Treatment Of Hypertension In Special Situation Modified Fina Lc


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  • 02/16/10
  • 02/16/10
  • 02/16/10 The Comparative Risk Assessment module of the World Health Organization (WHO)’s Global Burden of Disease 2000 study performed a systematic assessment of changes in population health that would result from modifying exposure to environmental and physiological health risk factors. The methodology used to determine the attributable mortality and attributable burden of disease due to each risk factor was a counterfactual analysis in which the contribution of 1 or a group of risk factors is estimated by comparing the current disease burden with the magnitude that would be expected in an alternative scenario characterized by a theoretical minimal exposure. In the case of high BP and cholesterol, the theoretical minimal exposures were levels of 115 mm Hg and 3.8 mmol/L, respectively. This analysis of the contribution of 26 selected risk factors to global disease burden found that high BP was the leading cause of mortality in both developing regions and developed regions of the world. The study looked at the impact of risk factors on mortality. High mortality, developing regions such as many countries in Africa and Southeast Asia. Lower mortality, developing regions such as Latin America and countries in the Western Pacific. Developed regions including Europe, Japan, and North America. In high mortality, developing regions, the leading causes of death were reported to be childhood and maternal undernutrition, including being underweight. However, despite the large contribution of communicable, maternal, perinatal, and nutritional conditions and their underlying risk factors to disease burden in the high mortality, developing regions, the “industrialized” risks of high BP, tobacco, and blood cholesterol levels also resulted in significant loss of life in these regions. Across developed regions, high BP, tobacco use, alcohol, high cholesterol, and high body mass index (BMI) were reported to be consistently the leading causes of loss of life. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347-1360. SLIDE
  • 02/16/10 Hypertension is an important contributing risk factor for end-organ damage and subsequent increases in morbidity and mortality. The goal in treating hypertension is to prevent cardiovascular and renal complications. Even small elevations above optimal blood pressure (BP) values (<120/80 mm Hg) increase the likelihood of developing hypertension (BP ≥140/90 mm Hg) and incurring target-organ damage. Chronic elevations of BP lead to target-organ damage and the development of cardiovascular and renal diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, left-ventricular hypertrophy, and renal failure. Signs of target-organ damage herald a poorer prognosis and may present in the heart, blood vessels, kidneys, brain, or eyes. Later consequences include cardiac, cerebrovascular, vascular, and renal morbidities and death. Because of the complex nature of hypertension, it is not surprising that single antihypertensive agents normalize BP for less than a majority of hypertensive patients. Reference Cushman WC. J Clin Hypertens . 2003;5(suppl):14-22.
  • 02/16/10
  • 02/16/10 In summary, the key messages regarding BP targets for clinicians treating patients with diabetes and hypertension are as follows: SBP is a far more important target than DBP for both CV and renal protection; it is a particularly crucial modulator of risk in older patients and those with diabetes or CKD. Clinicians should focus on reducing SBP to currently recommended levels—<140 mm Hg in all patients with hypertension; <130 mm Hg in higher risk patients, such as those with diabetes and/or CKD. Only a small fraction of treated hypertensives are currently achieving appropriate BP control based on data from national surveys. The failure to achieve intensive BP targets results in less than maximum benefit to these patients. Patients with diabetes, especially those with renal impairment, usually require at least 2 different antihypertensive agents to achieve goal BP; many require at least 3 agents.
  • Although heart catheterization remains the “gold standard” for the diagnosis of coronary artery disease ….
  • Treatment Of Hypertension In Special Situation Modified Fina Lc

    1. 3. <ul><li>PRESENATATION BY </li></ul><ul><li>DR MISBAHUL FERDOUS </li></ul><ul><li>MBBS(USTC) </li></ul><ul><li>FMD (USTC) </li></ul><ul><li>PGT (CARDIOLOGY) NICVD.DHAKA </li></ul><ul><li>PUBLICATION- 1 (ORIGINAL ARTICLE) </li></ul><ul><li>METABOLIC SYNDROME AND ACUTE ST ELEVATION MI IN HOSPITAL OUTCOME. </li></ul><ul><li>PUBLISHED I N B.H.J. JANUARY-2008 </li></ul><ul><li>MD (CARDIOLOGY), COURSE </li></ul><ul><li>SHANDONG UNIVERSITY, CHINA. </li></ul>
    2. 4. Hypertension <ul><li>Rise of blood pressure above the normal level is called hypertension. </li></ul><ul><li>Types: </li></ul><ul><li>Primary or essential hypertension. </li></ul><ul><li>2. Secondary hypertension. </li></ul>
    3. 7. Korotkoff, 1905
    4. 9. Ref: Davidson’s Principles & Practice of Medicine 20th P-609
    5. 10. Management of Hypertension <ul><li>A.General management. </li></ul><ul><li>B.Antihypertensive Drug therapy. </li></ul><ul><li>General Treatment </li></ul><ul><li>(Non Pharmacological treatment) </li></ul><ul><li> </li></ul><ul><li>Life style modification: </li></ul>
    7. 12. Investigations of Hypertension <ul><li>Basic test for initial evaluation </li></ul><ul><li>Always included: </li></ul><ul><ul><li>Urine for: Protein, blood, glucose </li></ul></ul><ul><ul><li>Haematocrit </li></ul></ul><ul><ul><li>Serum electrolytes- specially POTASSIUM </li></ul></ul><ul><ul><li>Blood urea & serum creatinine </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Plasma cholesterol </li></ul></ul>
    8. 13. <ul><li>Basic test for initial evaluation </li></ul><ul><li>b) Usually included depending on cost & other factors: </li></ul><ul><ul><li>Microscopic analysis </li></ul></ul><ul><ul><li>WBC </li></ul></ul><ul><ul><li>Blood / plasma glucose </li></ul></ul><ul><ul><ul><ul><ul><li>Fasting Blood glucose level </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>2 HPP blood glucose level </li></ul></ul></ul></ul></ul><ul><ul><li>Serum – Total cholesterol, HDL, LDL, Triglycerides </li></ul></ul><ul><ul><li>Serum – calcium, phosphate, uric acid </li></ul></ul><ul><ul><li>X-ray chest P/A view </li></ul></ul><ul><ul><li>ECG </li></ul></ul>
    9. 14. Investigation of SELECTED PATIENT <ul><li>Ambulatory BP recording </li></ul><ul><li>Renal ultrasonography </li></ul><ul><li>Renal angiography </li></ul><ul><li>Renal isotope scan </li></ul><ul><li>24 hours urine assay for creatinine meta morphines and catacholamines on plasma catacolamines if phenochromocytoma suspected. </li></ul><ul><li>Plasma renin activity & aldesterone </li></ul>
    10. 15. Treatment of hypertension
    11. 16. Prehypertension … <ul><li>Is not a disease, </li></ul><ul><li>Is not “hypertension”, </li></ul><ul><li>Is not an indication for drug treatment of HTN, </li></ul><ul><li>Does not have a BP goal, </li></ul><ul><li>Does predict a higher risk for developing CV events, </li></ul><ul><li>Does predict a higher risk for developing HTN, </li></ul><ul><li>Should be an incentive to improve lifestyle practices for prevention of HTN and CVD. </li></ul>
    12. 17. Drug use in Hypertension Class Drugs / Trade name DIURETICS A. Thiazide diuretics <ul><li>Bendro fluazide </li></ul><ul><li>Cyclopenthiazide </li></ul><ul><li>Hydrochlorothiazide </li></ul>B. Loop diuretics <ul><li>Bumetanide </li></ul><ul><li>Frusemide </li></ul>C. Potassium-sparing <ul><li>Spironolactone </li></ul><ul><li>Amiloride </li></ul><ul><li>Triamterene </li></ul>
