sinusrhythmrhythm2.2. more if theremore if thereare multipleare multipleectopics or AFectopics or AF
    • 9. DefinitionsDefinitionsStage 1 hypertensionStage 1 hypertension::CBPCBP >>140/90140/90 andand ABPM or HBPMABPM or HBPM>>135/85 mmHg135/85 mmHgStage 2 hypertension:Stage 2 hypertension:CBPCBP >>160/100 160/100 andand ABPM or HBPM daytimeABPM or HBPM daytime>>150/95 mmHg150/95 mmHgSevere hypertension:Severe hypertension:C SBPC SBP >>180 180 oror C DBPC DBP >>110 mmHg110 mmHg
    • 10. Offer drug treatment to:Offer drug treatment to: stage 1 hypertension, aged <80 and meet identifiedstage 1 hypertension, aged <80 and meet identifiedcriteriacriteria stage 2 hypertension at any agestage 2 hypertension at any ageIf <40 with stage 1 hypertension and without evidence ofIf <40 with stage 1 hypertension and without evidence ofTOD, CVD, CKD or diabetes, consider:TOD, CVD, CKD or diabetes, consider: specialist evaluation of secondary causes of hypertensionspecialist evaluation of secondary causes of hypertensionInitiating drug treatmentInitiating drug treatment
    • 11. Choosing drugs for patients newly diagnosedChoosing drugs for patients newly diagnosedwith hypertensionwith hypertensionBHS Guidelines (2011)BHS Guidelines (2011)Younger than 55 years55 years or olderOr black patientsof any ageA CA+CA+C+DAdd•further diuretic therapy•Or alpha blocker•Or Beta Blocker•Consider seeking specialist adviceAbbreviations:A: ACE-I (orARB if ACEintolerant)C: CCBD: thiazidetype diureticStep 1Step 2Step 3Step 4
    • 12. Baseline characteristics of study population (n=158 998)Trial Year N Active Control FU, HT, SBP, Age, Incidencetreatment years % mm Hg years rate, controlRENAAL 2001 1513 Losartan Placebo 3.1 97 153 60 66.0IDNT 2001 1715 Irbesartan Amlo or placebo 2.9 100 159 59 54.0LIFE 2002 9193 Losartan/HCTZ Atenol/HCTZ 4.8 100 174 67 19.5ALLHAT 2002 33 357 Lisinopril Diur or Amlo 5.0 100 146 67 28.5ANBP-2 2003 6083 Enalapril HCTZ 4.1 100 168 72 17.1SCOPE 2003 4937 Candesartan Placebo 3.7 100 166 76 29.0Pilot HYVET 2003 1283 Lisinopril Diuretic 1.1 100 182 84 55.4JMIC B 2004 1650 Lisinopril or enal Nifedipine 2.3 100 146 65 6.2VALUE 2004 15 245 Valsartan Amlodipine 4.3 100 155 67 24.8MOSES 2005 1352 Eprosartan Nitrendipine 2.5 100 152 68 31.0ASCOT-BPLA 2005 19 257 Amlo/perindopril Atenolol/BTZ 5.5 100 164 63 15.5JIKEI HEART 2007 3081 Valsartan Non-ARB 2.81 88 139 65 6.2ADVANCE 2007 11 140 Perindopril/Indap Placebo 4.3 69 145 66 19.8HYVET 2008 3845 Indap/perindopril Placebo 2.1 90 173 84 59.3PRoFESS 2008 20332 Telmisartan Placebo 2.5 74 144 66 29.1TRANSCEND 2008 5926 Telmisartan Placebo 4.6 77 141 67 25.2CASE-J 2008 4703 Candesartan Amlodipine 3.3 100 163 64 11.1HIJ-CREATE 2009 2049 Candesartan Non-ARB 4.0 100 135 65 14.3KYOTO HEART 2009 3031 Valsartan Non-ARB 2.9 100 157 66 7.2NAVIGATOR 2010 9306 Valsartan Placebo 6.1 78 140 64 11.5OVERALL 4.3 91 153 67 23.3
