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Accerlerated hypertension

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  • 1. ACCERLERATEDHYPERTENSIONDr. Sachin Verma MD, FICM, FCCS, ICFCFellowship in Intensive Care MedicineInfection Control Fellows CourseConsultant Internal Medicine and Critical CareIvy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.comMob:- +91-7508677495 1
  • 2. Hypertension is defined as a usual BP of140/90 mm Hg or more.In children and adolescentsHypertension ▬ average SBP and/or DBP is≥95th percentile for sex, age, and height on 3 ormore occasions.Prehypertension ▬Children with average SBP or DBP levels are≥90th percentile, but <95th percentile.Adolescents with BP levels ≥120/80 mmHg.2
  • 3. Blood Pressure ClassificationBloodPressureClassificationSBP mmHgDBP mmHg LifestyleModificationInitial drug therapyWithout CompellingIndicationWith CompellingIndicationsNormal <120 and <80 EncourageNo antihypertensivedrug indicated.Drug(s) for compellingindications.‡Prehypertension 120–139 or 80–89 YesStage 1hypertension140–159 or 90–99 Yes Thiazide-type diureticsfor most. May considerACEI, ARB, BB, CCB,or combination.Drug(s) for the compellingindications.‡Other antihypertensivedrugs (diuretics, ACEI,ARB, BB, CCB)as needed.Stage 2hypertension≥160 or ≥100 Yes Two-drug combinationfor most† (usuallythiazide-type diureticand ACEI or ARB or BBor CCB).Isolated systolichypertension≥140 and <90* Treatment determined by highest BP category.† Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.3
  • 4. Classification of blood pressureThis classification of BP is for adults ages 18and older.The classification is based on the average of twoor more properly measured, seated BP readingson each of two or more office visits.Patients with prehypertension are at increasedrisk for progression to hypertension; those in the130–139/80–89 mmHg BP range are at twicethe risk to develop hypertension as those withlower values.4
  • 5. Hypertensive crises encompass a spectrum ofclinical presentations where uncontrolled BPslead to progressive or impending target organdysfunction (TOD).Hypertensive emergency represent severeHTN with acute impairment of an organ system(eg, central nervous system, cardiovascular,renal). In these conditions, the BP should belowered aggressively within 1 hours.Hypertensive urgency is defined as a severeelevation of BP, without evidence ofprogressive TOD. These patients require BPcontrol over several days to weeks.5
  • 6. 6Accelerated-Malignant HypertensionA syndrome associated with an abrupt increase ofblood pressure in a patient with underlyinghypertension or related to the sudden onset ofhypertension in a previously normotensiveindividual.When the rise in pressure causes retinalhemorrhages, exudates, or papilledema, the termaccelerated-malignant hypertension is usedThe absolute level of blood pressure is not asimportant as its rate of rise.
  • 7. Pathologically, the syndrome is associated withdiffuse necrotizing vasculitis, arteriolar thrombi, andfibrin deposition in arteriolar walls (arterioles ofkidney, brain, retina, and other organs).Clinically, the syndrome is recognized by progressiveretinopathy (arteriolar spasm, hemorrhages,exudates, and papilledema), deteriorating renalfunction with proteinuria, microangiopathic hemolyticanemia, and encephalopathy.In these patients, historic inquiry should includequestions about the use of monamine oxidaseinhibitors and recreational drugs (e.g., cocaine,amphetamines).7
  • 8. Why is it Important to control BloodPressure ? Reduce stroke incidence by 35-40% Reduce MI by 20-25 % Reduce Heart Failure by 50 %8
  • 9. What is the proper way of takingBlood Pressure ?1. Instruments should be properly calibrated.2. Patients should be seated quietly for atleast 5 minutes.3. Seated on a chair with arms supported atheart level and feet planted on the floor.4. Appropriate cuff size. (encircling at least80% of area)5. At least two measurements should bemade.9
