Role of ARBs in management of Hypertension

2. Scope of Discussion1. Case history 2. Definition & incidence of Hypertension 3. Classification of Hypertension 4. Diagnosis/ Confirmation of Hypertension 5. Technique of Hypertension Measurement 6. White coat Hypertension 7. Type of Hypertension 8. Suspicion of secondary hypertension 9. Management of Hypertension(Stage 1& 2) 10. Why treatment is necessary 11. Life style modification 12. Drug treatment of Hypertension 13. Rationalae of combination 14. Hypertension management in special situation/ with complications 15. Indications of ARBs 16. Mechanism of action of ARBs 17. Comparison of different ARBs-pharmacology, efficacy 18. Safety of ARBs-Recall, Malignancy 19. Study on Telmisartan drtoufiq19711@yahoo.com

3. Case scenario • Mr. J. K 35 years old business man presented with headache , neck pain and dizziness for last 15 days. He is smoker and dyslipidemic. His B. P is 135/85 mm Hg on both arms and pulse 104 b/min. What are the management startagies? drtoufiq19711@yahoo.com

4. Considering points • Stage of hypertension? 135/85 mm Hg • 1. Role of life style modifications? • 2. Role of diets ? • 3. first line of antihypertensives? drtoufiq19711@yahoo.com

5. Case continued • Pt was being treated with beta blockers ( Atenolol 50 mg once daily). After 10 days patient came for follow-up. Now, • Pulse-70 b/min • BP- 130/85 mm Hg • and he feels better but complained of erectile dysfuntion. drtoufiq19711@yahoo.com

6. What should be the next management? • Considering • 1. symptoms decreased • 2. BP not controlled yet • 3. Erectile Dysfuntion drtoufiq19711@yahoo.com

7. • His drug beta blockers were stopped and switched to calcium channel blockers ( Amlodipine 5 mg daily) and advised to follow up after 15 days. drtoufiq19711@yahoo.com

8. During follow-up • Pulse- 80 b /min • BP- 125/75 mm Hg • But patient now complained of ankle edema • What should be the next plan? drtoufiq19711@yahoo.com

9. Considering points • To control BP properly • Ankle edema • Shiftinng to another group of drugs/cilnidipine • Or add another drug to combat edema drtoufiq19711@yahoo.com

10. Options • Switch to another groups • Add on ACEi/ ARB • Add on Diuretics • Time of follow up drtoufiq19711@yahoo.com

11. Scope of Discussion1. Case history 2. Definition & incidence of Hypertension 3. Classification of Hypertension 4. Diagnosis/ Confirmation of Hypertension 5. Technique of Hypertension Measurement 6. White coat Hypertension 7. Type of Hypertension 8. Suspicion of secondary hypertension 9. Management of Hypertension(Stage 1& 2) 10. Why treatment is necessary 11. Life style modification 12. Drug treatment of Hypertension 13. Rationalae of combination 14. Hypertension management in special situation/ with coplications 15. Indications of ARBs 16. Mechanism of action of ARBs 17. Comparison of different ARBs-pharmacology, efficacy 18. Safety of ARBs-Recall, Malignancy 19. Study on Telmisartan drtoufiq19711@yahoo.co m

12. drtoufiq19711@yahoo.co m

13. Prevalence of Hypertension • The prevalence of HTN varies considerably by country • 20% in the USA, and 25–50% in different regions in Europe. • The exact prevalence of HTN in Bangladesh is not known. • the prevalence of HTN was first reported in 1976, which was 1.10%. • prevalence of HTN is 17.9% in general, 18.5% in men and 17.3% in women. NCD 2010 • Hypertension is probably more common in elderly population, • in one study 65% in general, 75% in urban area, and 53% in rural area. drtoufiq19711@yahoo.co m

15. Classification of Hypertension drtoufiq19711@yahoo.co m

16. *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure. BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg drtoufiq19711@yahoo.co m

18. Diagnosis/ Confirmation of Hypertension drtoufiq19711@yahoo.co m

19. Diagnosis/ Confirmation of Hypertension drtoufiq19711@yahoo.co m

21. Technique of Hypertension Measurement drtoufiq19711@yahoo.co m

23. ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure. Office/Clinic/Healthcare Setting Home/Nonhealthcare/ ABPM Setting Normotensive No hypertension No hypertension Sustained hypertension Hypertension Hypertension Masked hypertension No hypertension Hypertension White coat hypertension Hypertension No hypertension drtoufiq19711@yahoo.co m