    • 13. Comparison of morbidity/mortality trialsin hypertension/high risk patientsTrial TreatmentTotal mortality CV mortality MIHYVET Perindopril/indapamide RRR = 21% RRR = 27% RRR = 28%vs placebo p = 0.019 p = 0.029 p = 0.45ADVANCEPerindopril/indapamide RRR = 14% RRR = 18% RRR = 14%vs control p = 0.025 p = 0.027 p = 0.02ASCOT Amlodipine/perindopril RRR = 11% RRR = 24% RRR = 13%vs b-blocker/thiazide p = 0.02 p = 0.001 p = 0.007ONTARGETTelmisartan vs ramipril NS NS Ramipril > telmisartanRRR = 7% in favour oframiprilONTARGETTelmisartan+Ramipril vs Ramipril > combination Ramipril > combination Ramipril > combinationramipril RRR = 7% in favour of RRR = 4% in favour of RRR = 8% in favour oframipril NS ramipril NS ramiprilTRANSCENDTelmisartan vs placebo Placebo > telmisartan RRR = 21% in favourRRR = 3% in favour of of telmisartan NSplacebo NSVALUEValsartan vs amlodipine Amlodipine > valsartan Amlodipine > valsartan Amlodipine > valsartanRRR = 4% in favour RRR = 1% in favour RRR = 19% in favouramlodipine amlodipine of amlodipineNS NS p = 0.02LIFELosartan/HCTZ vs NS NS Atenolol > losartanAtenolol /HCTZ RRR = 7% in favour ofatenololACCOMPLISHBenazepril/amlodipine vs NS NS RRR = 22% p = 0.04benazepril/HCTZ
    • 14. Circulation2006Neutral effect of ARBs on mortality,MI increaseARBs vs comparators(11 trials, n=55 050)RRR, %+8%ACE inhibitors vs comparators(39 trials, n=150 943)RRR, %-6%-9%*** -12%** -14%***Adapted from: Strauss MH, Hall AS.Circulation. 2006;114:838-854.*+1% +1%-8%*P=0.03; **P=0.0005; ***P<0.00001
    • 15. Bangalore S, Kumar S, Messerli F.BMJ. 2011;342:d2234.
    • 16. Dose-Dependent AntihypertensiveDose-Dependent AntihypertensiveEfficacy and Tolerability of CoversylEfficacy and Tolerability of Coversylin a Large, Observational,12-Week,in a Large, Observational,12-Week,General Practice-Based Study.General Practice-Based Study.George TsoukasGeorge Tsoukas11, Sanjiv Anand, Sanjiv Anand22and Kwang Yangand Kwang Yang33for thefor theCONFIDENCECONFIDENCE InvestigatorsInvestigators1.1. McGill University Health Centre, Montreal, Quebec, CanadaMcGill University Health Centre, Montreal, Quebec, Canada2.2. Dr Georges-L. Dumont Regional Hospital, Moncton, New Brunswick, CanadaDr Georges-L. Dumont Regional Hospital, Moncton, New Brunswick, Canada3.3. University of British Columbia, Surrey, British Columbia, CanadaUniversity of British Columbia, Surrey, British Columbia, Canada
    • 17. Perindopril efficacy Results in OverallPopulationStrong Efficacy is consistent across the entiregroups
    • 18. Perindopril results in Severe HTNPopulationPowerful BP reduction needed to achieveTarget Blood pressure
    • 19. High tissue ACE AffinityHigh tissue ACE Affinity
    • 20. Trough/Peak ratio: What does itTrough/Peak ratio: What does itmean?mean?
    • 21. 6-week run-in period ofactive BP-lowering withperindopril-indapamideRegistrationRandomizationN = 11,140Optimal Therapy++Intensive glucosecontrolOptimal Therapy ++Standardglucose controlOptimal Therapy +Placebo+Intensive glucosecontrolOptimal Therapy+Placebo+Standard glucosecontrolEND OF FOLLOW-UP (average (5.5 years)2 x 2 factorial multicenter, randomized control trial with 5-6 years followupPatients were all allowed other Preventive Therapy including: other Blood Pressure Lowering Drugs, LipidLowering Drugs, Glucose Lowering Drugs, Anti-plateletsADVANCE - Lancet 2007; 370: 829–40COVERSYL- NATRILIXCOVERSYL- NATRILIX
    • 22. ADVANCE Collaborative Group. Lancet. 2007;370:829-840.
