Uncontrolled blood pressure had become most common cause of death accounting for more than 7 million deaths per year worldwide. Despite the availability of potent lifestyle and pharmacologic approaches, rates of control of blood pressure are unsatisfactory and additional strategies to curb the burden of hypertension are warranted. Several novel pharmacological and device-based approaches have recently been tested and may prove helpful to achieve better blood pressure control rates and thereby improve cardiovascular outcomes in patients with hypertension.

1. RECENT ADVANCEMENT IN THE
MANAGEMENT OF HYPERTENSION
PRESENTED BY:-AKSHATA RANGNATH DARANDALE
PHARM D
SUBJECT :- PHARMACOTHERAPEUTICS -I

2. Abstract
• Uncontrolled blood pressure remains the single most common cause of
death accounting for more than 7 million deaths per year worldwide. Despite
the availability of potent lifestyle and pharmacologic approaches, rates of
control of blood pressure are unsatisfactory and additional strategies to curb
the burden of hypertension are warranted. Several novel pharmacological
and device-based approaches have recently been tested and may prove
helpful to achieve better blood pressure control rates and thereby improve
cardiovascular outcomes in patients with hypertension.

3. INTRODUCTION
• Hypertension is the most frequent chronic and non-communicable disease all over the world .
• Notwithstanding the large number of clinical observational studies and randomized trials over the past four
decades, it is sad to note that in the last few years there has been an impressive paucity of innovative studies.
• Research focused on BP mechanisms and novel antihypertensive drugs is slowing dramatically.
• The present review discusses some advances in the management of hypertensive patients, and could play a clinical
role in the years to come.
• First, digital/health technology is expected to be increasingly used, although some crucial points remain
(development of non-intrusive and clinically validated devices for ambulatory BP measurement, robust storing
systems enabling rapid analysis of accrued data, physician-patient interactions, etc.).
• Second, several areas should be better outlined with regard to BP diagnosis and treatment targets.
• Third, from a therapeutic standpoint, existing antihypertensive drugs, which are generally effective and well
tolerated, should be better used by exploiting available and novel free and fixed combinations. In particular,
spironolactone and other mineral-corticoid receptor antagonists should be used more frequently to improve BP
control.
• In particular, some drugs initially developed for conditions different from hypertension including heart failure and
diabetes have demonstrated to lower BP significantly and should therefore be considered. Finally, renal artery
denervation is another procedure that has proven effective in the management of hypertension.

4. About disease -
HYPERTENSION-
Hypertension is defined as an abnormal elevation in diastolic pressure and/or
systolic pressure; mean arterial pressure is also elevated in hypertension .
• There are two main types of high blood pressure:
• Essential (primary) hypertension
• Secondary Hypertension

5. Diagnostic Criteria
• Hypertension is diagnosed on the basis of a persistently high blood pressure.
Traditionally, this requires three separate sphygmomanometer measurements at one
monthly interval. Initial assessment of the hypertensive people should include a complete
history and physical examination. With the availability of 24-hour ambulatory blood
pressure monitors and home blood pressure machines, the importance of not wrongly
diagnosing those who have white coat hypertension has led to a change in protocols. In
the United Kingdom, current best practice is to follow up a single raised clinic reading
with ambulatory measurement, or less ideally with home blood pressure monitoring over
the course of 7 days.
• Equipment:
• Cuff size, Manometer, ECG, Chest Radiograph, Transthoracic Doppler-
echocardiography, Prognostric parameters in patients with idiopathic pulmonary arterial
hypertension Clinical Parameters, Exersice capacity, Echocardiographic parameters,
Haemodynamics, Blood tests.

6. Risk factors for high blood pressure
• Long term increased sodium intake.
• Reduced dietary potassium, calcium and magnesium.
• Diabetes mellitus and insulin resistance.
• Smoking
• Excessive alcohol consumption.
• Lack of physical activity.
• Obesity
• High stress levels

7. Objectives
• The Objectives of management in cardiovascular disease condition are :
• To present the standard treatment/therapies involved in hypertension so as to
prevent from further risk/ complications.
• The objectives are also how to manage primary hypertension condition by standart
drug therapies in short intervals.
• To emphasis the importance of therapies and management of hypertension and
reduce the risk and complication.
• To obtain the benefits of varies therapies involved in hypertension management.
• To understand the importance treatment goals in hypertension.

8. Traditional treatment for Hypertension
• Diuretics
• Thiazides
• Loop diuretics
• β/ Blockers
• ACE Inhibitors
• Calcium channel blockers

9. Recent Advancement in Therapy
• Pharmacological approaches Chronotherapy
The concept of chronotherapy relates to the adjustment of medication based on
circadian rhythm. The time of drug administration can be determined by the
assessment of the 24-h ambulatory BP profile. There are two key parameters that play
a particularly important role in this context: the nocturnal fall in BP and the magnitude
of the morning BP surge. Long-lasting drugs administered in the morning are
suggested for hypertensive patients with normal circadian BP pattern. For non dippers
or reverse-dippers chronotherapy can not only revert an abnormal dipping profile, but
also attenuate an exaggerated morning rise in BP

10. Novel approaches to renin–angiotensin–aldosterone system
blockade
• The renin–angiotensin–aldosterone system (RAAS) plays apivotal role in BP
regulation and its pharmacological inhibition is associated with reduced CV
risk and CV complications. The RAAS cascade can be targeted at various
levels with drugs such as direct renin inhibitors, ACE inhibitors (ACEIs),
AT1-receptor blockers and mineralocorticoid receptor antagonists