    13. 18. Class Drugs / Trade name Drugs / Trade name Anti-adrenergic agents <ul><li>β -adreno receptor antagonist (BBs) </li></ul><ul><li>Cardio selective </li></ul><ul><li>Atenolol </li></ul><ul><li>Metaprolol </li></ul><ul><li>Acebutolol </li></ul><ul><li>Betaxolol </li></ul><ul><li>Bisoprolol </li></ul><ul><li>Non selective </li></ul><ul><li>Propranolol </li></ul><ul><li>Oxprenolol </li></ul><ul><li>Alprenolol </li></ul><ul><li>Timolol </li></ul><ul><li>Pindolol </li></ul>B. α - adreno receptor antagonist <ul><li>Prazosin </li></ul><ul><li>Doxazonic </li></ul><ul><li>Indoramin </li></ul>C. Non selective adrenergic receptor blocker <ul><li>Phantolamine </li></ul><ul><li>Phenoxy benzamine </li></ul><ul><li>Central acting </li></ul><ul><li>Methyldopa </li></ul><ul><li>Clonidine </li></ul>α / β receptor blocker a. Lebetolol
    14. 19. Calcium channel blocker Dihydropyridine Phenyl alkylamine <ul><li>Nifidipine </li></ul><ul><li>Amlodipine </li></ul><ul><li>Nicardipine </li></ul><ul><li>Isradipine </li></ul><ul><li>Felodipine </li></ul><ul><li>Varapamil </li></ul><ul><li>Diltiazem </li></ul>ACE inhibitor <ul><li>Captopril </li></ul><ul><li>Enalopril </li></ul><ul><li>Lisinopril </li></ul><ul><li>Ramipril </li></ul><ul><li>Benapril </li></ul><ul><li>Fosinopril </li></ul>
    15. 20. Angiotensin II receptor blocker <ul><li>Losartan </li></ul><ul><li>Valsartan </li></ul>Vasodilator (Direct) <ul><li>Hydralazine </li></ul><ul><li>Minoxidil </li></ul><ul><li>Diazoxide </li></ul><ul><li>Na-Nitropruside </li></ul>
    17. 26. Treatment of hypertension in special situations <ul><li>Hypertension in children and adolescent </li></ul><ul><ul><ul><li>Life style modification,. if fail pharmacological therapy should be started </li></ul></ul></ul><ul><ul><ul><li>Dosage of antihypertensive medication should be smaller and adjusted very carefully for children. </li></ul></ul></ul><ul><ul><ul><li>ACE inhibitor & A-II receptor blocker should not be used In pregnant mother </li></ul></ul></ul><ul><ul><ul><li>Use of anabolic steroid for body building & smocking strictly prohibited . </li></ul></ul></ul>
    18. 27. <ul><ul><li>b) Hypertension in PREGNANCY </li></ul></ul><ul><ul><ul><li>In the 2 nd & 3 rd trimester , antihypertensive agents often are not indicated unless the Diastolic BP exceeds 100 mm Hg. </li></ul></ul></ul><ul><ul><ul><li>If drugs will be methyldopa, Beta-blocker, CCB in order of preference. </li></ul></ul></ul><ul><ul><ul><li>Hydralazine (Parenteral) & prazosin may be used. </li></ul></ul></ul><ul><ul><ul><li>Should not be used: </li></ul></ul></ul><ul><ul><ul><li>ACEi, A-II Receptor blocker, Diuretics, Nitroprusside </li></ul></ul></ul>
    19. 28. <ul><ul><li>c ) Hypertension with HORMONE REPLACEMENT THERAPY </li></ul></ul><ul><ul><ul><li>Presence of hypertension is not contraindicated for post menopausal estrogen replacement therapy. </li></ul></ul></ul><ul><ul><ul><li>frequent FOLLOW UP should be advised . </li></ul></ul></ul>
    20. 29. 3 . Hypertension with co-existing cardiovascular diseases <ul><li>Hypertension with CCF </li></ul><ul><ul><li>Diuretics & ACEi are preferable drugs. </li></ul></ul><ul><ul><li>Contraindications : Ca ++ channel blockers & β -blockers. </li></ul></ul><ul><ul><li>ACEi used alone or in conjugation with DIGOXIN or DIURETICS . </li></ul></ul><ul><ul><li>When ACEi is contraindicated, the vesodilators combination of HYDRALAZINE and ISOSORBIDE DINITRATE is also effective in this patient. </li></ul></ul><ul><ul><li>In one trial A-II receptor blocker (LOSARTAN POTASSIUM) was superior to CAPTROPIL in decrease mortality. </li></ul></ul>