    • 23. HYVET, an internationalHYVET, an internationaltrialtrialThe trial:International, multicenter, randomized, double-blind, placebo-controlledInclusion criteria: Exclusion criteria:Aged 80 or more, Standing SBP <140 mm HgSystolic BP 160-199 mm Hg Stroke in last 6 months+ diastolic BP <110 mm Hg, DementiaInformed consent Need for daily nursing carePrimary end point:All strokes (fatal and nonfatal)
    • 24. Total mortality(21% reduction)PlaceboP=0.02Natrilix SR+COVERSYLNumberofeventsper100patientsFollow-up (years)Beckett N, et al. NEJM 2008;358:1887-1898.This result is at odds with findings from previous trials
    • 25. CaseCase 55 years old obese Diabetic with Type 2 DM,55 years old obese Diabetic with Type 2 DM,SBP is consistently above 150 mmHg, the bestSBP is consistently above 150 mmHg, the bestinitial treatment will be ???initial treatment will be ??? 1-HCTZ 12.5 mg po daily.1-HCTZ 12.5 mg po daily. 2-Atenolol 50 mg po daily.2-Atenolol 50 mg po daily. 3-Perindoril 10 mg po daily3-Perindoril 10 mg po daily
    • 26.  Perindopril 10 mg po daily is chosenPerindopril 10 mg po daily is chosen You FU the patient byYou FU the patient by A-POTASSIUMA-POTASSIUM B-RENINB-RENIN C-CREATININEC-CREATININE D-ECGD-ECG E— A&CE— A&C F-A,B,C,DF-A,B,C,D
    • 27.  E— A&CE— A&C The patient after starting Lisinopril will be seenThe patient after starting Lisinopril will be seenafter with Basic Screenafter with Basic Screen A- one week then 3 monthyA- one week then 3 monthy B- every 3 monthsB- every 3 months C- within 3 days then 3monthsC- within 3 days then 3months
    • 28.  A- one week then 3 monthyA- one week then 3 monthy
    • 29.  45 years old male with DM , Prior history of45 years old male with DM , Prior history ofIHD, Last echo report EF 45%, SBP 155,IHD, Last echo report EF 45%, SBP 155,Creatinine 140, potassium 4, started onCreatinine 140, potassium 4, started onPerindopril 10 mg po daily, after 3 month on aPerindopril 10 mg po daily, after 3 month on aroutine visit SBP 115, creatinine 155, potassiumroutine visit SBP 115, creatinine 155, potassiumis 4.5 , No chest Pain or SOB, the next step willis 4.5 , No chest Pain or SOB, the next step willbe ????be ????
    • 30.  A- DIC perindopril & Start Amlor .A- DIC perindopril & Start Amlor . B- refer to cardiology.B- refer to cardiology. C-No change & BC-No change & B D- DIC Perindopril& start ARBsD- DIC Perindopril& start ARBs E- Start AliskirenE- Start Aliskiren
    • 31.  70 years old female with no prior active cardiac70 years old female with no prior active cardiacproblems, Informed in a private clinic aboutproblems, Informed in a private clinic aboutbeing Hypertensive, 3 separate visits, SBP 160-being Hypertensive, 3 separate visits, SBP 160-170 ,what is the next step??170 ,what is the next step?? A-life style modfication.A-life style modfication. B-single agent anti hypertensiveB-single agent anti hypertensive C- combination of two anti hypertensive agents.C- combination of two anti hypertensive agents. D- a diagnosis of HTN cannot be made at thisD- a diagnosis of HTN cannot be made at thistime.time.
    • 32.  C- combination of two anti hypertensive agents.C- combination of two anti hypertensive agents.