  • 10. Ambulatory blood pressuremonitoring(ABPM) It provides information about BP during daily activities and sleepand ambulatory BP values are usually lower than clinic readings. Warranted for evaluation of “white-coat” hypertension in theabsence of target organ injury. To assess patients with apparent drug resistance, hypotensivesymptoms with antihypertensive medications, episodichypertension, and autonomic dysfunction. Correlates better than office measurements with target organinjury. Awake, individuals with hypertension have an average BP of morethan 135/85 mmHg and during sleep, more than 120/75 mmHg. In most individuals, BP decreases by 10 to 20 percent during thenight; those in whom such reductions are not present are atincreased risk for cardiovascular events.10
  • 11. Three Objectives in Evaluating Patientswith Documented Hypertension1. To assess the lifestyle & identify othercardiovascular risk factors orconcomitant disorders that may affectprognosis & guide treatment.2. To reveal identifiable causes of high BP.3. To asses the presence or absence oftarget organ damage & CVD.11
  • 12. Cardiovascular Risk Factors12Major Risk Factors•Hypertension*•Cigarette smoking•Obesity* (body mass index ≥30 kg/m2)•Physical inactivity•Dyslipidemia*•Diabetes mellitus*•Microalbuminuria or estimated GFR <60 mL/min•Age (older than 55 for men, 65 for women)•Family history of premature cardiovascular disease(men under age 55 or women under age 65)
  • 13. Target Organ Damage13Heart• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failureBrain• Stroke or transient ischemic attackPeripheral arterial diseaseChronic kidney diseaseRetinopathy
  • 14. Blood Pressure Variability and ItsDeterminantsNicotine in cigarette smoke (10 to 20 mmHg rise in BP with every single cigarette)Alcohol consumptionCaffeine consumption (only a smalltransient rise in BP).Habitual physical inactivity (in part becauseof weight gain).Excessive consumption of calories andsalt. 14
  • 15. Types of HypertensionIn ~80–95% of hypertensive patients are diagnosed ashaving "essential" hypertension (also referred to asprimary or idiopathic hypertension).In the remaining 5–20% of hypertensive patients, aspecific underlying disorder causing the elevation ofblood pressure can be identified.In individuals with "secondary" hypertension, aspecific mechanism for the blood pressure elevation isoften more apparent. Renal disease is the most commoncause of secondary hypertension.15
  • 16. Identifiable causes of hypertension•Sleep apnea•Drug-induced or related causes (see table 9)•Chronic kidney disease•Primary aldosteronism•Renovascular disease•Chronic steroid therapy and Cushing’s syndrome•Pheochromocytoma•Coarctation of the aorta•Thyroid or parathyroid disease16
  • 17. Systolic Hypertension with WidePulse Pressure1. Decreased vascular compliance (arteriosclerosis)2. Increased cardiac outputa. Aortic regurgitationb. Thyrotoxicosisc. Hyperkinetic heart syndromed. Fevere. Arteriovenous fistulaf. Patent ductus arteriosus17
  • 18. Secondary Causes of Systolic andDiastolic HypertensionRenal Parenchymal diseases, renal cysts (including polycystic kidneydisease), renal tumors (including renin-secreting tumors), obstructiveuropathyRenovascular Arteriosclerotic, fibromuscular dysplasiaAdrenal Primary aldosteronism, Cushings syndrome, 17-hydroxylasedeficiency, 11-hydroxylase deficiency, 11-hydroxysteroiddehydrogenase deficiency (licorice), pheochromocytomaAortic coarctationObstructive sleep apneaPreeclampsia/eclampsiaNeurogenic Psychogenic, diencephalic syndrome, familial dysautonomia,polyneuritis (acute porphyria, lead poisoning), acute increasedintracranial pressure, acute spinal cord sectionMiscellaneous endocrine Hypothyroidism, hyperthyroidism, hypercalcemia, acromegalyMedications High-dose estrogens, adrenal steroids, decongestants, appetitesuppressants, cyclosporine, tricyclic antidepressants, monamineoxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatoryagents, cocaineMendelian forms of hypertension18
