2. Hypertension
A World Wide Epidemic
Nearly 1 billion hypertensive in the world
Hypertension is poorly controlled, with less
than 25% controlled in developed countries
and less than 10% in developing countries.
Hypertension which is responsible for 3
million death annually.
May 14th is World Hypertension Day
India 28% in Urban and 10% in Rural Areas
3. Prevalence of Hypertension
131 144
302
584
240
0
100
200
300
400
500
600
Prevalence
Rate/1000
1
India (2000) Bangladesh (2002) Malaysia (2002)
China (2002) USA (2002)
4. Hypertension is a hemodynamic disorder
A well accepted definition of hypertension was
suggested by Evans and Rose:
“Hypertension should be defined in the terms of
blood pressure level above which investigation and
treatment do good more than harm”
A patient is said to be hypertensive when his
SBP≥ 140 mm Hg & DBP ≥ 90 mm Hg provided
that the patient is not on antihypertensive drugs.
Hypertension: Definition
6. Classification of BP for Adults
JNC-VI;1997
BP Classification Systolic BP Diastolic BP
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT 160-179 or 100-109
Stage 3 HT ≥ 180 or ≥ 110
BP Classification Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT ≥ 160 or ≥ 100
JNC-VII;2003
14. Systolic Hypertension in Teenagers and Young Adults
(typically 17 to 25 years of age)
Diastolic Hypertension in Middle Age
(typically, 30 to 50 years of age)
Isolated Systolic Hypertension in Older Adults
After the age of 55 years, ISH (systolic blood pressure >
140 mm Hg and diastolic blood pressure < 90 mm Hg)
predominates
15. Haemodynamic Pattern in Primary
Hypertension
Young : BP = CO X TPR
Middle Aged : BP = CO X TPR
Elderly : BP = CO X TPR
16. •Age-dependent changes in systolic
and diastolic blood pressure
Age-dependent changes in systolic and diastolic blood pressure
17.
18.
19. Aetiology of Systemic Hypertension
A) Essential or Primary HTN (95%)
From 90% to 95% of hypertensive patients have no
apparent single reversible cause of elevated blood
pressure, hence the term Primary Hypertension
20. Aetiology of Systemic Hypertension
A) Essential or Primary HTN (95%)
A. Age
B. Genetic • Both parents (45%)
• Single (25%)
C. Environment • Diet Fat
Salt
alcohol
• Obesity
• Physical inactivity
• Stress
• Smoking
D. Hormonal
22. C) Others
Coarctation of the aorta
Pregnancy Induced HTN (Pre-eclampsia)
Sleep Apnea Syndrome.
Aetiology of Systemic Hypertension
23.
24. Clinical Manifestation
• Asymptomatic in the majority of patients.
Can remain undetected for many years
• Headache may occur when SBP rises above
200mmHg or when blood pressure is rapidly
elevated.
25.
26. Measuring Blood Pressure
• Patient seated quietly for at least
5minutes in a chair, with feet on the
floor and arm supported at heart
level
•An appropriate-sized cuff (cuff bladder encircling
at least 80% of the arm)
•At least 2 measurements
Continue…
27. Measuring Blood Pressure
• Systolic Blood Pressure is the point at which
the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…
28. Measuring Blood Pressure
• Ambulatory BP Monitoring - information about
BP during daily activities and sleep.
• Correlates better than office measurements
with target-organ injury.