    • 33. Recommendations: Hypertension/Blood PressureRecommendations: Hypertension/Blood PressureControlControlScreening and diagnosisScreening and diagnosis Blood pressure should be measured atBlood pressure should be measured atevery routine visitevery routine visit Patients found to have elevated bloodPatients found to have elevated bloodpressure should have blood pressurepressure should have blood pressureconfirmed on a separate day (B)confirmed on a separate day (B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S28-S29.
    • 34. Recommendations: Hypertension/Blood PressureRecommendations: Hypertension/Blood PressureControlControlTreatment (1)Treatment (1) Patients with a blood pressure (BP)Patients with a blood pressure (BP)>120/80 mmHg should be advised on>120/80 mmHg should be advised onlifestyle changes to reduce BP (B)lifestyle changes to reduce BP (B) Patients with confirmed BP ≥140/80Patients with confirmed BP ≥140/80mmHg should, in addition to lifestylemmHg should, in addition to lifestyletherapy, have prompt initiation and timelytherapy, have prompt initiation and timelysubsequent titration of pharmacologicalsubsequent titration of pharmacologicaltherapy to achieve BP goals (B)therapy to achieve BP goals (B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
    • 35. Recommendations: Hypertension/Blood PressureRecommendations: Hypertension/Blood PressureControlControl Lifestyle therapy for elevated BP (B)Lifestyle therapy for elevated BP (B) Weight loss if overweightWeight loss if overweight DASH-style dietary pattern includingDASH-style dietary pattern includingreducing sodium, increasing potassiumreducing sodium, increasing potassiumintakeintake Moderation of alcohol intakeModeration of alcohol intake Increased physical activityIncreased physical activityADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
    • 36. Recommendations: Hypertension/BloodRecommendations: Hypertension/BloodPressure ControlPressure Control Pharmacological therapy for patients with diabetes andPharmacological therapy for patients with diabetes andhypertension (C)hypertension (C) A regimen that includes either an ACE inhibitor orA regimen that includes either an ACE inhibitor orangiotensin II receptor blocker; if one class is not tolerated,angiotensin II receptor blocker; if one class is not tolerated,substitute the othersubstitute the other Multiple drug therapy (two or more agents at maximalMultiple drug therapy (two or more agents at maximaldoses) generally required to achieve BP targets (B)doses) generally required to achieve BP targets (B) Administer one or more antihypertensive medicationsAdminister one or more antihypertensive medicationsat bedtime (A)at bedtime (A)ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
    • 37. Recommendations: Hypertension/Blood PressureRecommendations: Hypertension/Blood PressureControlControl If ACE inhibitors, ARBs, or diuretics are used,If ACE inhibitors, ARBs, or diuretics are used,kidney function, serum potassium levels should bekidney function, serum potassium levels should bemonitored (E)monitored (E) In pregnant patients with diabetes and chronicIn pregnant patients with diabetes and chronichypertension, blood pressure target goals of 110–hypertension, blood pressure target goals of 110–129/65–79 mmHg are suggested in interest of129/65–79 mmHg are suggested in interest oflong-term maternal health and minimizing impairedlong-term maternal health and minimizing impairedfetal growth; ACE inhibitors, ARBs, contraindicatedfetal growth; ACE inhibitors, ARBs, contraindicatedduring pregnancy (E)during pregnancy (E)ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
    • 38. © 2008, American HeartAssociation. All rightsreserved.• Blood pressure remaining above goal in spiteof concurrent use of 3 antihypertensive agentsof different classes.• Ideally, 1 of the 3 agents should be adiuretic & all agents should be prescribed atoptimal dose amounts.Resistant Hypertension
    • 39. Conclusion HTN is a silent killer responsible for significantproportion of mortality and morbidity. Effective lowering of BP and choice ofAntihypertensive Rx is equally important.
    • 40. ‫ينفعنا‬ ‫ما‬ ‫يعلمنا‬ ‫أن‬ ‫ا‬ ‫نسأل‬،‫علمنا‬ ‫بما‬ ‫ينفعنا‬ ‫،وأن‬‫علما‬ ‫وأ‬‫النهاية‬ ‫وفي‬‫النهاية‬ ‫وفي‬

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