  • 19. DiagnosisDiagnostic ProcedureInitial AdditionalChronic renal disease Urinalysis, serum creatinine, renalsonographyIsotopic renography, renal biopsyRenovascular disease Renal sonography Magnetic resonance or computedtomography (CT) angiography,aortographyDuplex Doppler sonographyEndocrine Serum sodium, potassium, calcium,TSHMetabolic Fasting blood glucose, totalcholesterol, HDL and LDL (oftencomputed) cholesterol, triglyceridesCoarctation Blood pressure in legs Echocardiography, magnetic resonanceimaging or contrast aortographyPrimary aldosteronism Plasma and urinary potassium, plasma reninand aldosteroneUrinary aldosterone after oral salt load,adrenal CT, adrenal venous samplingCushing syndrome Morning plasma cortisol after 1 mgdexamethasone at bedtimeUrinary cortisol after variable doses ofdexamethasone, adrenal CT, andscintiscansPheochromocytoma Plasma-free metanephrineUrine metanephrines and catecholsPlasma normetanephrine (basal and after0.3 mg clonidine)Other Hematocrit, electrocardiogram19
  • 20. Other laboratory tests may includecardiac enzymesFor cushings syndrome- 24-h excretion rates ofurine free cortisol or an overnight dexamethasone-suppression test and late night salivary cortisol(sensitive and convenient screening test)For pheochromocytoma- 24-hour urine collectionfor vanillylmandelic acid and catecholamines.Chest radiograph - cardiac enlargement,pulmonary edema, or involvement of otherthoracic structures, such as rib notching with aorticcoarctation or a widened mediastinum with aorticdissection.20
  • 21. As a screening test, Renal blood flow may beevaluated with a radionuclide [131I]-ortho iodohippurate (OIH) scan. or Glomerular filtration ratemay be evaluated with [99mTc]-diethylene triaminepentaacetic acid (DTPA) scan, before and after asingle dose of captopril .Doppler ultrasound of the renal arteries producesreliable estimates of renal blood flow velocity and . To track a renal artery lesion Gadolinium-contrastmagnetic resonance angiography, Contrastarteriography remains the "gold standard" forevaluation and identification of renal artery lesions.21
  • 22. Physical Examination Recommended1. BP measurement / includes contralateral arm2. Examination of optic disc3. Calculation of BMI (Wt (Kg)/sq (Ht(m))4. Auscultation ( carotid, renal & femoral bruits)5. Palpation of thyroid gland6. Examination of Heart & Lungs7. Examination of Abdomen8. Lower extremities9. Neurological assessment22
  • 23. ABSTRACTThe “Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure” a new guideline for hypertensionprevention and management. The following are thereport’s key messages:In persons older than 50 years, systolic blood pressuregreater than 140 mmHg is a much more importantcardiovascular disease (CVD) riskfactor than diastolicblood pressure.The risk of CVD beginning at 115/75 mmHg doubles witheach increment of 20/10 mmHg; individuals who arenormotensive at age 55 have a 90 percent lifetime risk fordeveloping hypertension.23
  • 24. Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89mmHg should be considered as prehypertensiveand require health-promoting lifestyle modificationsto prevent CVD.Thiazide-type diuretics should be used in drugtreatment for most patients with uncomplicatedhypertension, either alone or combined with drugsfrom other classes.Certain high-risk conditions are compellingindications for the initial use of otherantihypertensive drug classes (angiotensinconverting enzyme inhibitors, angiotensin receptorblockers,beta-blockers, calcium channel blockers).24
  • 25. Most patients with hypertension will requiretwo or more antihypertensive medications toachieve goal blood pressure (<140/90 mmHg,or <130/80 mmHg for patients with diabetesor chronic kidney disease).If blood pressure is >20/10 mmHg above goalblood pressure, consideration should begiven to initiating therapy with two agents,one of which usually should be a thiazide-typediuretic.The most effective therapy will controlhypertension only if patients are motivated.25
  • 26. Goals in Therapy1. Reduction of Cardiovascular &Renal Morbidity & Mortality.2. For >50 year old, the focus is SBPcontrol.3. <140/90 mmHg4. <130/80 mmHg for patients withhypertension, DM & renal disease.26
  • 27. Algorithm for Treatment of HypertensionNot at Goal Blood Pressure (<140/90 mmHg)(<130/80 mmHg for those with diabetes or chronic kidney disease)Initial Drug ChoicesDrug(s) for the compellingindicationsOther antihypertensive drugs(diuretics, ACEI, ARB, BB, CCB)as needed.With CompellingIndicationsLifestyle ModificationsStage 2 Hypertension(SBP >160 or DBP >100 mmHg)2-drug combination for most(usually thiazide-type diuretic andACEI, or ARB, or BB, or CCB)Stage 1 Hypertension(SBP 140–159 or DBP 90–99mmHg)Thiazide-type diuretics for most.May consider ACEI, ARB, BB, CCB,or combination.Without CompellingIndicationsNot at GoalBlood PressureOptimize dosages or add additional drugsuntil goal blood pressure is achieved.Consider consultation with hypertensionspecialist. 27
  • 28. Hypertension: TreatmentLifestyle InterventionsLifestyle modifications are the first line of treatment inhypertension.Implications for both the prevention and treatment ofhypertension.Recommended for individuals with pre-hypertension andas an adjunct to drug therapy in hypertensive individuals.According to the JNC, lifestyle modifications can reducesystolic blood pressure from a low of 2-8 mm Hg fordietary sodium restriction, to a high of 5-20 mm Hg forweight reduction.28
  • 29. Life Style Modifications
  • 30. Dietary Approaches to StopHypertension (DASH Diet)Promotes fruits, vegetables, whole grains and low fat dairyproducts. Low in saturated fat, cholesterol, and total fat.Rich in Calcium, Potassium, Magnesium, protein, andfiber.Low in red meat, sweets and sugar beverages.Lowering homocysteine with DASH may reduce CVD riskan additional 7%-9%.Fully compatible with dietary recommendations forreducing risk of CVD, osteoporosis and cancer.Lowers systolic BP in normotensive patients by anaverage of 3.5 mm Hg and in hypertensive patients by11.4 mm Hg.30
  • 31. Pharmacologic TherapyDrug therapy is recommended for individuals with bloodpressures ≥140/90 mmHg. The degree of benefit derivedfrom antihypertensive agents is related to the magnitudeof the blood pressure reduction.Lowering systolic blood pressure by 10–12 mmHg anddiastolic blood pressure by 5–6 mmHg confers relativerisk reductions of 35–40% for stroke and 12–16% forCHD within 5 years of initiating treatment. Risk of heartfailure is reduced by >50%.Low-dose aspirin therapy should be considered onlywhen BP is controlled, because the risk of hemorrhagicstroke is increased in patients with uncontrolledhypertension.31
  • 32.  Thiazide-type diuretics have been the basis of antihypertensivetherapy in most outcome trials. In these trials, including the recentlypublished Antihypertensive and Lipid Lowering Treatment toPrevent Heart Attack Trial (ALLHAT), diuretics have been virtuallyunsurpassed in preventing the cardiovascular complications ofhypertension. Diuretics enhance the antihypertensive efficacy of multidrugregimens, can be useful in achieving BP control, and are moreaffordable than other antihypertensive agents. Thiazide-type diuretics should be used as initial therapy for mostpatients with hypertension, either alone or in combination with oneof the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to bebeneficial in randomized controlled outcome trials.32
  • 33. Blood Pressure Goals ofAntihypertensive TherapyThe maximum protection against combined cardiovascularendpoints is achieved with pressures <135–140 mmHg forsystolic blood pressure and <80–85 mmHg for diastolic bloodpressure.More aggressive blood pressure targets for blood pressurecontrol (< 130/80 mmHg) may be appropriate for patients withdiabetes, CHD, chronic kidney disease, or with additionalcardiovascular disease risk factors.In diabetic patients, effective blood pressure control reducesthe risk of cardiovascular events and death as well as the riskfor microvascular disease (nephropathy, retinopathy). Riskreduction is greater in diabetic than in nondiabetic individuals.33
  • 34. Clinical Trial & Guideline basis for compellingIndications for individual Drug Classes34
  • 35. Heart failureHeart failure(HF), in the form of systolic or diastolicventricular dysfunction, results primarily fromsystolic hypertension and IHD. Fastidious BP andcholesterol control are the primary preventivemeasures for those at high risk for HF.In asymptomatic individuals with demonstrableventricular dysfunction, ACEIs and BBs arerecommended.For those with symptomatic ventricular dysfunctionor end-stage heart disease, ACEIs, BBs, ARBs andaldosterone blockers are recommended along withloop diuretics. 35