    21. 30. <ul><li>b) Hypertension with coronary artery disease: </li></ul><ul><ul><li>Goal BP < 140/ 90 mm Hg </li></ul></ul><ul><ul><li>β -blocker & Ca ++ channel blocker may be specially useful in patient with HTN & angina pectoris. </li></ul></ul><ul><ul><li>ACEi also useful in MI. </li></ul></ul><ul><ul><li>If β -Blockers are ineffective on contraindicated VERAPAMIL or DILTIAZEM may be used in following conditions </li></ul></ul><ul><ul><ul><li>(i) Non- myocardial infraction </li></ul></ul></ul><ul><ul><ul><li>(ii) After MI with presented left ventricular function. </li></ul></ul></ul>
    22. 31. <ul><li>c)Hypertension with LVF: </li></ul><ul><ul><li>All antihypertensive drug can be used except direct vasodilatation e.g. HYDRALAZINE </li></ul></ul><ul><ul><li>In one study treatment with diuretics & an ACEi are better than other drug. </li></ul></ul><ul><li>d) Hypertension with BRADYCARDIA: </li></ul><ul><ul><li>Nifidipine & ACEi are preferable drugs. </li></ul></ul><ul><ul><li>Better to avoid β - BLOKERS, VERAPAMIL, DILTIAGEM </li></ul></ul>
    23. 32. 4. Hypertension in Diabetes: <ul><li>Goal BP <140 / 80 mm Hg [ref: Davidson’s 20 th ] </li></ul><ul><li>Goal BP <130 / 80 mm Hg [ref: JNC 7 ] </li></ul><ul><li>Life style modification </li></ul><ul><li>No antihypertensive are contraindicated in DM </li></ul><ul><li>ACEi, A-II receptor, Alpha blocker, CCB, low dose diuretics are preferred choice. </li></ul><ul><li>Better avoid β -blocker and high dose diuretics unless special situation. </li></ul><ul><li>*ACEi -> ↓69% protein urea in type-I DM </li></ul><ul><li>[ ref: Davidson’s 20 th ] </li></ul>
    24. 33. 5. Hypertension in Dyslipidaemia: <ul><li>Common co-existence & demand aggressive management of both conditions. </li></ul><ul><li>High dose THIAZIDES, LOOPS DIURETICS & BETA BLOCKERS may transiently increase total cholesterol, still has significant reduction CV morbidity & sudden death. So should be used without hesitation . </li></ul>
    25. 34. 6. Hypertension with ASTHMA & COPD: <ul><li>Ca++ channel blocker is the preferable drug. </li></ul><ul><li>ACEi are safe in most patients with asthma. </li></ul><ul><li>A-II receptor blocker may be used if cough is trouble some problem after using ACEi. </li></ul><ul><li>Contraindications: </li></ul><ul><li>β -blocker, α -blocker should not be used in patient with asthma except in special circumstances. </li></ul>
    26. 35. 7. Hypertension with CVD: <ul><li>BP is actually raised after stroke. Unless end organ damage in present or malignant HTN is present, elevated BP should not be lowered in acute stage since it will always return towards normal within 24-28 hours. </li></ul><ul><li>After 10 days gentle reduction of BP started as a part of secondary prevention strategy of ischemic stroke. </li></ul><ul><li>If hemorrhage stroke there is no value in reducing the high BP (except very high) until at least some days after stroke. </li></ul>
    27. 36. 8. Hypertension with LIVER DISEASE: <ul><li>ALL Antihypertensive drugs can be used except METHYLDOPA. </li></ul>
    28. 37. 9. Hypertension with GOUT <ul><li>All hypertensive drugs can be used </li></ul><ul><li>But all Diuretics can increase serum uric acid level but rarely induced acute gout. So diuretics should be avoided if possible. </li></ul><ul><li>Contraindications : NO DIURETICS </li></ul>
    29. 38. 10. Hypertension with PSORIASIS: <ul><li>β -Blocker and ACEi aggravate psoriasis. So better to avoid them. </li></ul>11. Hypertension with Scleroedema with Reynaud's phenomenon <ul><li>NIFIDIPINE and PROSTACYCLINE infusion may occasionally helpful in patient with severe Reynaud's phenomenon . </li></ul>
    30. 39. 12. Hypertension with peripheral vascular disease <ul><li>Better to use Ca ++ channel blocker & Vasodilators. </li></ul>13. Hypertension with Renal parenchymal disease <ul><li>Goal BP 130 / 85 or <125 /75 mm Hg. </li></ul><ul><li>Unless contraindicated ACEi + Diuretic should be used. </li></ul><ul><li>Loop diuretics should be used & potassium sparing diuretics should be avoided. </li></ul><ul><li>Thiazide diuretics are not effective with advanced renal insufficiency. </li></ul><ul><li>ACEi used with caution if serum creatinine> 3 mg / dl </li></ul>
    31. 40. 14. Adjuvant drug therapy <ul><li>Aspirin: Anti Platelet therapy is a powerful means of reducing cardiovascular risk. </li></ul><ul><li>Indications: Age 50 or more, who have well controlled BP and either target organ damage, Diabetes, or a 10 year coronary heart disease- Risk of > 15% </li></ul><ul><li>Statins: Treating hyperlipidaemia & also produce a reduction of cardiovascular risk. </li></ul><ul><li>Indications: Established vascular disease or hypertension with a high risk of developing coronary heart disease. </li></ul>
    32. 41. 15. Hypertensive crises <ul><li>Hypertensive crises </li></ul><ul><li>Emergency B) Urgency </li></ul><ul><ul><li>i) Malignant HTN </li></ul></ul><ul><ul><li>ii) Accelerated HTN </li></ul></ul><ul><li>Goal of reducing BP 160/100 mm of Hg with in 24 hrs </li></ul><ul><li>Drugs of Choice: </li></ul><ul><li>Oral Drugs are better than I/V </li></ul>
    33. 42. Follow up & Monitoring <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 months interval. [ref: JNC 7] </li></ul>
    34. 43. Recommendations for Improving Outcomes <ul><li>Physician </li></ul><ul><li> Establish treatment goals </li></ul><ul><li> Maintain adherence </li></ul><ul><li> Minimize side effects </li></ul><ul><li>Patient </li></ul><ul><li> Self-Monitor BP </li></ul><ul><li> Keep diary of BP therapy </li></ul><ul><li> Make life-style changes </li></ul>
    35. 44. Approximately 50 Million Americans Have Hypertension Uncontrolled 72.6% Controlled 27.4% 13.7 million 36 million
    36. 45. Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors Ezzati et al. Lancet. 2002;360:1347-1360. Attributable Mortality (In thousands; total 55,861,000) 0 8000 7000 6000 5000 4000 3000 2000 1000 High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight High mortality, developing region Lower mortality, developing region Developed region
    37. 46. Complications of Hypertension : TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; HF = heart failure. Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22. Hypertension is a risk factor Retinopathy Renal failure Peripheral vascular disease LVH, HF,CHD, TIA, stroke
    38. 49. 35%-40% 20%-25% >50% Average reduction in events (%) – 60 – 50 – 40 – 30 – 20 – 10 0 Stroke Myocardial infarction Heart failure Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964. Long-Term Antihypertensive Therapy Significantly Reduces CV Events
    39. 50. JNC 7: Appropriate BP Targets <ul><li>For both CVD and kidney disease, systolic BP is far more important than diastolic BP </li></ul><ul><li>Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease) </li></ul><ul><li>Only a small fraction of hypertensives are achieving appropriate BP control </li></ul><ul><li>Multiple antihypertensive agents are needed for most patients </li></ul><ul><li>Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD. </li></ul>
    40. 51. JNC 7: Considerations for older persons with hypertension <ul><li>This population has the lowest rates of BP control and the </li></ul><ul><li>greatest absolute benefit with effective therapy. </li></ul><ul><li>Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. </li></ul><ul><li>More than two-thirds of people over 65 have HTN, i.e. ISH </li></ul><ul><li>(Isolated systolic hypertension). </li></ul>
    42. 54. The END! Thank You! <ul><li>Oh, sorry, not the END, just the beginning ! </li></ul>Email: 26. TAKHDIR. SUGANDHA. R/A ,CHITTAGONG BANGLADESH