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  • 2 nd most common reason for visit All family physicians should be experts at HTN.
  • Hypertension

    2. 2. Hypertension <ul><li>Hypertension is the most common public health problem in developed countries </li></ul><ul><li>Called Silent Killer </li></ul><ul><li>No cure is available, but prevention and management decrease the incidence of hypertension and disease sequelae. </li></ul><ul><li>Definition: Persistently high arterial blood pressure, defined as systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg </li></ul>
    3. 3. Hypertension: The Silent Killer Facts & Figures <ul><li>50 million Americans & 1 billion worldwide affected </li></ul><ul><li>Most common primary care diagnosis (35 million visits annually) </li></ul><ul><li>Normotensive at age 55 have 90% lifetime risk of Hypertension </li></ul><ul><li>Continuous & consistent relationship with CVD </li></ul><ul><ul><li>Between ages 40-70, starting from 115/75 </li></ul></ul><ul><ul><li>CVD risk doubles with each increment of 20/10 </li></ul></ul>
    4. 4. Prevalence Prevalence on hypertension by age Age % Hypertension 18~29 4 30~39 11 40~49 21 50~59 44 60~69 54 70~79 64 80 + 65
    5. 5. Causes of Hypertension <ul><li>1- Primary hypertension (90 – 95%) </li></ul><ul><li>- Essential hypertension </li></ul><ul><li>2- Secondary hypertension (5 – 10%) </li></ul><ul><li>- Renal diseases </li></ul><ul><li>- Endocrine disease </li></ul><ul><li>- Steroid excess </li></ul><ul><li>- Growth hormone excess </li></ul><ul><li>- Catecholamine excess </li></ul><ul><li>- Vascular causes </li></ul><ul><li>- Drugs </li></ul>
    6. 6. Hypertension - Guidelines <ul><li>JNC- VII Classification of BP for adults (+18 yrs) </li></ul>CATEGORY SBP mm Hg DBP mm Hg Normal <120 & <80 Prehypertension 120-139 or 80-89 Stage-I 140-159 or 90-99 Stage-II >160 or >100
    7. 7. VARIOUS TERMS & DEFINITIONS <ul><li>Isolated systolic hypertension </li></ul><ul><li>SBP greater than 140mm, DBP less than 90mm </li></ul><ul><li>65-75 % of elderly hypertensive have ISHT </li></ul><ul><li>Resistant hypertension </li></ul><ul><li>It is the failure to reach goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. </li></ul><ul><li>Uncontrolled hypertension </li></ul><ul><li>BP above recommended level (treated or untreated) </li></ul><ul><li>Complicated hypertension </li></ul><ul><li>Hypertension with co-morbidities </li></ul>
    8. 8. Chronic Complications End / Target organ damage Organ Condition Symptoms, signs/events Heart LVH, CAD Angina / MI Artery Atherosclerosis CAD/CVD/PAD Aneurysm Stroke Kidney Nephropathy Microalbuminuria Eye (retina) Retinopathy Blurring of vision Brain CVD TIA/Stroke
    9. 9. Prevalence of Cardiovascular Disease <ul><li>Estimated Number of Persons With Cardiovascular Disease in the US </li></ul>10 20 30 40 50 60 High BP CAD CHF Stroke Other 50,000,000 12,200,000 4,600,000 4,400,000 2,800,000 Prevalence (millions) BP=blood pressure, CAD=coronary artery disease, CHF=congestive heart failure (24%) American Heart Association® . 2000 Heart and Stroke Statistical Update. 1999
    10. 10. Hypertension Risk Factors <ul><li>Modifiable </li></ul><ul><ul><li>Cigarette smoking </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Physical inactivity- sedentary life style </li></ul></ul><ul><ul><li>Dyslipidemia </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Microalbuminuria </li></ul></ul><ul><li>Non - Modifiable </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Sex </li></ul></ul>
    11. 11. Hypertension : Symptoms <ul><li>Most of the patients do not complain of any symptoms </li></ul><ul><li>Symptomatic patients may have one or more of the following symptoms </li></ul><ul><ul><li> - Headache </li></ul></ul><ul><ul><li> - Confusion </li></ul></ul><ul><ul><li> - Severe shortness of breath </li></ul></ul><ul><ul><li> - Visual disturbances </li></ul></ul><ul><ul><li> - Nausea and vomiting </li></ul></ul>