  • 36. Diabetic HypertensionCombinations of two or more drugs are usuallyneeded to achieve the target goal of <130/80mmHg.Thiazide diuretics, BBs, ACEIs, ARBs, andCCBs are beneficial in reducing CVD and strokeincidence in patients with diabetes.ACEI- or ARB-based treatments favourablyaffect the progression of diabetic nephropathyand reduce albuminuria, and ARBs have beenshown to reduce progression tomacroalbuminuria. 36
  • 37. Chronic Kidney DiseaseIn people with chronic kidney disease (CKD), asdefined by either(1) reduced excretory function with an estimatedGFR below 60 ml/min per 1.73 m2 (correspondingapproximately to a creatinine of >1.5 mg/dL in menor >1.3 mg/dL in women), or(2) the presence of albuminuria (>300 mg/day or200 mg albumin/g creatinine).Therapeutic goals are to slow deterioration of renalfunction and prevent CVD. Hypertension appears inthe majority of these patients, and they shouldreceive aggressive BP management, often with ≥3drugs to reach target BP values <130/80 mmHg.37
  • 38. ACEIs and ARBs have demonstrated favorableeffects on the progression of diabetic andnondiabetic renal disease. A limited rise inserum creatinine of as much as 35 percentabove baseline with ACEIs or ARBs isacceptable and is not a reason to withholdtreatment unless hyperkalemia develops.With advanced renal disease (estimated GFR<30 ml/min 1.73 m2, corresponding to a serumcreatinine of 2.5–3 mg/dL), increasing doses ofloop diuretics are usually needed in combinationwith other drug classes. 38
  • 39. Cerebrovascular DiseaseControl of BP at intermediate levels(approximately 160/100 mmHg) isappropriate until the condition hasstabilized or improved.Recurrent stroke rates are lowered by thecombination of an ACEI and thiazide-typediuretic.39
  • 40. Obesity and the metabolic syndromeObesity (BMI >30 kg/m2) is an increasingly prevalentrisk factor for the development of hypertension andCVD.Metabolic syndrome as the presence of three or moreof the following conditions: abdominal obesity (waistcircumference >40 inches in men or >35 inches inwomen), glucose intolerance (fasting glucose >110mg/dL), BP >130/85 mmHg, high triglycerides (>150mg/dL), or low HDL (<40 mg/dL in men or <50 mg/dLin women).Intensive lifestyle modification should be pursued in allindividuals with the metabolic syndrome, andappropriate drug therapy should be instituted for eachof its components as indicated.40
  • 41. Left ventricular hypertrophyLeft ventricular hypertrophy (LVH) is anindependent risk factor that increases therisk of subsequent CVD.Regression of LVH occurs withaggressive BP management, includingweight loss, sodium restriction, andtreatment with all classes ofantihypertensive agents except the directvasodilators hydralazine, and minoxidil.41
  • 42. Peripheral arterial diseasePeripheral arterial disease (PAD)is equivalent in risk to IHD. Anyclass of antihypertensive drugscan be used in most PAD patients.Other risk factors should bemanaged aggressively, and aspirinshould be used.42
  • 43. Hypertension in older personsHypertension occurs in more than two-thirds ofindividuals after age 65. This is also the populationwith the lowest rates of BP control.Treatment recommendations for older people withhypertension, including those who have isolatedsystolic hypertension, should follow the sameprinciples outlined for the general care ofhypertension.In many individuals, lower initial drug doses may beindicated to avoid symptoms; however, standarddoses and multiple drugs are needed in the majorityof older people to reach appropriate BP targets. 43
  • 44. Postural hypotensionA decrease in standing SBP >10 mmHg, whenassociated with dizziness or fainting, is morefrequent in older patients with systolichypertension, diabetes, and those takingdiuretics, venodilators (e.g., nitrates, alpha-blockers, and sildenafil like drugs), and somepsychotropic drugs.BP in these individuals should also be monitoredin the upright position. Caution should be used toavoid volume depletion and excessively rapiddose titration of antihypertensive drugs.44
  • 45. DementiaDementia and cognitiveimpairment occur more commonlyin people with hypertension.Reduced progression of cognitiveimpairment may occur witheffective antihypertensive therapy.45
