Challenges and Opportunities: A Qualitative Study on Tax Compliance in Pakistan
Jc1
1. Hypertension (1)
• Laragh JH, Sealey JE. The plasma renin
test reveals the contribution of body
sodium-volume content (V) and renin-
angiotensin (R) vasoconstriction to
long-term blood pressure. Am J
Hypertens. 24:1164-80, 2011
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3. V (volume) and R (renin)
• BP = volume x resistance (arteriole tone)
HTN can be :
– V (volume-sensitive): Na+
– R (renin-sensitive): RAAS (renin-angiotensin-
aldosterone system)
Regardless of etiology, all forms of HTN
comprise inappropriate Na+ retention,
excessive vasoconstriction, or a combination
of both.
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6. Interdependency of R and V
• For HTN to develop,
plasma renin activity
(PRA) doesn’t have
to be elevated. In fact,
it can be normal, if
Na+ content (volume)
is too high.
fixed BP line
R
V
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7. Long-term Antihypertensive
Drugs
• Natriuretic to reduce body salt and volume
content (anti-V), or
• Antirenin to reduce or block the activity of
the circulating renin-angiotensin system
(anti-R).
• Low renin HTN is best first treated with
natriuretics drugs, whereas high renin
HTN best started with anti-R drugs.
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9. V-sensitive HTN
• Rx: low salt diet, restriction of Na+
intake
natriuresis with diuretics
• In low renin, V (volume)-dependent
essential HTN, body Na+ content can
increase beyond the point where PRA is
turned off; natriuresis rather than anti-R
class drugs is the treatment of choice.
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10. Reactive increase in PRA during
Na+ (volume) depletion
• The price of diuretics strategy
– High PRA
– High degree of vasoconstriction
– High BUN
– High uric acid
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11. Reactive increase in PRA during
RAAS blockade
• Patients treated with captopril (Muller,et al)
–Renovascular HTN: 2~10x increase in
PRA
–Essential HTN: 1~2x increase in PRA
• When PRA is measured in patients taking
ACEI / ARB, blockade of RAAS is usually
incomplete as there is a reactive increase
in PRA.
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12. Vasodilator as Natriuretics
• Ca2+ channel blockers, nitroprusside,
hydralazine and minoxidil are listed as
vasodilators because they all cause renal
vasodilation. However, they also increase
renal Na+ excretion. Hence, they can be
regarded as an anti-V drugs.
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13. Action Points
• Patents with essential HTN can be V- or
R-sensitive (dependent), or a combination
of both. PRA may be useful for guiding
therapy.
• Anti-V and anti-R drugs should be
carefully selected and titrated based on
the patient’s response.
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