11. Dual RAAS blockade with ACEI & ARBs
• Inhibition of the RAAS cascade with either ACEIs or angiotensin II receptor blocking
agents (ARBs) is a powerful strategy to lower BP, to reduce progression of CV and renal
disease, and to improve CV outcomes. More complete blockade of the RAAS, as can be
achieved by combining ACEIs and ARBs, appeared to be a logical approach to further
exploit the potential of RAAS inhibition. Indeed, several studies have suggested that dual
blockade of RAAS provides additional nephroprotective and cardioprotective benefits
beyond BP lowering. For example, ARBs in combination with ACEIs decreased proteinuria
in hypertensive Type 2 diabetic patients with nephropathy , and the reduction of
albuminuria in patients with renal disease achieved with dual blockade was more
pronounced than with either drug alone.

12. Cont….
• Aliskiren 150 mg was as effective as irbesartan 150 mg in lowering BP, but less
effective than aliskiren 300 mg .
• The effectiveness in reducing BP and tolerability of aliskiren compared with
ramipril was studied in a large cohort of 901 patients above 65 years of age (mean
age: 72.1 years) with stage one to three systolic hypertension (Aliskiren for Geriatric
Lowering of Systolic Hypertension [AGELESS]). In this 36-week randomized
controlled double-blind optionaltitration study aliskiren reduced SBP from baseline
to week 12 (-14.0 ± 0.8 vs -11.6 ± 0.8 mmHg; p < 0.001) and diastolic BP (DBP) (-
5.1 ± 0.4 vs -3.6 ± 0.4 mmHg; p < 0.01) significantly more than ramipril. Those
patients who remained uncontrolled received an optional add-on therapy with
hydrochlorothiazide at 12 weeks and amlodipine at 22 weeks.

13. Renin inhibitors
• The availability of orally active direct renin inhibitors such as aliskiren triggered
considerable research efforts to assess the utility of blocking the RAAS at this level.
Indeed, PRA can be reduced by 70–75% via this approach. In healthy normotensive
subjects aliskiren reduces angiotensin I, angiotensin II and aldosterone
concentrations in a dose-dependent fashion , and consequently abolishes adverse
consequences of RAAS stimulation. In 226 patients with mild-to-moderate
hypertension, aliskiren dose-dependently reduced both mean ambulatory BP and
PRA over 4 weeks In a randomized double-blind placebo-controlled trial including
652 patients with stage one and two essential hypertension, aliskiren effectively
decreased sitting BP after 8 weeks of treatment and was generally well tolerated
Aliskiren 150 mg was as effective as irbesartan 150 mg in lowering BP, but less
effective than aliskiren 300 mg .

14. Aldosterone antagonists
• Aldosterone antagonists have been shown to have significant mortality and morbidity benefits in
patients with congestive heart failure. Accumulating evidence exists to suggest that aldosterone
antagonists are also very useful in lowering BP, particularly in patients with resistant hypertension in
whom the use of these agents has been discussed as an appropriate fourth-line therapy.
• This is based on various studies including a retrospective analysis of 1411 participants in the Anglo–
Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPL) where
spironolactone, which was added as a fourth-line treatment lowered mean BP by as much as 21.9/9.5
mmHg at a relatively small dose (25–50 mg/day), while sides effects were reported in only 6% of
study individuals More recently, a study including 175 patients with resistant hypertension has
confirmed a significant and persistent reduction in office and ambulatory BP with aldosterone
antagonism, particularly in patients with abdominal obesity .
• Eplerenone, a highly selective aldosterone-blocking agent has less affinity to androgen and
progesterone receptors, thereby limiting spironolactone-related side effects such as gynecomastiaand
breast tenderness

15. Cont…
• . The efficacy and safety of eplerenone in resistant hypertension was
demonstrated in a prospective study of 52 patients who had uncontrolled
hypertension despite receiving a mean of 3.7 ± 0.8 antihypertensive agents

16. Aldosterone synthase inhibitors
• Blockade of aldosterone synthase has emerged as an alternative therapeutic
strategy to aldosterone antagonists for the treatment of heart failure, post-
MI and resistant hypertension. So far, available data comes primarily from
experimental studies demonstrating that inhibition of aldosterone synthase
(CYP11B2) reduces mortality, cardiac hypertrophy, albuminuria, and cardiac
and renal inflammation in transgenic rats overexpressing both the human
renin and angiotensinogen genes .

17. Device-based approaches
• Baroreflex stimulation
• Catheter-based renal nerve ablation

18. Conclusion
• Hypertension, and in particular treatment-resistant hypertension, remains a challenging
and growing clinical problem. Given the complex pathophysiology of the condition and
the large number of contributing factors it appears naive to think that one single remedy,
or even a few, could overcome the problem. By contrast, a concerted effort is regularly
required that embraces the diversity of factors commonly involved in the pathogenesis of
hypertension with a particular focus on lifestyle interventions, combination of appropriate
and supplementary pharmacological treatment principles including more recent
developments as described earlier. Novel device-based approaches are promising and may
well have the potential to become a very valuable addition to established principles and
even overcome some shortcomings of pharmacological treatment such as drug-related
side effects, drug intolerance and others.
•

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20. THANKYOU