  • 46. Hypertension in womenOral contraceptives may increase BP, and therisk of hypertension increases with duration ofuse. Women taking oral contraceptives shouldhave their BP checked regularly.Development of hypertension is a reason toconsider other forms of contraception. Incontrast, menopausal hormone therapy doesnot raise BP.Women with hypertension who becomepregnant should be followed carefully becauseof increased risks to mother and fetus. 46
  • 47. Methyldopa, BBs, and vasodilators are preferredmedications for the safety of the fetus ACEI and ARBsshould not be used during pregnancy because of thepotential for fetal defects and should be avoided inwomen who are likely to become pregnant.Preeclampsia, which occurs after the 20th week ofpregnancy, is characterized by new-onset orworsening hypertension, albuminuria, andhyperuricemia, sometimes with coagulationabnormalities.In some patients, preeclampsia may develop into ahypertensive urgency or emergency and may requirehospitalization, intensive monitoring, early fetaldelivery, and parenteral antihypertensive andanticonvulsant therapy47
  • 48. Hypertension in children andadolescentsLifestyle interventions are stronglyrecommended, with pharmacologictherapy instituted for higher levels of BP orif there is insufficient response to lifestylemodifications.Choices of antihypertensive drugs aresimilar in children and adults, but effectivedoses for children are often smaller andshould be adjusted carefully.48
  • 49. Hypertensive emergencyAlthough blood pressure should be lowered rapidlyin patients with hypertensive encephalopathy,there are inherent risks of overly aggressivetherapy.In hypertensive individuals, the upper and lowerlimits of autoregulation of cerebral blood flow areshifted to higher levels of arterial pressure, andrapid lowering of blood pressure to below the lowerlimit of autoregulation may precipitate cerebralischemia or infarction. Renal and coronary bloodflows may also decrease with overly aggressiveacute therapy. 49
  • 50. The initial goal of therapy is to reducemean arterial blood pressure by no morethan 25% within minutes to 2 h or to ablood pressure in the range of 160/100–110 mmHg.In patients with malignant hypertensionwithout encephalopathy or some othercatastrophic event, it is preferable toreduce blood pressure over hours orlonger rather than minutes. 50
  • 51. Acute, transient blood pressure elevations, lastingdays to weeks, frequently occur following thromboticand hemorrhagic strokes. Autoregulation of cerebralblood flow is impaired in ischemic cerebral tissue,and higher arterial pressures may be required tomaintain cerebral blood flow. Aggressive reductionsof blood pressure are to be avoided.In the absence of other indications for acute therapy,for patients with cerebral infarction who are notcandidates for thrombolytic therapy, onerecommended guideline is to instituteantihypertensive therapy only when a systolic bloodpressure > 220 mmHg or a diastolic blood pressure> 130 mmHg. 51
  • 52. If thrombolytic therapy is to be used, therecommended goal blood pressure is<185 mmHg systolic pressure and <110mmHg diastolic pressure.In patients with hemorrhagic stroke,suggested guidelines for initiatingantihypertensive therapy are systolic >180 mmHg or diastolic pressure > 130mmHg.52
  • 53. The management of hypertension aftersubarachnoid hemorrhage is controversial.Cautious reduction of blood pressure isindicated if mean arterial pressure is >130mmHg.In addition to pheochromocytoma, anadrenergic crisis due to catecholamine excessmay be related to cocaine or amphetamineoverdose, clonidine withdrawal, acute spinalcord injuries, and an interaction of tyramine-containing compounds with monamine oxidaseinhibitors. These patients may be treated withphentolamine or nitroprusside.53
  • 54. Preferred Parenteral Drugs for SelectedHypertensive EmergenciesHypertensive encephalopathy Nitroprusside, nicardipine, labetalolMalignant hypertension (when IV therapy isindicated)Labetalol, nicardipine, nitroprusside,enalaprilatStroke Nicardipine, labetalol, nitroprussideMyocardial infarction/unstable angina Nitroglycerin, nicardipine, labetalol, esmololAcute left ventricular failure Nitroglycerin, enalaprilat, loop diureticsAortic dissection Nitroprusside, esmolol, labetalolAdrenergic crisis Phentolamine, nitroprussidePostoperative hypertension Nitroglycerin, nitroprusside, labetalol,nicardipinePreeclampsia/eclampsia of pregnancy Hydralazine, labetalol, nicardipine54