26. Type of Hypertension 1. Primary HTN- 95% 2. Secondary HTN-5% drtoufiq19711@yahoo.co m

29. Suspicion of secondary hypertension drtoufiq19711@yahoo.co m

33. EVOLUTION OF HYPERTENSIONEVOLUTION OF HYPERTENSION MANAGEMENTMANAGEMENT JNC I 1977 JNC II 1980 JNC III 1984 JNC IV 1988 JNC V 1993 JNC VI 1997 JNC VII 2003 High Dose diuretic High Dose diuretic Lower Dose diuretic Or β-blocker Lower Dose diuretic Or β-blocker Or ACEI Or CCB Lower Dose diuretic Or β-blocker Or ACEI Or CCB α-blocker Or α / β blocker • Individulised Therapy •Single-agent titration preferred •Loe-dose combo therapy as a secondary option •Focus on Systolic BP Control •Thiazide- type diuretics preferred as initial drug treatment •Emphasis on combination therapy High-dose Monotherapy Low-dose Combination drtoufiq19711@yahoo.co m

40. Effects of Antihypertensive Drug Treatment onEffects of Antihypertensive Drug Treatment on CV Mortality and MorbidityCV 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 HTNManagement of HTN drtoufiq19711@yahoo.co m

41. 140 120 100 80 60 40 20 0 50 40 30 20 10 0 Historical Lessons About HypertensionHistorical Lessons About Hypertension Hypertension Increases Morbidity and Mortality Men Women CHDIncidenceRate/1000 personsperyear THE FRAMINGHAM STUDY Cumulativefatal& NonfatalEndpoints 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 drtoufiq19711@yahoo.co m

42. Implication of reduction in Diastolic BP forImplication of reduction in Diastolic BP for Primary PreventionPrimary Prevention 30 20 %Reduction 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 drtoufiq19711@yahoo.co m

43. Millimeters Matter……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 drtoufiq19711@yahoo.co m

44. Benefits of Lowering BPBenefits of Lowering BP Average percent reduction Stroke reduction 35-40% Myocardial infarction 20-25% Heart failure 50% drtoufiq19711@yahoo.co m

53. Possible Combination ofPossible Combination of Antihypertensive AgentsAntihypertensive Agents Diuretics Beta Blocker ∝-Blocker ACE inhibitor CCBs ARBs EHS-ESC Guidelines, 2003;drtoufiq19711@yahoo.co m

55. Hypertension management in special situation/ with complications HTN with Increased cardiovascular risk HTN with Heart Failure HTN with MI HTN with Stroke HTN with AF HTN with DM HTN with Diabetic nephropathy HTN with Metabolic Syndrome HTN with Hyperuricemia HTN with Erectile dysfunction HTN with TOD HTN with Pregnancy HTN in elderly drtoufiq19711@yahoo.co m

57. Indications of ARBs/ACEIs drtoufiq19711@yahoo.co m

58. Indications of ARB drtoufiq19711@yahoo.co m

64. Mechanism of action of ARBs/ACEIs drtoufiq19711@yahoo.co m

67. Plasma Half life Distribution Volume Activation of PPAR gene drtoufiq19711@yahoo.co m

74. ONTARGET STUDY Telmisartan drtoufiq19711@yahoo.co m

93. FDA Recalls Some Valsartan Drugs Due to Impurity drtoufiq19711@yahoo.co m

94. • ARBs and Cancer Risk • A meta-analysis published in Lancet Oncology (2010)52 raised the possibility that angiotensin receptor blockers (ARBs) might increase the risk of malignancy. This generated a significant debate until the publication of two further meta- analyses,53,54 neither of which demonstrated an increased risk of new cancer occurrence or cancer- related death with the use of ARBs in patients with hypertension, heart failure, and/or nephropathy. Overall, the bulk of evidence today indicates that ARBs are not associated with increased cancer risk, as endorsed by the FDA.54 drtoufiq19711@yahoo.co m

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Role of ARBs in management of Hypertension

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