Continue…
31. •Average daytime pressure below 135/85 mm Hg
•Nighttime pressure below 120/70 mm Hg
•24-hour pressure below 130/80 mm Hg
•least two measurements per hour should be taken
during the patient’s waking hours, and the
average value of at least 14 measurements
during that time confirms the diagnosis of
hypertension
33. White Coat Hypertension
If the daytime blood pressure is below 135/85 mm Hg
and there is no target organ damage despite
consistently elevated office readings, the patient has
“office-only” or white coat hypertension, caused by a
transient adrenergic response to the measurement of
blood pressure only in the physician’s office
The prognostic importance of white coat hypertension
depends on treatment status. In untreated patients, the
long-term cardiovascular risk in older persons with white
coat hypertension is indistinguishable from that in
normotensive persons treated patients with high office
readings but normal ambulatory readings are at greater
cardiovascular risk than untreated normotensive patients
34. Masked Hypertension
•Sympathetic overactivity in daily life
caused by job or home stress,
tobacco abuse, or other adrenergic
stimulation that dissipates when they
come to the office
•Affect more than 10% of patients and
clearly increases cardiovascular risk,
despite normal office blood pressure
readings
35. Assessment of Htn
Personal history
• Time of the first diagnosis of hypertension, including
records of any previous medical screening,
hospitalization
• Stable or rapidly increasing BP
• Recordings of current and past BP values by self BP
measurements
• Current/past antihypertensive medications including
their effectiveness and intolerance
• Adherence to therapy
• Previous hypertension in pregnancy/preeclampsia
36. Assessment of Htn
Risk factors
• Family history of hypertension, CVD, stroke or kidney
disease
• Smoking history
• Dietary history, alcohol consumption
• Lack of physical exercise/sedentary lifestyle
• Weight gain or loss in the past
• History of erectile dysfunction
• Sleep history, snoring, sleep apnea (information also from
partner)
• Distress or eustress with job or at home (subjective stress
level)
• Long term cancer survivor
37. Assessment of Htn(HMOD)
Brain and eyes: headache, vertigo, syncope, impaired vision,
TIA, sensory or motor deficit, stroke, carotid revascularization,
cognitive impairment, memory loss, dementia (in older people)
Heart: chest pain, shortness of breath, edema, myocardial
infarction, coronary revascularization, syncope, history of
palpitations, arrhythmias (especially AF), heart failure
Kidney: thirst, polyuria, nocturia, hematuria, urinary tract
infections
Peripheral arteries: cold extremities, intermittent claudication,
pain-free walking distance, pain at rest, ulcer or necrosis,
peripheral revascularization
Patient or family history of CKD (e.g. polycystic kidney disease)
38. Assessment of Htn (20)
• Young onset of grade 2 or 3 hypertension (<40 years), or
sudden development of hypertension or rapidly worsening BP in
older patients
• History of repetitive renal/urinary tract disease
• Repetitive episodes of sweating, headache, anxiety or
palpitations, suggestive of pheochromocytoma
• History of spontaneous or diuretic-provoked hypokalemia,
episodes of muscle weakness and tetany (hyperaldosteronism)
• Symptoms suggestive of thyroid disease or
hyperparathyroidism
• History of or current pregnancy, postmenopausal status and
oral contraceptive use or hormonal substitution
39. Assessment of Htn
Risk factors
• Family history of hypertension, CVD, stroke or kidney
disease
• Smoking history
• Dietary history, alcohol consumption
• Lack of physical exercise/sedentary lifestyle
• Weight gain or loss in the past
• History of erectile dysfunction
• Sleep history, snoring, sleep apnea (information also from
partner)
• Distress or eustress with job or at home (subjective stress
level)
• Long term cancer survivor
40. Cardiovascular Risk
Stratification
Risk Factors for Cardiovascular Disease
• Increased systolic and diastolic blood
pressure levels