    12. 12. Hypertension - Management <ul><li>Life style modification: </li></ul><ul><ul><li>Regular physical exercise </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul><ul><ul><li>Stop alcohol </li></ul></ul><ul><ul><li>Dietary controls : weight control </li></ul></ul><ul><ul><ul><li>Restrict salt intake 4-6 gm/day </li></ul></ul></ul><ul><ul><ul><li>Restrict saturated fats </li></ul></ul></ul>
    13. 13. Hypertension - Management Pharmacological management Category Drugs Diuretics Hydrochlorothiazide, Indapamide ACE-Is Enalapril, Perindopril ARBs Olmesartan, Valsartan, Losartan Beta blockers Nebivolol, Atenolol Alpha blockers Terazosin, Prazosin CCB Amlodipine, Diltiazem
    14. 14. Hypertension - Management <ul><li>Goals of Therapy </li></ul><ul><li>The goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. </li></ul><ul><li>Most patients with hypertension, reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal. </li></ul><ul><li>Goal BP <140/90 mmHg : Achieving target BP is associated with a decrease in CVD complications. </li></ul><ul><li>Goal BP is <130/80 mmHg (patients with HT and diabetes or renal disease) </li></ul>
    15. 15. Ideal Antihypertensive Drug <ul><li>Good efficacy </li></ul><ul><li>Minimal or no serum glucose imbalance </li></ul><ul><li>Minimal or no electrolyte imbalance </li></ul><ul><li>Minimal or no lipid profile imbalance </li></ul><ul><li>Improve quality of life </li></ul><ul><ul><li>Physical activity, sleep, sexual functions. </li></ul></ul><ul><li>Dosage compliance </li></ul>
    16. 16. The correct Approach to Hypertension
    17. 17. JNC 7 Algorithm
    18. 18. Anti Hypertensive drug classes The A, B, C, D approach
    19. 19. Anti Hypertensive Drug Classes <ul><li>ACEi – Angiotensin converting enzyme inhibitors - let us call them ‘A’ </li></ul><ul><li>ARB – Angiotensin Receptor Blockers – Let us call them also as ‘A’ </li></ul><ul><li>BB – Beta Receptor Blockers – let us call them ‘B’ </li></ul><ul><li>CCB – Calcium channel blockers – let us call them ‘C’ </li></ul><ul><li>Diuretics – let us call them ‘ D ’ </li></ul>
    20. 20. AB/CD Rule – HT Treatment AGE Younger (< 55) ACEi, Beta-blocker Ca++-blocker, Diuretic) (AB/CD = Dickerson et al. Lancet 353:2008-11;1999 Older (> 55) ACEi / ARB BB A + B A + B + D Diuretic CCB D + C + A D + C I II III III II I Resistant HT / Intolerance Add / substitute alpha blocker Re-consider 2 0 causes  trial of spironolactone IV: V:
    21. 21. Drugs for Compelling Indications
    22. 22. DIURETICS <ul><li>Mode Of Action: </li></ul><ul><li>Eliminate excess fluid & NaCl </li></ul><ul><li>Decrease Na + & water reabsorption </li></ul><ul><li>Reduce Blood Volume </li></ul>Reduce BP
    23. 23. DIURETICS <ul><li>Indications: </li></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Management of CHF </li></ul></ul></ul><ul><ul><ul><li>Edema due to Renal Dysfunction </li></ul></ul></ul><ul><li>Side effects: </li></ul><ul><ul><ul><li>Electrolyte imbalance - Arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Dyslipidemia </li></ul></ul></ul><ul><ul><ul><li>Impotence </li></ul></ul></ul><ul><ul><ul><li>Loss of Libido </li></ul></ul></ul>
    24. 24. BETA BLOCKERS <ul><li>Mode of action </li></ul><ul><ul><li>Block Beta Adrenoreceptors </li></ul></ul><ul><ul><li>Decrease in CO </li></ul></ul><ul><ul><li>Decrease in Renin Release from the Kidneys </li></ul></ul>Reduce BP
    25. 25. BETA BLOCKERS <ul><li>Indications: </li></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Angina with Myocardial Ischemia </li></ul></ul></ul><ul><ul><ul><li>Post MI </li></ul></ul></ul><ul><ul><ul><li>Arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Heart failure </li></ul></ul></ul><ul><li>Side effects: </li></ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul><ul><ul><ul><li>Bronchospasm </li></ul></ul></ul><ul><ul><ul><li>Impotence </li></ul></ul></ul><ul><ul><ul><li>Dyslipidemia </li></ul></ul></ul>