  • 55. Intravenous Doses of AntihypertensiveAgents Used in HypertensiveEmergenciesAntihypertensive Agent Intravenous DoseNitroprusside Initial 0.3 (g/kg)/min; usual 2–4 (g/kg)/min; maximum 10(g/kg)/min for 10 minNicardipine Initial 5 mg/h; titrate by 2.5 mg/h at 5–15 min intervals; max 15mg/hLabetalol 2 mg/min up to 300 mg or 20 mg over 2 min, then 40–80 mg at10-min intervals up to 300 mg totalEnalaprilat Usual 0.625–1.25 mg over 5 min every 6–8 h; maximum 5mg/doseEsmolol Initial 80–500 g/kg over 1 min, then 50–300 (g/kg)/minPhentolamine 5–15 mg bolusNitroglycerin Initial 5 g/min, then titrate by 5 g/min at 3–5 min intervals; if noresponse is seen at 20 g/min, incremental increases of 10–20g/min may be usedHydralazine 10–50 mg at 30-min intervals 55
  • 56. DrugclassExamples Usual Total DailyDose (DosingFrequency/Day)OtherIndicationsContraindications/CautionsDiureticsThiazides Hydrochlorothiazide 6.25–50 mg (1–2) Diabetes,dyslipidemia,hyperuricemia,gout,hypokalemiaChlorthalidone 25–50 mg (1)LoopdiureticsFurosemide 40–80 mg (2–3) CHF, renalfailureDiabetes,dyslipidemia,hyperuricemia,gout,hypokalemiaEthacrynic acid 50–100 mg (2–3)AldosteroneantagonistsSpironolactone 25–100 mg (1–2) CHF, primaryaldosteronismRenal failure,hyperkalemiaEplerenone 50–100 mg (1–2)K+retaining Amiloride 5–10 mg (1–2) Renal failure,hyperkalemiaTriamterene 50–100 mg (1–2)56
  • 57. Drug Class Examples Usual TotalDaily Dose(DosingFrequency/Day)OtherIndicationsContraindications/CautionsBetablockersAsthma, COPD, 2ndor 3rd degree heartblock, sick-sinussyndromeCardioselectiveAtenolol 25–100 mg (1) Angina, CHF,post-MI, sinustachycardia,ventriculartachyarrhythmiasMetoprolol 25–100 mg (1–2)Nonselective Propranolol 40–160 mg (2)Propranolol LA 60–180 (1)Combinedalpha/betaLabetalol 200–800 mg (2) ? Post-MI, CHFCarvedilol 12.5–50 mg (2)AlphaantagonistsSelective Prazosin 2–20 mg (2–3) ProstatismDoxazosin 1–16 mg (1)Terazosin 1–10 mg (1–2)Nonselective Phenoxybenzamine20–120 mg (2–3) Pheochromocytoma57
  • 58. Drug Class Examples Usual TotalDaily Dose(DosingFrequency/Day)OtherIndicationsContraindications/CautionsSympatholyticsCentral Clonidine 0.1–0.6 mg (2)Clonidine patch 0.1–0.3 mg(1/week)Methyldopa 250–1000 mg (2)Reserpine 0.05–0.25 mg (1)Guanfacine 0.5–2 mg (1)ACE inhibitors Captopril 25–200 mg (2) Post-MI, CHF,nephropathyRenal failure,bilateral renal arterystenosis,pregnancy,hyperkalemiaLisinopril 10–40 mg (1)Ramipril 2.5–20 mg (1–2)Angiotensin IIantagonistsLosartan 25–100 mg (1–2) CHF, diabeticnephropathy,ACE inhibitorcoughRenal failure,bilateral renal arterystenosis,pregnancy,hyperkalemiaValsartan 80–320 mg (1)Candesartan 2–32 mg (1–2)58
  • 59. Drug Class Examples Usual TotalDaily Dose(DosingFrequency/Day)OtherIndicationsContraindications/CautionsCalcium antagonists Heart failure, 2dor 3d degreeheart blockDihydropyridines Nifedipine(long acting)30–60 mg (1) AnginaNondihydropyridines Verapamil(long acting)120–360 mg (1–2)Post-MI,supraventriculartachycardias,anginaDiltiazem(long-acting)180-420 mg (1)Direct vasodilators Hydralazine 25–100 mg (2) Severe coronaryartery diseaseMinoxidil 2.5–80 mg (1–2) 59
  • 60. Resistant HypertensionBlood pressure persistently >140/90mmHg despite taking three or moreantihypertensive agents, including adiuretic, in reasonable combination and atfull doses.Exclusion of identifiable cause of HTNMore common in patients >60 years60
  • 61. Causes of Resistant Hypertension61
  • 62. Followup and MonitoringOnce antihypertensive drug therapy is initiated, most patientsshould return for followup and adjustment of medications atapproximately monthly intervals until the BP goal is reached.More frequent visits will be necessary for patients with stage2 hypertension or with complicating comorbid conditions.Serum potassium and creatinine should be monitored at least1–2 times/year.After BP is at goal and stable, followup visits can usually beat 3- to 6-month intervals.Comorbidities, such as heart failure, associated diseasessuch as diabetes, and the need for laboratory tests influencethe frequency of visits. Other cardiovascular risk factorsshould be treated to their respective goals, and tobaccoavoidance should be promoted vigorously. 62
  • 63. THANKS63