• Increased pulse pressure (in the elderly)
Age: men, > 55 years; women, > 65 years
• Smoking
• Dyslipidemia (LDL cholesterol > 115
mg/dL)
• Impaired fasting glucose (100-125 mg/dL)
or abnormal glucose tolerance test result
• Family history of premature cardiovascular
disease
• Abdominal obesity
• Diabetes mellitus
Subclinical Target Organ Damage
• Left ventricular hypertrophy
• Carotid wall thickening or plaque
• Low estimated glomerular filtration rate ≤
60 mL/min/1.73 m2
• Microalbuminuria
• Ankle-brachial index < 0.9
• Established Target Organ Damage
Cerebrovascular disease: ischemic stroke,
cerebral hemorrhage, transient ischemic
attack
• Heart disease: myocardial infarction,
angina, coronary revascularization, heart
failure
• Renal disease: diabetic nephropathy, renal
impairment
• Peripheral arterial disease Advanced
retinopathy: hemorrhages or exudates,
papilledema
41. Physical Examination
• Body habitus
• Weight and height measured on a calibrated scale, with calculation of BMI
• Waist circumferenceSigns of hypertension-mediated organ damage
• Neurological examination and cognitive status
• Fundoscopic examination for hypertensive retinopathy in emergencies
• Auscultation of heart and carotid arteries
• Palpation of carotid and peripheral arteries
• Ankle–brachial indexSigns of secondary hypertension
• Skin inspection: cafe-au-lait patches of neurofibromatosis (pheochromocytoma)
• Kidney palpation for signs of renal enlargement in polycystic kidney disease
• Auscultation of heart and renal arteries for murmurs or bruits indicative of aortic
coarctation, or renovascular hypertension
• Signs of Cushing’s disease or acromegaly
• Signs of thyroid disease
42. Evaluation of Hypt. Mediated
organ damage(HMOD)
•Hypertensive Heart Disease
•Large-Vessel Disease
•Cerebrovascular Disease
•Chronic Kidney Disease
•hypertensive nephrosclerosis
•Microalbuminuria (defined as a urine
albumin–to–urine creatinine ratio of 30 to
300 mg/g) is a sensitive early marker of
kidney damage and a powerful
independent predictor of cardiovascular
complications from hypertension
45. The scope of the problem
• Heart Attack (MI)
• Heart Failure
• Stroke
• Kidney Disease
EARLY DIAGNOSIS IS ESSENTIAL TO MINIMISE
CARDIOVASCULAR RISK AND DAMAGE TO TARGET ORGANS
46.
47. Secondary Hypertension
• Younger patients (<40 years) with grade 2 or 3 hypertension or
hypertension of any grade in childhood
• Sudden onset of hypertension in individuals with previously
documented normotension
• Acute worsening of BP control in patients with previously well
controlled by treatment
• True resistant hypertension hypertension
• Hypertensive emergency
• Severe (grade 3) or malignant hypertension
• Severe and/or extensive HMOD, particularly if disproportionate for the
duration and severity of the BP elevation
• Clinical or biochemical features suggestive of endocrine causes of
hypertension
• Clinical features suggestive of renovascular hypertension or
fibromuscular dysplasia
• Clinical features suggestive of obstructive sleep apnea
• Severe hypertension in pregnancy (>160/110mmHg) or acute
worsening of BP control in pregnant women with preexisting
hypertension
49. Identifiable (Secondary) Forms of
Hypertension
Renal Parenchymal Disease
• most common cause of secondary hypertension,
responsible for 2% to 5% of cases
• obstruction of the urinary tract, depletion of effective
circulating volume, nephrotoxic agents, and most
important, uncontrolled hypertension
Acute Renal Diseases
Reversal of hypertension has been particularly
striking in men with high-pressure chronic retention of
urine
Chronic Renal Diseases
Hemodialysis Patients
50. Renovascular Hypertension
•14% of hypertensive patients undergoing
coronary angiography
•Atherosclerotic disease affecting mainly
the proximal third of the main renal artery
•Fibromuscular disease (FMD) involving
mainly the distal two thirds and branches
of the renal arteries appears most
commonly in women between 20 and 60
years of age.
•FMD typically affects the media but also
can involve the intima and adventitia;
bilateral carotid FMD may accompany
renal FMD.
51. Laboratory Findings
Secondary aldosteronism
Higher plasma renin level
Low serum potassium level
Low serum sodium level
Proteinuria, usually moderate Elevated
serum creatinine level Unilateral small
(atrophic) kidney size by ultrasound
examination
Physical Examination Findings
Abdominal bruits Other bruits Advanced
fundal changes
History
Onset of hypertension before 30 years or
after 50 years of age Abrupt onset of
hypertension
Severe or resistant hypertension
Symptoms of atherosclerotic disease
elsewhere
Negative family history of hypertension
Smoker
Worsening renal function after renin-
angiotensin inhibition Recurrent “flash”
pulmonary edema
52. Diagnosis & Management of RAS
• The initial diagnostic study in most patients should be noninvasive,
and abnormal results should lead to a study of renal perfusion to
confirm that any renovascular lesion is pathogenic and to guide
consideration for revascularization
• During the past decade, contrast-enhanced computed tomography
(CT) and magnetic resonance angiography have become the
preferred screening tests for renal artery stenosis because initial
studies suggested better sensitivity and specificity
• Balloon angioplasty (without stenting) is the treatment of choice for
renal FMD
• conservative approach based on medical management of
cardiovascular risk factors—with antihypertensive medication,
statins, and antiplatelet therapy—is the cornerstone for the
treatment of patients with atherosclerotic renal artery stenosis
• Medically refractory hypertension and progressive decline in renal
function (ischemic nephropathy) currently are the only two firm
indications for balloon angioplasty
53. ADRENAL AND OTHER CAUSES
OF HYPERTENSION (≤ 1%)
•primary excesses of aldosterone
•Cortisol
•catecholamines; deoxycorticosterone
•<1% to ~15% of hypertensive individuals
•patients with resistant hypertension
commonly have the condition
•more cardiovascular events occur in
patients with primary aldosteronism than in
patients with primary hypertension
matched for age, sex, and blood pressure
levels
54. PHEOCHROMOCYTOMA
Paraganglioma
• account for hypertension in ~0.05% of patients
• benign tumors arising from neuroectodermal chromaffin cells
• adrenal medulla and abdomen, but they may arise anywhere
within the plexus of sympathetic adrenergic nerves
• wild fluctuations in blood pressure and dramatic symptoms of pheo
usually alert both the patient and physician to the possibility the
hypertension may be persistent
• Spells typical of a pheochromocytoma
• Headache
• Sweating
• Palpitations
• pallor
• Weight Loss
55. MISCELLANEOUS CAUSES OF
HYPERTENSION
•Obstructive sleep apnea
•Coarctation of the aorta
•Hypothyroidism
•Hyperthyroidism
•Hypercalcemia
•Acromegaly
•Glucocorticoid-remediable primary
aldosteronism
57. The "Rule of Halves" in
Hypertension
Only 1/2 have been
diagnosed
Only 1/2 of those
diagnosed have been
treated
Only 1/2 of those
treated are adequately
controlled
Not
diagnosed
Not treated
Not
controlled
Controlled
Only 12.5% overall are adequately controlled
58. Evaluation of hypertensive patients
Objectives:
To know accurate and representative
measurement of BP
To identity any known cause of Hypertension
To assess presence or absence of HMOD
To assess response to therapy
To identity cardiovascular risks factor
To know concomitant disorders
Continue….
59. Evaluation of hypertensive patients
Evaluation by
Medical history
Physical Examination
Laboratory investigation
Routine tests
Optional tests.