    26. 26. <ul><li> 1 blocker </li></ul><ul><li>Inhibit  1 receptor </li></ul><ul><li>↓ Peripheral vascular resistance </li></ul><ul><li>↓ Blood pressure </li></ul>ALPHA BLOCKER Mechanism of action:
    27. 27. ALPHA BLOCKER <ul><li>Indications: </li></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><li>Side effects: </li></ul><ul><li>Dizziness </li></ul><ul><li>Headache </li></ul><ul><li>Nasal congestion </li></ul>
    28. 28. CALCIUM CHANNEL BLOCKERS <ul><li>Mode of action: </li></ul><ul><ul><ul><li>Interference with Ca ++ uptake in smooth muscles & cardiac muscle </li></ul></ul></ul><ul><ul><ul><li>Dilation of peripheral arterioles </li></ul></ul></ul><ul><ul><ul><li>Reduction in PVR </li></ul></ul></ul><ul><ul><ul><li>Reduction in Afterload </li></ul></ul></ul><ul><ul><ul><li>No effect on preload </li></ul></ul></ul><ul><ul><ul><li>Negative inotropic effect </li></ul></ul></ul>
    29. 29. CALCIUM CHANNEL BLOCKERS <ul><li>Indications: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Angina </li></ul></ul><ul><li>Side effects: </li></ul><ul><ul><ul><li>Reflex tachycardia </li></ul></ul></ul><ul><ul><ul><li>Flushing </li></ul></ul></ul><ul><ul><ul><li>Edema </li></ul></ul></ul><ul><ul><ul><li>Headache </li></ul></ul></ul><ul><ul><ul><li>Constipation </li></ul></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul>
    30. 30. ACE - INHIBITORS <ul><li>Mode of action: </li></ul><ul><li>Inhibit Angiotensin converting enzyme </li></ul><ul><li>Decrease formation of angiotensin II </li></ul><ul><li>Prevent degradation of bradykinin </li></ul>
    31. 31. ACE - INHIBITORS <ul><li>Indications: </li></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Heart failure </li></ul></ul></ul><ul><ul><ul><li>Post MI </li></ul></ul></ul><ul><ul><ul><li>Diabetic Nephropathy </li></ul></ul></ul><ul><li>Adverse effects: </li></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Hyperkalemia </li></ul></ul></ul><ul><ul><ul><li>Dry cough </li></ul></ul></ul><ul><ul><ul><li>Angioedema </li></ul></ul></ul><ul><ul><ul><li>Rash </li></ul></ul></ul>
    32. 32. ANGIOTENSIN-II RECEPTOR INHIBITOR <ul><li>Blocks the AT 1 receptors </li></ul><ul><li>Cause effective blockage of RAAS </li></ul><ul><li>Indications: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><ul><li>Post MI </li></ul></ul>
    33. 33. Follow-up and Monitoring <ul><li>Patients should return for follow-up and adjustment of medications until the BP goal is reached. </li></ul><ul><li>More frequent visits for stage 2 HTN or with complicating co morbid conditions. </li></ul><ul><li>Serum potassium and creatinine monitored 1–2 times per year. </li></ul><ul><li>After BP at goal and stable, follow-up visits at 3- to 6-month intervals. </li></ul><ul><li>Co morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits. </li></ul>
    34. 34. New Features and Key Messages <ul><li>Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. </li></ul><ul><li>Certain high-risk conditions are compelling indications for other drug classes. </li></ul><ul><li>Most patients will require two or more antihypertensive drugs to achieve goal BP. </li></ul><ul><li>If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a Thiazide-type diuretic. </li></ul>
    35. 35. New Features and Key Messages <ul><li>The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated. </li></ul><ul><li>Motivation improves when patients have positive experiences with, and trust in, the clinician. </li></ul><ul><li>Empathy builds trust and is a potent motivator. </li></ul><ul><li>The responsible physician’s judgment remains paramount. </li></ul>
    36. 36. THANK YOU