1) The document outlines guidelines from JNC 7 for the treatment of hypertension, including classification of blood pressure levels, treatment goals, and recommendations for initial drug classes based on patient characteristics and comorbidities.
2) Key recommendations include initiating therapy for most patients with a thiazide diuretic either alone or in combination with other drug classes, and targeting a blood pressure of less than 140/90 mmHg or less than 130/80 mmHg for patients with diabetes or chronic kidney disease.
3) The guidelines also emphasize lifestyle modifications like weight loss, following the DASH diet, reducing sodium intake, and increasing physical activity to help lower blood pressure in addition to pharmacotherapy.
This document discusses heart failure with preserved ejection fraction (HFpEF). It begins by defining HFpEF and noting that approximately half of heart failure patients have normal or near-normal ejection fractions. The document then reviews various classification systems for HF, diagnostic criteria, echocardiographic assessment of HFpEF, risk factors, and challenges in diagnosing and treating HFpEF. It concludes by discussing current and potential future treatment approaches for HFpEF, including drugs targeting comorbid conditions that are common in HFpEF patients.
This document summarizes guidelines for diagnosing and treating hypertension. It discusses:
- Preferred methods for diagnosing hypertension including ambulatory blood pressure monitoring and home monitoring.
- Lifestyle modifications that are recommended as first-line treatment options such as reducing sodium, weight loss, limiting alcohol, and regular exercise.
- Classes of antihypertensive drugs and their comparative effects, with ACE inhibitors recommended as initial drug therapy.
- Treatment guidelines for hypertension in patients with conditions like heart disease, stroke, and heart failure which emphasize controlling blood pressure and recommend ACE inhibitors in many cases.
The document summarizes key findings from the LIFE study, a large clinical trial that compared losartan to atenolol for reducing cardiovascular risk in hypertensive patients with left ventricular hypertrophy. The main findings were:
1) Losartan reduced the primary composite endpoint of cardiovascular death, stroke or myocardial infarction by 13% compared to atenolol, with comparable blood pressure reduction in both groups.
2) Secondary analyses found losartan reduced risks for several individual components of the primary endpoint including stroke and heart failure hospitalizations.
3) Losartan provided greater regression of left ventricular hypertrophy compared to atenolol based on electrocardiogram and echocardiogram assessments
The document discusses guidelines from JNC 7 and ESH/ESC for treating hypertension. JNC 7 recommends initially treating stage 1 hypertension with thiazide diuretics and considering other drug classes. For stage 2 hypertension, it recommends starting with a two-drug combination, usually including a thiazide. ESH/ESC guidelines state that most patients will require two or more drugs to reach blood pressure goals and recommend considering initial therapy with a low-dose two-drug combination. Both emphasize lifestyle changes and medication combinations or adjustments to achieve blood pressure control.
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
The document summarizes the results of the HYVET trial, which provided the first clear evidence for treating hypertension in patients aged 80 or over. The trial found that treating hypertensive patients aged 80 or over with the Natrilix SR-based regimen reduced total mortality by 21%, all strokes by 30%, fatal strokes by 39%, and heart failure by 64% compared to placebo. The treatment was also well-tolerated with few serious adverse events reported.
The document summarizes guidelines from JNC 8 (2014) on the management of hypertension. It provides 3 key recommendations from JNC 8:
1) Treatment should begin for general population aged ≥60 years with SBP ≥150 mmHg or DBP ≥90 mmHg, and for those <60 years with SBP ≥140 mmHg or DBP ≥90 mmHg.
2) The treatment goal for non-diabetic, non-CKD patients is SBP <150 mmHg and DBP <90 mmHg. Lower goals may apply if no adverse effects.
3) Initial treatment should include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers or thiaz
Hurdles and new players in the management of chronic heart failure with reduc...Dhritisdiary
Watch the slideshow for a better understanding: https://youtu.be/CsXvS1hA330
1. Learn the standard therapy in HFrEF
2. Learn its challenges
3. Learn the new drugs for HFrEF.
This document discusses heart failure with preserved ejection fraction (HFpEF). It begins by defining HFpEF and noting that approximately half of heart failure patients have normal or near-normal ejection fractions. The document then reviews various classification systems for HF, diagnostic criteria, echocardiographic assessment of HFpEF, risk factors, and challenges in diagnosing and treating HFpEF. It concludes by discussing current and potential future treatment approaches for HFpEF, including drugs targeting comorbid conditions that are common in HFpEF patients.
This document summarizes guidelines for diagnosing and treating hypertension. It discusses:
- Preferred methods for diagnosing hypertension including ambulatory blood pressure monitoring and home monitoring.
- Lifestyle modifications that are recommended as first-line treatment options such as reducing sodium, weight loss, limiting alcohol, and regular exercise.
- Classes of antihypertensive drugs and their comparative effects, with ACE inhibitors recommended as initial drug therapy.
- Treatment guidelines for hypertension in patients with conditions like heart disease, stroke, and heart failure which emphasize controlling blood pressure and recommend ACE inhibitors in many cases.
The document summarizes key findings from the LIFE study, a large clinical trial that compared losartan to atenolol for reducing cardiovascular risk in hypertensive patients with left ventricular hypertrophy. The main findings were:
1) Losartan reduced the primary composite endpoint of cardiovascular death, stroke or myocardial infarction by 13% compared to atenolol, with comparable blood pressure reduction in both groups.
2) Secondary analyses found losartan reduced risks for several individual components of the primary endpoint including stroke and heart failure hospitalizations.
3) Losartan provided greater regression of left ventricular hypertrophy compared to atenolol based on electrocardiogram and echocardiogram assessments
The document discusses guidelines from JNC 7 and ESH/ESC for treating hypertension. JNC 7 recommends initially treating stage 1 hypertension with thiazide diuretics and considering other drug classes. For stage 2 hypertension, it recommends starting with a two-drug combination, usually including a thiazide. ESH/ESC guidelines state that most patients will require two or more drugs to reach blood pressure goals and recommend considering initial therapy with a low-dose two-drug combination. Both emphasize lifestyle changes and medication combinations or adjustments to achieve blood pressure control.
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
The document summarizes the results of the HYVET trial, which provided the first clear evidence for treating hypertension in patients aged 80 or over. The trial found that treating hypertensive patients aged 80 or over with the Natrilix SR-based regimen reduced total mortality by 21%, all strokes by 30%, fatal strokes by 39%, and heart failure by 64% compared to placebo. The treatment was also well-tolerated with few serious adverse events reported.
The document summarizes guidelines from JNC 8 (2014) on the management of hypertension. It provides 3 key recommendations from JNC 8:
1) Treatment should begin for general population aged ≥60 years with SBP ≥150 mmHg or DBP ≥90 mmHg, and for those <60 years with SBP ≥140 mmHg or DBP ≥90 mmHg.
2) The treatment goal for non-diabetic, non-CKD patients is SBP <150 mmHg and DBP <90 mmHg. Lower goals may apply if no adverse effects.
3) Initial treatment should include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers or thiaz
Hurdles and new players in the management of chronic heart failure with reduc...Dhritisdiary
Watch the slideshow for a better understanding: https://youtu.be/CsXvS1hA330
1. Learn the standard therapy in HFrEF
2. Learn its challenges
3. Learn the new drugs for HFrEF.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
This document discusses biomarkers for acute heart failure syndrome (AHF). It provides definitions of AHF and notes that symptoms are primarily due to pulmonary congestion from elevated left ventricular filling pressures. Biomarkers can help with rapid assessment of hemodynamic status, guide therapy, and assess disease severity and prognosis. Examples of biomarkers discussed include B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP), which reflect myocardial stress and correlate with symptoms severity. Biomarkers are also affected by cardiac and extracardiac factors. Point-of-care testing devices are being developed to rapidly measure biomarker levels to help with triage and guide therapy.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
Acute Heart Failure: Current Standards and Evolution of Care.2015hivlifeinfo
This document provides an overview of the current standards and evolution of care for acute heart failure (AHF). It summarizes the use of biomarkers like natriuretic peptides and troponins in the diagnosis and risk stratification of AHF. It discusses the clinical considerations in stratifying AHF patients, including systolic blood pressure, worsening renal function, and the distribution of left ventricular ejection fraction. The document reviews current treatment options for AHF such as diuretics, vasodilators like nitroglycerin, and nesiritide based on clinical trials and guidelines.
Hyper tension and diabetes the two terrorists together Kyaw Win
This document summarizes a presentation on the topic of hypertension and diabetes. It discusses how the two conditions commonly occur together and exacerbate each other's risks. Some key points:
- Hypertension is twice as common in people with diabetes, and new onset diabetes is 2.5 times more common in people with hypertension. Only 1/4 of hypertension in diabetes is controlled.
- The risk of cardiovascular events triples when a person has both diabetes and hypertension. Tight control of blood pressure reduces morbidity and mortality in people with both conditions.
- Certain antihypertensive medications like beta blockers may modestly increase the risk of new onset diabetes, though this risk is largely explained by the underlying hypertension itself.
ACEI/ARB are effective medications for treating heart failure (HF) and reducing morbidity and mortality after acute coronary syndrome (ACS). For HF, ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended to reduce HF hospitalizations and death by inhibiting the renin-angiotensin-aldosterone system. In ACS patients, ACEI reduce death from cardiovascular causes after myocardial infarction based on evidence from large randomized controlled trials. The combination of an ARB with neprilysin inhibition provides additional benefits for symptomatic HF patients beyond ACEI or ARB alone.
This document summarizes recent clinical trials evaluating new treatments for heart failure with reduced ejection fraction (HFrEF). It finds that sodium-glucose cotransporter-2 inhibitors (SGLT2i) like dapagliflozin and empagliflozin are now foundational therapies for HFrEF as they reduce mortality, hospitalizations, and improve outcomes. Two novel agents, vericiguat and omecamtiv mecarbil, are described as well-tolerated therapies that may provide additional benefit by reducing residual risk in select HFrEF patients. Vericiguat is now FDA-approved and recommended by guidelines for recent worsening HF, while omecamtiv me
This document provides guidelines for the management of hypertension including:
1. Definitions of hypertension based on different blood pressure measurement methods and thresholds from recent guidelines.
2. Treatment goals for higher-risk and lower-risk populations.
3. Causes and complications of hypertension like left ventricular hypertrophy, heart failure, stroke, myocardial infarction, and renal failure.
4. Classes of antihypertensive agents used for treatment including thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers, and beta blockers.
5. Specific definitions and management recommendations for hypertension in pregnancy and its complications.
This document summarizes guidelines for treating hypertension. It defines hypertension and classifications of blood pressure. The goals of treatment are to reduce risks of stroke, heart disease, heart failure, and kidney disease. Lifestyle changes and medication are used to achieve a target blood pressure of less than 140/90 mmHg or 130/80 mmHg for those with diabetes or chronic kidney disease. Initial drug therapy typically involves thiazide diuretics alone or combined with other classes of drugs depending on individual risk factors and medical conditions. Special considerations are given to treating hypertension in pregnancy, kidney disease, heart disease and other compelling indications.
Treatment Of Hypertension In Special Situation Modified Fina Lcdrmisbah83
This document discusses hypertension, including its types, causes, investigations, management, treatment in special situations, complications, and global mortality. It notes that hypertension is a major risk factor for heart disease and stroke worldwide. Treatment involves lifestyle changes and medications, with goals of controlling blood pressure to reduce cardiovascular risks and events.
This document provides an overview of hypertension including:
- Prevalence rates in various countries including the US, China, Egypt, and Saudi Arabia
- Guidelines for classifying blood pressure levels from organizations like JNC 7 and ESC/ESH
- Consequences of uncontrolled hypertension like increased risks of stroke, myocardial infarction, heart failure, and kidney disease
- Results from clinical trials demonstrating reduced risks with tighter blood pressure control
- Recommendations for achieving blood pressure targets and choosing antihypertensive medications
This document summarizes guidelines from the Eighth Joint National Committee (JNC 8) on the prevention, detection, evaluation, and treatment of high blood pressure. It provides recommendations on when to initiate pharmacologic treatment based on age, race, presence of diabetes or chronic kidney disease. It recommends treating to a blood pressure goal of less than 150/90 mmHg for those aged 60 or older, and less than 140/90 mmHg for others. It also provides guidance on first-line antihypertensive drug classes based on patient characteristics.
The document summarizes key information about acute heart failure, including epidemiology, pathophysiology, treatment approaches, and trial data. It describes the ASCEND-HF trial which investigated the effects of nesiritide vs placebo on outcomes in over 7,000 patients hospitalized for acute decompensated heart failure. The trial found no significant differences between nesiritide and placebo for its co-primary endpoints of 30-day mortality or heart failure rehospitalization and dyspnea relief at 6 and 24 hours.
Ischemic heart disease (IHD), also known as coronary heart disease (CHD) or coronary artery disease (CAD), is caused by a reduction of blood flow to the heart due to atherosclerosis of the coronary arteries. Risk factors include metabolic syndrome, smoking, diabetes, hypertension and high cholesterol. Symptoms range from stable angina to acute coronary syndrome (ACS). Diagnosis involves electrocardiogram (ECG), stress testing, coronary angiography and biochemical markers. Treatment depends on severity but may include lifestyle changes, medications like nitrates, beta-blockers, calcium channel blockers, statins, aspirin and revascularization procedures like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (C
CAD -RISK FACTOR MODIFICATION AND PRIMARY PREVENTIONPraveen Nagula
This document discusses primary prevention of coronary artery disease. It defines primary prevention as action taken prior to disease onset to prevent disease from ever occurring, through screening, health exams, and modifying risk factors. The document outlines modifiable risk factors for heart disease like smoking, hypertension, diabetes, obesity, and high cholesterol. It provides strategies for risk factor modification including lifestyle changes like a healthy diet, exercise, and medication if needed. The goal of primary prevention is to tailor therapy to high risk individuals before significant disease develops.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
1) Hypertension is a major risk factor for cardiovascular disease which accounts for a large portion of deaths worldwide.
2) The ALLHAT study was a large clinical trial that compared the effects of different antihypertensive medications on cardiovascular outcomes. It found that a diuretic (chlorthalidone) was more effective at reducing risks than a calcium channel blocker (amlodipine) or ACE inhibitor (lisinopril).
3) While mean blood pressures were similar between groups during the study, the diuretic was superior in reducing risks of heart attacks and heart disease, establishing diuretics as a first-line treatment for hypertension.
- Studies have shown that lowering LDL cholesterol through statin therapy such as atorvastatin provides significant cardiovascular benefits in both primary and secondary prevention. Atorvastatin in particular has been shown in clinical trials to reduce cardiovascular events and mortality when used for acute coronary syndromes, stable coronary heart disease, and among those at high risk of cardiovascular disease. Atorvastatin may be a good choice of statin due to its proven efficacy in improving cardiovascular outcomes.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
This document discusses biomarkers for acute heart failure syndrome (AHF). It provides definitions of AHF and notes that symptoms are primarily due to pulmonary congestion from elevated left ventricular filling pressures. Biomarkers can help with rapid assessment of hemodynamic status, guide therapy, and assess disease severity and prognosis. Examples of biomarkers discussed include B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP), which reflect myocardial stress and correlate with symptoms severity. Biomarkers are also affected by cardiac and extracardiac factors. Point-of-care testing devices are being developed to rapidly measure biomarker levels to help with triage and guide therapy.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
Acute Heart Failure: Current Standards and Evolution of Care.2015hivlifeinfo
This document provides an overview of the current standards and evolution of care for acute heart failure (AHF). It summarizes the use of biomarkers like natriuretic peptides and troponins in the diagnosis and risk stratification of AHF. It discusses the clinical considerations in stratifying AHF patients, including systolic blood pressure, worsening renal function, and the distribution of left ventricular ejection fraction. The document reviews current treatment options for AHF such as diuretics, vasodilators like nitroglycerin, and nesiritide based on clinical trials and guidelines.
Hyper tension and diabetes the two terrorists together Kyaw Win
This document summarizes a presentation on the topic of hypertension and diabetes. It discusses how the two conditions commonly occur together and exacerbate each other's risks. Some key points:
- Hypertension is twice as common in people with diabetes, and new onset diabetes is 2.5 times more common in people with hypertension. Only 1/4 of hypertension in diabetes is controlled.
- The risk of cardiovascular events triples when a person has both diabetes and hypertension. Tight control of blood pressure reduces morbidity and mortality in people with both conditions.
- Certain antihypertensive medications like beta blockers may modestly increase the risk of new onset diabetes, though this risk is largely explained by the underlying hypertension itself.
ACEI/ARB are effective medications for treating heart failure (HF) and reducing morbidity and mortality after acute coronary syndrome (ACS). For HF, ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended to reduce HF hospitalizations and death by inhibiting the renin-angiotensin-aldosterone system. In ACS patients, ACEI reduce death from cardiovascular causes after myocardial infarction based on evidence from large randomized controlled trials. The combination of an ARB with neprilysin inhibition provides additional benefits for symptomatic HF patients beyond ACEI or ARB alone.
This document summarizes recent clinical trials evaluating new treatments for heart failure with reduced ejection fraction (HFrEF). It finds that sodium-glucose cotransporter-2 inhibitors (SGLT2i) like dapagliflozin and empagliflozin are now foundational therapies for HFrEF as they reduce mortality, hospitalizations, and improve outcomes. Two novel agents, vericiguat and omecamtiv mecarbil, are described as well-tolerated therapies that may provide additional benefit by reducing residual risk in select HFrEF patients. Vericiguat is now FDA-approved and recommended by guidelines for recent worsening HF, while omecamtiv me
This document provides guidelines for the management of hypertension including:
1. Definitions of hypertension based on different blood pressure measurement methods and thresholds from recent guidelines.
2. Treatment goals for higher-risk and lower-risk populations.
3. Causes and complications of hypertension like left ventricular hypertrophy, heart failure, stroke, myocardial infarction, and renal failure.
4. Classes of antihypertensive agents used for treatment including thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers, and beta blockers.
5. Specific definitions and management recommendations for hypertension in pregnancy and its complications.
This document summarizes guidelines for treating hypertension. It defines hypertension and classifications of blood pressure. The goals of treatment are to reduce risks of stroke, heart disease, heart failure, and kidney disease. Lifestyle changes and medication are used to achieve a target blood pressure of less than 140/90 mmHg or 130/80 mmHg for those with diabetes or chronic kidney disease. Initial drug therapy typically involves thiazide diuretics alone or combined with other classes of drugs depending on individual risk factors and medical conditions. Special considerations are given to treating hypertension in pregnancy, kidney disease, heart disease and other compelling indications.
Treatment Of Hypertension In Special Situation Modified Fina Lcdrmisbah83
This document discusses hypertension, including its types, causes, investigations, management, treatment in special situations, complications, and global mortality. It notes that hypertension is a major risk factor for heart disease and stroke worldwide. Treatment involves lifestyle changes and medications, with goals of controlling blood pressure to reduce cardiovascular risks and events.
This document provides an overview of hypertension including:
- Prevalence rates in various countries including the US, China, Egypt, and Saudi Arabia
- Guidelines for classifying blood pressure levels from organizations like JNC 7 and ESC/ESH
- Consequences of uncontrolled hypertension like increased risks of stroke, myocardial infarction, heart failure, and kidney disease
- Results from clinical trials demonstrating reduced risks with tighter blood pressure control
- Recommendations for achieving blood pressure targets and choosing antihypertensive medications
This document summarizes guidelines from the Eighth Joint National Committee (JNC 8) on the prevention, detection, evaluation, and treatment of high blood pressure. It provides recommendations on when to initiate pharmacologic treatment based on age, race, presence of diabetes or chronic kidney disease. It recommends treating to a blood pressure goal of less than 150/90 mmHg for those aged 60 or older, and less than 140/90 mmHg for others. It also provides guidance on first-line antihypertensive drug classes based on patient characteristics.
The document summarizes key information about acute heart failure, including epidemiology, pathophysiology, treatment approaches, and trial data. It describes the ASCEND-HF trial which investigated the effects of nesiritide vs placebo on outcomes in over 7,000 patients hospitalized for acute decompensated heart failure. The trial found no significant differences between nesiritide and placebo for its co-primary endpoints of 30-day mortality or heart failure rehospitalization and dyspnea relief at 6 and 24 hours.
Ischemic heart disease (IHD), also known as coronary heart disease (CHD) or coronary artery disease (CAD), is caused by a reduction of blood flow to the heart due to atherosclerosis of the coronary arteries. Risk factors include metabolic syndrome, smoking, diabetes, hypertension and high cholesterol. Symptoms range from stable angina to acute coronary syndrome (ACS). Diagnosis involves electrocardiogram (ECG), stress testing, coronary angiography and biochemical markers. Treatment depends on severity but may include lifestyle changes, medications like nitrates, beta-blockers, calcium channel blockers, statins, aspirin and revascularization procedures like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (C
CAD -RISK FACTOR MODIFICATION AND PRIMARY PREVENTIONPraveen Nagula
This document discusses primary prevention of coronary artery disease. It defines primary prevention as action taken prior to disease onset to prevent disease from ever occurring, through screening, health exams, and modifying risk factors. The document outlines modifiable risk factors for heart disease like smoking, hypertension, diabetes, obesity, and high cholesterol. It provides strategies for risk factor modification including lifestyle changes like a healthy diet, exercise, and medication if needed. The goal of primary prevention is to tailor therapy to high risk individuals before significant disease develops.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
1) Hypertension is a major risk factor for cardiovascular disease which accounts for a large portion of deaths worldwide.
2) The ALLHAT study was a large clinical trial that compared the effects of different antihypertensive medications on cardiovascular outcomes. It found that a diuretic (chlorthalidone) was more effective at reducing risks than a calcium channel blocker (amlodipine) or ACE inhibitor (lisinopril).
3) While mean blood pressures were similar between groups during the study, the diuretic was superior in reducing risks of heart attacks and heart disease, establishing diuretics as a first-line treatment for hypertension.
- Studies have shown that lowering LDL cholesterol through statin therapy such as atorvastatin provides significant cardiovascular benefits in both primary and secondary prevention. Atorvastatin in particular has been shown in clinical trials to reduce cardiovascular events and mortality when used for acute coronary syndromes, stable coronary heart disease, and among those at high risk of cardiovascular disease. Atorvastatin may be a good choice of statin due to its proven efficacy in improving cardiovascular outcomes.
This document discusses the management of hypertension in patients with type 2 diabetes. It provides an overview of clinical trials that have evaluated blood pressure targets for reducing cardiovascular risk in this population. The trials have shown that intensive control of blood pressure below 140/80 mmHg reduces microvascular complications, but trials targeting levels under 120/80 mmHg have found no additional cardiovascular benefit and an increased risk of side effects. Current guidelines recommend a systolic blood pressure goal of 130-140 mmHg for most patients with diabetes.
An Evidence Based Approach To HypertensionAline Chammas
This document summarizes evidence for an evidence-based approach to hypertension treatment. It finds that diuretics should be the first-line treatment according to major guidelines, as they have been shown in multiple trials including ALLHAT to reduce cardiovascular events like stroke and heart disease more than other drugs. While both SBP and DBP are important, SBP control is particularly challenging and reducing it by even 10 mmHg provides substantial benefits. Global hypertension prevalence is increasing and control remains inadequate in most of the world.
The document summarizes guidelines for treating hypertension and their evidence basis. It discusses several major studies that informed guidelines recommending a target blood pressure of 130/80 mmHg or lower to slow kidney disease progression, including the MDRD trial which found a 32% reduction in kidney failure risk with intensive control to 125/75 mmHg compared to 140/90 mmHg. However, later trials like ACCORD and REIN-2 found no additional benefit from intensive control below 130/80 mmHg or additional medications to reach lower targets.
The document discusses guidelines for the treatment of hypertension from the 2007 European Society of Hypertension. It defines blood pressure levels and cardiovascular risk categories. It outlines factors that influence prognosis like risk factors, diabetes, subclinical organ damage, and established cardiovascular or renal disease. It provides recommendations on lifestyle changes, goals of treatment, choice of antihypertensive drugs, and when to initiate treatment. The primary goal is to reduce blood pressure and lower cardiovascular risk through treatment and controlling associated risk factors.
The document summarizes the SPRINT trial which compared intensive blood pressure control (target SBP <120 mm Hg) to standard treatment (target SBP 135-139 mm Hg) in patients at high risk for cardiovascular disease but without diabetes or history of stroke. The trial found that intensive treatment reduced the occurrence of heart attacks, heart failure, and death by about 25% compared to standard treatment. However, intensive treatment also increased the risk of acute kidney injury, particularly in those without chronic kidney disease at baseline. Overall, the trial demonstrated that intensive blood pressure control provides significant cardiovascular benefits for high-risk patients.
The document discusses hypertension (high blood pressure) and its role in cardiovascular disease risk. It summarizes several studies showing that controlling hypertension, through lifestyle changes and medication such as diuretics, ACE inhibitors, and ARBs, can significantly reduce the risks of heart attack, stroke, heart failure, and death. The use of combination drug therapy to control blood pressure is often more effective than single drug therapy alone.
This document summarizes several studies on the use of ACE inhibitors and angiotensin receptor blockers (ARBs) in treating heart failure and reducing cardiovascular risk. The HOPE trial showed that the ACE inhibitor ramipril reduced cardiovascular events in high-risk patients. The CHARM trial found that the ARB candesartan reduced cardiovascular outcomes in heart failure patients, both alone and in combination with ACE inhibitors. The ONTARGET trial aimed to compare the ARB telmisartan to ramipril, and their combination, to determine if telmisartan was non-inferior to ramipril and if their combination provided additional benefit.
Prevention of stroke - Dự phòng đột quỵ nãodangphucduc
This document provides guidelines for preventing stroke in patients who have had a stroke or transient ischemic attack. It discusses controlling risk factors such as hypertension, dyslipidemia, diabetes, obesity, and atrial fibrillation. It recommends treating hypertension to a target blood pressure under 140/90 mmHg. It suggests statin therapy for patients with atherosclerotic ischemic stroke or TIA. It also recommends screening post-stroke patients for diabetes and obesity. For carotid artery disease, it supports carotid endarterectomy for severe stenosis, and optimal medical therapy for mild-moderate stenosis. The document provides guidance on anticoagulation and antiplatelet therapies for atrial fibrillation and general stroke prevention respectively.
The Systolic Blood Pressure Intervention Trial (SPRINT) aims to test whether treating high blood pressure to a goal of lower than 120 mm Hg can reduce cardiovascular risks more than the current recommended goal of lower than 140 mm Hg. SPRINT will randomize over 9,000 patients at risk of heart disease to either an intensive treatment group aiming for systolic blood pressure under 120 mm Hg or a standard group under 140 mm Hg. The primary outcome is a composite of heart attack, stroke, heart failure, and cardiovascular death. SPRINT will provide evidence on the feasibility and risks/benefits of this more intensive blood pressure control strategy.
Diagnosis and Treatment in Young Hypertensives.pptSuyash Tated
- Hypertension is increasing globally and is a major risk factor for death and disability. The prevalence of hypertension among young Indians ages 18-39 is 19%.
- Evaluation of young hypertensive patients should include assessing secondary causes through medical history, examination, and targeted laboratory/imaging tests. Lifestyle modification is key to management.
- Treatment goals for young hypertensive patients without comorbidities are systolic blood pressure <140 mmHg and diastolic <90 mmHg. More stringent goals of <130/80 mmHg are recommended for patients with comorbidities like diabetes, kidney disease, or heart disease.
- First-line pharmacological therapy includes ACE inhibitors, ARBs, calcium channel block
Los fármacos recomendados para iniciar el tratamiento antihipertensivo en este paciente son:
- Candesartán: por su demostrada capacidad para disminuir la hipertrofia ventricular izquierda y reducir la proteinuria, lo que es importante dado que el paciente presenta diabetes e hipertrofia ventricular.
- Telmisartán: al igual que el candesartán, ha demostrado reducir la proteinuria en pacientes diabéticos. Además, posee efecto antioxidante y antiaterogénico que son beneficiosos en este tipo de pacientes.
- V
1. The document discusses the 2017 ACC/AHA Hypertension Guidelines, which introduced new definitions for blood pressure categories and recommendations for treatment.
2. It summarizes key findings from the SPRINT trial showing benefits of intensive blood pressure control to below 120/80 mmHg in high-risk individuals.
3. The guidelines recommend lifestyle modifications and use of antihypertensive agents from four classes as first-line therapy, with a goal of lowering blood pressure to below 130/80 mmHg in high-risk individuals to reduce cardiovascular events.
This document summarizes guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). It provides recommendations on lifestyle modifications, measurement of blood pressure, causes and treatment of hypertension, and evidence from clinical trials on blood pressure control. The key recommendations include lifestyle modifications like weight loss, following the DASH diet, reducing sodium, regular exercise, and moderate alcohol intake to control blood pressure. It also provides guidance on drug therapy based on blood pressure levels and number of medications typically needed to achieve control.
This document provides an overview of the updated management of chronic heart failure. It defines heart failure and discusses its classification, diagnosis, etiologies, investigations, and management strategies. For heart failure with reduced ejection fraction, the major goals of treatment are to reduce mortality and prevent hospitalizations through use of pharmacotherapy including angiotensin receptor-neprilysin inhibitors, SGLT2 inhibitors, beta-blockers, and MRAs. Device therapies like ICDs and CRT may also be considered. For heart failure with mid-range and preserved ejection fraction, no treatments have proven to reduce mortality, but targeting comorbidities is recommended.
This document summarizes key information from a presentation on optimal prevention of cardiovascular outcomes in type 2 diabetes:
1) Type 2 diabetes significantly increases the risk of cardiovascular disease and other chronic complications. Both intensive lipid and blood pressure lowering through medications like statins and ACE inhibitors have been shown to reduce cardiovascular events.
2) While glucose lowering also aims to reduce cardiovascular risk, trials yielded mixed results. Intensive control increased mortality in ACCORD but showed long-term benefits after the UKPDS trial. Current guidelines target HbA1c under 7%.
3) The choice of glucose-lowering medications is also important. Rosiglitazone increased cardiovascular risk and was withdrawn. Ongoing monitoring of
The document discusses treatment of hypertensive patients who also have dyslipidemia. It describes a case study of a 57-year-old man with prior myocardial infarction, uncontrolled hypertension, and elevated LDL cholesterol. Clinical trials show that intensive statin therapy to achieve lower LDL levels reduces cardiovascular risks more than moderate statin therapy. The Heart Protection Study also found that simvastatin reduced cardiovascular events in high-risk patients, regardless of baseline LDL level.
This randomized controlled trial involved 4444 patients with coronary heart disease who were assigned to either simvastatin or placebo treatment. Over the median 5.4 year follow-up period, simvastatin treatment reduced total mortality by 30% compared to placebo. Specifically, 256 patients died in the placebo group compared to 182 in the simvastatin group, representing a relative risk of death of 0.70 for those receiving simvastatin. Simvastatin also reduced major coronary events such as heart attacks and procedures by 34% compared to placebo. This study provides evidence that long-term cholesterol lowering with simvastatin improves survival rates for patients with coronary heart disease.
This study examined malnutrition among school-aged children in rural and urban areas of two districts in Ethiopia. The researchers collected anthropometric and dietary intake data from 886 children and analyzed differences in stunting and thinness between settings. The prevalence of stunting was higher in rural (42.7%) versus urban (29.2%) areas. In rural areas, factors associated with stunting included recent fever, consumption of animal foods, and family cattle ownership. In urban areas, only older age and the head of household's education were associated with stunting. Thinness was linked to household size and rice farming in rural communities and animal food intake and head of household literacy in urban communities. The study found varying factors impacting malnutrition
This study assessed the nutritional status of school-age children in urban slums in India. The researchers found high rates of malnutrition, with over 30% of children wasted and nearly 20% stunted. Younger children, those from joint families, and those whose mothers had low education levels were most at risk. Interventions like nutrition education and food fortification were recommended to address the poor nutritional status found.
Differentiating trigeminal neuropathy from trigeminal neuralgiaDr P Deepak
1. This case involves a 26-year-old female with left-sided facial pain in the trigeminal distribution along with a history of chronic migraines, depression, and hypothyroidism.
2. Based on her pain characteristics, triggers, and physical exam findings, she most likely has atypical facial pain secondary to trigeminal neuropathic pain rather than classic trigeminal neuralgia.
3. It is important to differentiate the two conditions, as trigeminal neurolysis could worsen trigeminal neuropathy pain. She will undergo nerve blocks and be considered for additional procedures depending on response. Managing her transformed migraine and multiple medications will also be important.
Beck depression-inventory-real-time-reportDr P Deepak
A 64-year-old widowed male college graduate scored 51 on the Beck Depression Inventory II indicating severe depression. His responses showed sadness, hopelessness about the future, feelings of failure, loss of pleasure, guilt, feelings of punishment, disappointment in himself, self-blame, suicidal thoughts, crying, restlessness, loss of interest, indecisiveness, lack of worth, lack of energy, sleeping most of the day, irritability, increased appetite, difficulty concentrating, and loss of interest in sex.
This study analyzed 397 prescriptions from an outpatient pharmacy department to identify errors related to prescription writing requirements and prescribing errors. The key findings were:
1) 96.7% of prescriptions had one or more errors of omission, such as missing information on patient age, date, dosage, strength, or quantity to supply.
2) There were also errors of commission, such as wrong dosage form, in 8.4% of prescribed drugs. A total of 39 drug-drug interactions were identified.
3) The results show a low compliance rate with legal and procedural prescription writing requirements. This indicates a need for improved education for prescribers on clear and complete prescription writing to reduce errors.
Antihistamines and-asthma-patients-2002Dr P Deepak
H1 antihistamines are not first-line treatment for asthma but should not be withheld when needed to treat other conditions like allergic rhinitis. While not a replacement for other asthma medications, H1 antihistamines have demonstrated bronchoprotective effects and modest bronchodilation. Their benefits in asthma appear to be dose-related. For mild intermittent asthma with allergic rhinitis, H1 antihistamines can improve asthma symptoms. In moderate persistent asthma, some H1 antihistamines show clinical benefits including steroid-sparing effects, but risks may outweigh benefits at high doses. H1 antihistamines are not expected to provide significant benefits for severe persistent asthma.
Corticosteroids are the most effective treatment for asthma. They work by suppressing the chronic inflammation in the airways that is characteristic of asthma. This inflammation is mediated by increased expression of inflammatory genes regulated by transcription factors like NF-κB. Corticosteroids suppress these inflammatory genes by reversing the histone acetylation that activates them. This involves binding of glucocorticoid receptors to coactivators and recruitment of histone deacetylases, switching off the inflammatory gene expression. Understanding this molecular mechanism of corticosteroid action may help develop new anti-inflammatory therapies for asthma.
Review anti-cancer agents in medicinal chemistry, 2013Dr P Deepak
This document summarizes different types of kinase inhibitors for treating cancer. It discusses Type I inhibitors which compete with ATP for binding in the kinase catalytic site. While some Type I inhibitors have been FDA approved, they have limitations like low selectivity. Type II inhibitors bind in both the catalytic site and a lipophilic pocket, conferring higher selectivity. Type III or allosteric inhibitors bind outside the catalytic domain, providing subtle regulation. The document focuses on advantages of Type II inhibitors and strategies to design drugs that selectively inhibit targets or overcome drug resistance.
This document discusses the underlying pathophysiology of type 2 diabetes, specifically insulin resistance and beta-cell dysfunction. It notes that insulin resistance, where tissues do not respond properly to insulin, is a major defect in type 2 diabetes and closely associated with obesity. Beta-cell dysfunction refers to the reduced ability of pancreatic beta cells to secrete insulin in response to high blood glucose levels. