Herat - Afghanistan

1. Management of
Hypertension
DR. AH JAWID YOUSUFI

2. Nonpharmacologic Therapy
▪ Lifestyle modification may have an impact on morbidity and mortality of HTN.
▪ A diet rich in fruits, vegetables, and low-fat has been shown to lower blood
pressure and dietary fiber seems especially important.
▪ Approaches of proven but modest value include weight reduction, reduced
alcohol consumption, and, in some patients, reduced salt intake (less than 5 g
salt or 2 g sodium).
▪ Smoking cessation will reduce cardiovascular risk.
Overall, the effects of lifestyle modification on blood pressure are modest

3. Who Should Be Treated With Medications?
▪ patients with office-based blood pressure measurements that consistently
exceed 160/100 mm Hg will benefit from antihypertensive therapy irrespective
of cardiovascular risk.
▪ Treatment should be offered at lower thresholds in those with elevated
cardiovascular risk or in the presence of existing end-organ damage.
▪ The American College of Cardiology has developed an online toolkit relevant
to primary prevention (http://www.acc.org/tools-and-practicesupport/clinical-
toolkits/prevention), and an associated App called ASCVD plus .

4. ASCVD plus

5. Drug Therapy: Current Antihypertensive Agents
▪ There are many classes of antihypertensive drugs are suitable for initial
therapy based on efficacy and tolerability.
o Diuretics
o Beta-blockers
o ACE inhibitors
o Calcium channel blockers
o ARBs

6. Diuretics
▪ Thiazide diuretics: Most of the antihypertensive effect of these agents is achieved at
lower dosages than used previously.
• They lower blood pressure initially by:
o Decreasing plasma volume, but during long-term therapy
o Their major hemodynamic effect is reduction of peripheral vascular resistance.
▪ Loop diuretics: They lead to electrolyte and volume depletion more readily than the
thiazides and have short durations of action.
• In these cases they are more effective than thiazides:
o Renal failure (serum creatinine greater than 2.5 mg/dl, GFR less than 30 mL/min)
o Heart failure
▪ Potassium-sparing agent: In these cases could be used:
• Those taking digoxin
• History of ventricular arrhythmias
• Hypokalemia

7. Conti…
▪ Adverse effect
o Hypokalemia
o Hyponatremia
o Hyperglycemia
oHypercholesterolemia
o Impotence
o Gynecomastia (Spironolactone and Eplerenone)
o Ototoxicity
o Muscular cramps
o Skin rashes

8. Conti…

9. Beta-Adrenergic Blocking Agents
▪ they decrease:
• The heart rate and cardiac output
• Renin release and are more efficacious in populations with elevated plasma renin
activity.
▪ They neutralize the reflex tachycardia caused by vasodilators and are
especially useful in patients with associated conditions that benefit from the
cardioprotective effects of these agents. These include individuals with:
• Angina pectoris
• Previous myocardial infarction
• Stable heart failure
• Migraine headaches
• Somatic manifestations of anxiety

10. Conti…
▪ The side effects of beta-blockers include
o Inducing or exacerbating bronchospasm in predisposed patients
o Sinus node dysfunction and atrioventricular (AV) conduction depression (resulting in
bradycardia or AV block)
o Nasal congestion
o Raynaud phenomenon
o Central nervous system symptoms
• Nightmares
• Depression
• Confusion
• Fatigue
• Lethargy
o Erectile dysfunction

11. Conti…

12. Angiotensin-Converting Enzyme Inhibitors
▪ ACE inhibitors are commonly used as the initial medication in mild to moderate
hypertension.
▪ Their primary mode of action is inhibition of the renin–angiotensin–
aldosterone system, but they also:
▪ Inhibit bradykinin degradation
▪ Stimulate the synthesis of vasodilating prostaglandins
▪ Reduce sympathetic nervous system activity
▪ ACE inhibitors appear to be more effective in younger white patients.
▪ They are relatively less effective in blacks and older persons and in
predominantly systolic hypertension.
▪ ACE inhibitors are the .agents of choice in persons with type 1 diabetes.

13. Conti…
▪ An advantage of the ACE inhibitors is their relative freedom from troublesome
side effects.
o Severe hypotension
o Sudden increases in creatinine
o Hyperkalemia
o Chronic dry cough
o Skin rashes
o Angioedema
o Exposure of the fetus to ACE inhibitors during the second and third trimesters of
pregnancy has been associated with a variety of defects due to hypotension and
reduced renal blood flow.

14. Conti...

15. Angiotensin II Receptor Blockers
▪ ARBs are like ACE inhibitors.
▪ Unlike ACE inhibitors, the ARBs rarely cause cough and are less likely to be
associated with skin rashes or angioedema.

16. Conti…

17. Calcium Channel Blocking Agents
▪ These agents act by causing peripheral vasodilation.
▪ They are effective as single-drug therapy in approximately 60% of patients in all
demographic groups and all grades of hypertension.
▪ The most common side effects of calcium channel blockers are:
o Headache
o Peripheral edema
o Bradycardia
o Constipation (especially with verapamil in older adults)
▪ Calcium channel blockers have negative inotropic effects and should be used
cautiously in patients with cardiac dysfunction.
▪ Amlodipine is the only calcium channel blocker with established safety in patients
with severe heart failure.

18. Conti…

19. Alpha-Adrenoreceptor Antagonists
▪ They block postsynaptic alpha-receptors, relax smooth muscle, and reduce
blood pressure by lowering peripheral vascular resistance.
▪ Post-dosing palpitations, headache, and nervousness may continue to occur
during long-term therapy.

20. Conti…

21. Drugs With Central Sympatholytic Action
▪ lower blood pressure by stimulating alpha-adrenergic receptors in the central
nervous system, thus reducing efferent peripheral sympathetic outflow.
▪ they are usually used as second- or third-line agents because of the high
frequency of drug intolerance, including:
o Sedation
o Fatigue
o Dry mouth
o Postural hypotension
o Erectile dysfunction
▪ An important concern is rebound hypertension following withdrawal.

22. Conti…