63. Effects of Antihypertensive Drug Treatment on CV
Mortality and Morbidity
Combined result from 17 randomized, placebo-controlled treatment trials; decreased in
events-treated compared to control
Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478
-52%
-38%
-35%
-25%
-16%
-60%
-50%
-40%
-30%
-20%
-10%
0%
CHF Strokes
(fatal/nonfatal)
LVF CVD Deaths CVD events
(fatal/nonfatal
Management of HTN
64. 140
120
100
80
60
40
20
0
50
40
30
20
10
0
Historical Lessons About Hypertension
Hypertension Increases
Morbidity and Mortality
Men Women
THE FRAMINGHAM STUDY
Treatment Decreases
Morbidity and Mortality
Men Women Placebo Active
Treatment
THE VET.ADM. STUDY II
Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152
Normotension
Hypertension
65. Implication of reduction in Diastolic BP for
Primary Prevention
30
20
Change in DBP
0
-10
-20
-30
-40
-50
7.5 mm Hg 5-6 mm Hg 2 mm Hg
-21
-46
-16
-38
-6
-15
CHD
Stroke
Cook, et al. Arch Int med. 1995; 155:711-109
66. Millimeters Matter……
“ A 2-mm Hg reduction in DBP would
result in…
a 6% reduction in the risk of CHD and a 15%
reduction
in the risk of stroke and TIAs”
Cook, et al. Arch Int med. 1995; 155:711-109
67. Impact of High Normal BP on CV
Disease Risk in Men
High Normal
130-139/ 85-89 mm Hg
Normal
120-129/ 80-84 mm Hg
Optimal
<120/ 80 mm Hg
N Engl J Med. 2001;345:1291-97
68. Benefits of Lowering BP
Average percent
reduction
Stroke reduction 35-40%
Myocardial infarction 20-25%
Heart failure 50%
69. Goals of Therapy
•Reduction of cardiovascular and renal
morbidity and mortality. 1
• The primary focus should be on achieving the
systolic BP goal.
• Systolic BP and diastolic BP to targets <
130/80mmHg = decrease in CVD complications.
70. JNC VII Algorithm for Treatment of
Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle Modifications
Not at Goal BP
(< 130/80 mmHg < 60 yrs
Initial Drug Choices
71.
72. Lifestyle Modification: 1
Socioeconomic condition in the world suggest that
prevention through Lifestyle Modifications is the
universal “vaccine” against Hypertension
Weight Reduction
• Maintain normal body weight
• BMI: 18.5 – 24.9
• BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan
• Dietary Approaches to Stop Hypertension
• Fruits, Vegetables, Low-fat dairy
• Reduce saturated and total fat
• 8-14 mmHg BP reduction
Mediterranean Pattern
73. Lifestyle Modification: 2
Dietary Sodium Reduction
•2.4 grams Sodium or 6 grams Sodium Chloride
•2-8 mmHg BP reduction
Physical Activity
–Regular aerobic physical activity
•4-9 mmHg BP reduction
74. Lifestyle Modification: 3
Smoking Cessation
•Any independent chronic effect of smoking on BP is
small
•Smoking cessation does not decrease BP
•BUT total cardiovascular risk is increased by
smoking.
Therefore hypertensives
who smoke should be
counselled on smoking
cessation
76. ACD of anti-hypertensives
Category Drugs Spl issues
ACEI / ARB Enalapril
Ramipril
Losartan
Telmasartan
Dizziness
Dry cough
CC Amplodepin Pedal edema
D Hydrochlorthiazide
Chlorthalidone
Lethargy
Hyponatremia
77. Drugs and dosages
Class Drug Starting
dose
Optimal
dose
Maximu
m dose
A ACEI Enalapril 2.5mg 10mg 40mg
Ramipril 2.5mg 5mg 20mg
ARB Losartan 25mg 50mg 100mg
Telmisartan 40mg 40mg 80mg
C CCB Amlodepin 2.5mg 5mg 10mg
D Diuretic Hydrochlorthiazide 12.5mg 25mg 50mg
Chlorthalidone 6.25mg 12.5mg 25mg
78.
79. A person with hypertension
To be initiated on drug treatment
C
Step 1:
• Initiate with a low dose, escalate to optimal dose.
• Prefer CCB (Amlodepin) especially if age >65 years
• In younger patients low dose ACEI / ARB may be preferred
(Losartan or Telmisartan)
• If person develops swelling over feet with amlodepin, add an
ACEI/ARB).
• Beta-blocker is not preferred as initial therapy due to long term
risk of development of diabetes mellitus.
• Allow 4 weeks for blood-pressure response, if target BP is
achieved.
A
or
Target BP
<130/80if age <60 years
80. A person with hypertension
To be initiated on drug treatment
C
A + C
Step 2:
If target BP is not achieved with optimal dose of
single drug, review adherence.
If adherence is good add a second drug in low
dose.
Prefer either ACEI/ARB with CCB (Amlodepin +
Losartan / Telmisartan) or Diuretic with CCB
(HCTZ + Amlodepin).
Allow 4 weeks for blood-pressure response.
C + D
or
A
or
A + D
Target BP
<140/90 if age <60 years
<150/90 if age >/=60 years
81. A person with hypertension
To be initiated on drug treatment
C
A + C
A + C + D
C + D
or
A
or Step 3: If target is not achieved, with
optimal dose of two drugs, review
adherence.
If adherence is good, consider to add a
third drug. ACEI/ARB + CCB + Diuretic is a
preferred option.
If blood pressure remains uncontrolled
with three drugs label as resistant
hypertension and refer to a specialist.
Unacceptable combinations are
• ACEI and ARB
• Dual ACEI/ARB
• ACEI/ARB with a beta-blocker
• Beta-blocker with a non-amlodepin calcium channel
blocker (such as diltiazem or verapamil).
A + D
Target BP
<140/90 if age <60 years
<150/90 if age >/=60 years
82. Adherence to drugs
•Take your blood pressure medicines every day
•It is better to fix a particular time in the day for
taking medicines.
•Involve family members to promote
adherence, ask spouse to give verbal
reminders.
•Keep your medicines at a place where it is
visible, such as near a place where you have
food.
•Adherence to medication is key to blood
pressure control. Promote adherence at
every visit.
83. Add-On Drug Classes for Difficult
Hypertension
•Aldosterone Antagonists
• Low-dose spironolactone (12.5 to 100 mg daily)
•Beta-Adrenergic Blockers
•Vasodilating beta blockers (labetalol, carvedilol,
and nebivolol)
•Alpha-Adrenergic Blockers
•Central Sympatholytics
•Direct Vasodilators
•Mechanism of Action
•Minoxidil and hydralazine
•short-acting clonidine
84. Renal Denervation
• Office SBP ≥ 160 mm Hg (≥150 mm Hg if type 2 diabetes)
• >3 Antihypertensive drugs in adequate dosage and
combination (including a diuretic)
• Lifestyle modification
• Exclusion of secondary hypertension
• Exclusion of pseudoresistance using ABPM (average SBP
≥ 130 mm Hg or mean daytime SBP ≥ 135 mm Hg)
• Preserved renal function (eGFR ≥ 45 mL/min/1.73 m2)
• Eligible renal arteries: no polar or accessory arteries, no
renal artery stenosis, no previous revascularization
85.
86. Set targets
•BP control <130/80 in all. <140/90 in those at or
above 60 years of age.
•Tobacco cessation
•Reduce salt in diet
•Weight reduction (7% of current weight,
eventually BMI <25 or wt=height -100)
• Physical activity
• Healthy diet
87. Intelligent HTN prescription
•Quit tobacco use / alcohol use
•Increase Physical activity – at least 45-
60min/day x 5-6 days a week
•Omit Salty snacks from diet
•Increase fresh fruits / vegetables (3-5
servings in a day)
•Blood pressure lowering drug (s) (A +
C + D)
•Screen /prevent complications
•Advise when next visit is required.
90. Hypertension in Pregnancy
• Measure BP at every ANC visit
• Cut-off for diagnosis
• Mild >140-149 /90-99
• Moderate 150-159 / 100-109
• Severe >160/110
91. Hypertension in Pregnancy
• Subtypes
• Chronic HTN in a pregnant woman
• Known HTN before delivery or detected to be
HTN before 20 weeks of gestation
• Pregnancy induced Hypertension
(PIH)
• HTN detected after 20 weeks of gestation
• Pre-eclampsia
• PIH and Proteinuria
92. Managing HTN in Pregnancy
•Chronic Hypertension
•Discontinue ACEI/ARB & diuretics as soon
as pregnancy is detected, shift to alternate
drugs
•Measure for Urinary proteins at each visit
•Target BP <150/100 mm Hg*. Do not
lower DBP < 80 mm Hg.
•Continue salt restriction in diet
•Refer to specialist Obstetrics for further
management
* If end organ damage, Target BP <140/90 mm Hg
93. Managing HTN in Pregnancy
•Pregnancy induced Hypertension
•Drug therapy to be initiated if BP >150/100
mm Hg, Hospitalization if BP >160/110
•Test for Proteinuria at each visit
•Refer to specialist Obstetrics for further
management
•If Proteinuria is present at any time (Pre-
eclampsia)
•Refer to specialist Obstetrics for further
management
94. First line anti-HTN drugs to be
used in pregnancy
•Alpha-Methyldopa
•Initiate at 250mg Twice daily
•Can escalate to 1500mg twice daily
•Nifedipine
•Initiate at 30mg (SR) once daily
•Can escalate to 120mg (SR) once daily
•Labetalol
•Initiate at 100mg twice daily
•Can escalate to 400mg thrice daily
95. Post-partum management
•Measure BP four times on day one, daily
between days 2 and 5, and thereafter at six
weeks
•Chronic HTN
• Stop Methyldopa in 2 days after delivery
• Drug dosages may need reduction after delivery
• Shift to previous or ACD drugs for HTN
•Pregnancy Induced Hypertension
• Stop Methyldopa in 2 days after delivery
• Drug dosages may need reduction after delivery
• Shift to ACD drugs, if BP >150/100
• Assess need for long term drugs at 6 weeks post-
partum
97. Indications and Contraindications for the
Major Classes of Antihypertensiue Drugs
Class Conditions favouring
the use
Compelling
contraindications
Possible
contraindications
ACEIs CHF
LV dysfunction
Post-MI
Nondiabetic nephropathy
Type 1 diabetic nephropathy
Protienuria
Pregnancy
Hyperkalaemia
Bilateral RAS
ARBs Type 2 diabetic nephropathy
Diabetic microalbuminuria
Proteinuria
LVH
ACE inhibitor cough
Pregnancy
Hyperkalaemia
Bilateral RAS
a-Blockers Prostatic hyperplasia (BPH)
Hyperlipidaemia
Orthostatic
hypotension
CHF
EHS-ESC Guidelines, 2003;
98. Management of HTN in Special
Situation
1. Hypertension Crises
Hypertension Emergencies
Hypertension Urgencies
2. Refractory/ Resistant hypertension
3. HTN in Pregnancy
4. HTN with coexisting Cardiovascular & other
disorders
4. Management of Secondary HTN
99. Resistant Hypertension
•Not uncommon : 15-20%
•Persistence of elevated systo-diastolic pressure
in spite of at 3 anti-hypertensive drugs (
including diuretics)
•Pre-requisites: Exclusion of pseudo-
hypertension; white-coat hypertension,use of
not-appropriate cuffs.
101. Therapeutic intervention
•Exclude undiagnosed secondary
hypertension
•Compliance of drugs
•Adherence to life style changes
•Consider use of 3 or more anti-
hypertensive drugs
•Consider the use of drugs such as
spironolactone
102. • Severe asymptomatic hypertension (systolic blood
pressure
• ≥180 mmHg or diastolic blood pressure ≥120 mmHg)
is considered a hypertensive “urgency
• HMOD then Emergency
•malignant hypertension is an example of
a hypertensive emergency that is associated with an
abrupt increase of blood pressure in a patient with
underlying hypertension or related to the sudden
onset of hypertension in a previously normotensive
individual
103. •rapidity with which blood pressure
should be lowered is dependent on the
presence of new or worsening target
organ damage and the presence or
absence of cardiovascular disease
complications
•In Urgency blood pressure is generally
gradually lowered
•over 24 h to ~25% of the initial value
104.
105. Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from
Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in
developing countries
Early diagnosis & management can prevent end organ damage from
HTN
Target goal of BP in hypertensive patients:-
< 140/90 mm Hg
< 130/80 mm Hg for patients with DM & renal disease
Lifestyle modification is the universal “Vaccine” against Hypertension
Conclusion
