Cardiac arrhythmia- Dr, Ashok Dutta. Associate professor and senior consultan...
Htn for nhf conference presentation1
1.
2. Dhaka 2012
SBP = 100 + your age
This may be usual but is not normal
BP>160/90
BP>140/90
These are BP levels to treat
3. Dhaka 2012
Hypertension SBP > 140
Borderline Hypertension SBP 130-140
Non Optimal BP SBP >115
Normal BP < 115/75
In the young DBP may be as or even
more important
9. 0 5 10 15 20
Percentage of Mortality Attributable to Risk Factors
*Based on The World Health Report 2003 Yach et al. JAMA. 2004;291:2616-2622.
Developing
countries
Developed
countries
Blood pressure
Tobacco
Underweight
Alcohol
Cholesterol
Unsafe sex
Overweight
Unsafe water, sanitation,
hygiene
Low fruit and vegetable intake
Indoor smoke from solid fuels
Physical inactivity
13. The available evidence does not support the use of
beta-blockers as first-line drugs in the treatment of
hypertension. This conclusion is based on the relatively
weak effect of beta-blockers to reduce stroke and the
absence of an effect on coronary heart disease when
compared to placebo or no treatment. More importantly,
it is based on the trend towards worse outcomes in
comparison with calcium-channel blockers, renin-
angiotensin system inhibitors, and thiazide(?) diuretics.
Wiysonge et al. Cochrane Database Sys Rev 2007;1:CD002003
14. Lifestyle modifications
Chobanian AV et al. JAMA. 2003;289:2560–2572.
Not at goal BP*
Hypertension without
compelling indications
Hypertension with
compelling indications
Stage 1
Thiazide-type diuretics for
most. May consider ACE
inhibitor, ARB, β-blocker,
CCB, or combination
Stage 2
Two-drug combination for
most (usually including
thiazide-type diuretic)
If not at goal, optimize dosages or add additional drugs until goal BP is achieved.
Consider consultation with hypertension specialist
Drug(s) for the compelling
indications
Other antihypertensive
drugs (diuretics, ACE
inhibitor, ARB, β-blocker,
CCB) as needed
*BP goal <140/90 mmHg or <130/80 mmHg for
those with diabetes or chronic kidney disease
15. ESH-ESC Guidelines 2007
Treatment algorithms
Marked BP elevation
High/very high CV risk
Lower BP target
Two-drug combination
at low dose
Mild BP elevation
Low/moderate CV risk
Conventional BP target
Choose between
Single agent
at low dose
Previous agent
at full dose
Switch to different agent
at low dose
Two-to three-drug
combination at full dose
Full dose
monotherapy
If goal BP not achieved
If goal BP not achieved
Two-to three-drug
combination at full dose
Monotherapy versus combination therapy strategies
Previous combinaton
at full dose
Add a third dose
at low dose
J Hypertens. 2007;25:1105–1187.
16.
17. • ACE inhibitor plus Diuretic
• ARB plus Diuretic
• CCB plus Diuretic
• ACE inhibitor plus CCB
• ARB plus CCB
= “A+D”
= “A+C”
25. No evidence for benefit of truly low-dose thiazides
vs. placebo
Low-dose thiazides vs. anything was inferior
(ANBP2, ASCOT, ACCOMPLISH)
Good evidence of CV benefits for
a) higher dose Thiazides (+/- K+ sparing)
b) Chlorthalidone
c) Indapamide
29. * Death from cardiovascular causes, myocardial infarction, stroke, or
hospitalization for heart failure.
ON-TARGET Trial:(27) Kaplan-Meier Curves for the Primary
Outcome*
30.
31. Study ID
Schweizer et al. 2007
Taylor et al. 2003
Asplund et al. 1984
Gerbino et al. 2004
Dickson et al. 2008
I-V Overall (I-squared = 0.0%, p = 0.655)
D+L Overall
1.08 (0.75, 1.54)
1.09 (0.80, 1.51)
1.74 (0.96, 3.15)
1.28 (0.93, 1.75)
1.29 (0.89, 1.89)
1.21 (1.03, 1.43)
1.21 (1.03, 1.43)
0.5 1.0 1.5 2.0
Favours FDCFavours free dose combination
N=18,004
OR (95% CI)
Odds Ratio
Gupta : Hypertension : 2010
32. Drug choice: summary and generic issues (BHS IV)
1. Overall benefits of BP lowering derive from BP level achieved
although
2. Possible class-specific benefits include:
- CCB’s less protective vs heart failure?
- CCB’s and ARB’s more protective vs stroke?
- Compelling indications for specific conditions?
4. Use once daily agents (full 24 hour effect)
5. Allow 4 weeks to evaluate
6. Titrate to manufacturer’s instructions (except Di)
7. When all else equal, use the least expensive drug
8. If no cost disadvantage – encourage fixed-dose combinations
33. BHS IV: Other medications for hypertensive patients
Primary prevention
(1) Aspirin: use 75mg daily if patient is aged 50 years with blood
pressure controlled to <150/90 mm Hg and either; target organ
damage, diabetes mellitus, or 10 year risk of cardiovascular disease
of 20% (measured by using the new Joint British Societies’
cardiovascular disease risk chart)
(2) Statin: use sufficient doses to reach targets if patient is aged up
to at least 80 years, with a 10 year risk of cardiovascular disease of
20% (measured by using the new Joint British Societies’
cardiovascular disease risk chart) and with total cholesterol
concentration 3.5mmol/l
(3) Vitamins—no benefit shown, do not prescribe
