4. Mrs. MW is a 50 year old male.
He works at an IT company with extended hours of work.
He regularly exercises.
He has no special habits of medical importance.
No family history of importance.
Presenting with increasing shortness of breath and palpitations.
Case Presentation
5. - BP 160/115 mmHg in both upper limbs.
- HR 105 bpm
- BMI 25.5 kg/m2
- Chest: clear
- Heart: apical S4.
Examination
6. A. ECG.
B. Chest X-ray.
C. Echocardiogram.
D. Laboratory.
E. All of the above.
?
What investigations would you
do?
20. A. >140/90 mmHg
B. >140/80 mmHg
C. >130/90 mmHg
D. >130/80 mmHg
?
According to the ESC/ESH guidelines,
what is the threshold for blood
pressure treatment?
22. ?
According to the ESC/ESH guidelines,
what is the target for blood pressure
treatment?
A. 130-139/80-89 mmHg
B. 130-139/70-79 mmHg
C. 120-129/80-89 mmHg
D. 120-129/70-79 mmHg
26. What combination of
medications would you
start with?
A. CCB (those which control the heart rate)?ACEi.
B. ACEi/CCB.
C. ARB/CCBs.
D. Amlodipine/Diuretics.
E. Combination therapy with RAAS and diuretics.
F. Beta blockers/CCBs
27. After taking
verapamil / trandolapril for 2 weeks:
The heart rate is 81bpm.
Now there is constipation, ankle edema.
BP is 138/95 mmHg.
28. After taking
ramipril / felodipine
for 4 weeks:
Her blood pressure is 134/82 mmHg.
She complains of irritative cough at times.
Her heart rate is 90 bpm.
29. After taking
valsartan / amlodipine
for 4 weeks:
Her blood pressure is 136/81 mmHg.
Headaches have stopped.
She is still complaining of palpitations and his heart rate is 88 bpm.
30. After taking
amlodipine / indapamide
for one week:
Her blood pressure is 131/80 mmHg.
She complains of frequency of micturition.
She still complains of palpitations and his heart rate is 85 bpm.
31. After taking
a combination of
candesartan and HCTZ
for one week:
BP is 129/79 mmHg.
Her heart rate is still 87 bpm.
40. Plasma
aldosterone
levels:
NORMAL
Amlodipine: Wealth of CV Outcome Data
Primary outcome: No difference in composite of fatal CHD
+ non-fatal MI vs. lisinopril
6% � combined CVD
23% � stroke
ALLHAT5
18,102 HTN patients: Randomized, prospective study vs.
lisinopril
Primary outcome: 10% � in non-fatal MI & fatal CHD
16% � total CV events and procedures
30% � new-onset diabetes
27% � stroke
11% � all-cause mortality
� central aortic pressure by 4.3 mmHg
ASCOT-BPLA/CAFE3,4
19,257 HTN patients: Multicenter, randomized,
prospective study vs. atenolol
Primary outcome: 31% � in CV events vs. placebo
41% � hospitalization for angina
27% � coronary revascularization
CAMELOT2
1,991 CAD patients (>20%): Double-blind, randomized
study vs. placebo and enalapril 20 mg
Primary outcome: No difference in mean 3 yr coronary
angiographic changes vs. placebo
35% � hospitalization for heart failure + angina 33%
� revascularization procedures
PREVENT1
825 CAD patients (≥30%): Multicenter, randomized,
placebo controlled
1Pitt et al. Circulation 2000;102:1503–10; 2Nissen et al. JAMA 2004;292:2217–26; 3Dahlof et al. Lancet 2005;366:895–906 4Williams et
al. Circulation 2006;113:1213 –25; 5Leenen et al. Hypertension 2006;48:374–84
41. Advantages of
Combination therapy
Complimentary mode of action for optimal BP control.
Inhibits the body’s counter regulatory responses when
using one anti-HTN agent.
More effective in moderate and severe HTN (10-15% of
HTN population, and are at high CV risk).
Decreases BP variability more than single agent (stroke
reduction).
43. Plasma
aldosterone
levels:
NORMAL
Benefits of bisoprolol/amlodipine combination
Any case of HTN, specially with a heart rate of 80 bpm or more.
Two anti-ischemic agents in one pill.
Contains the therapeutic doses of bisoprolol (5, 10 mg) (not subtherapeutic).
Can be given at any level of eGFR.
Can be given regardless of the liver function.
Metabolically neutral.
44. Take home messages
Hypertension is the most prevalent risk factor for
cardiovascular disease.
We should assess our patients thoroughly.
Choosing the correct class of medications is of utmost
importance for the sake of both efficacy and safety.
Not all beta blockers are the same, as they differ in potency to
control heart rate and incidence of side effects.
Bisoprolol/Amlodipine : Complimentary mode of action for
optimal BP control.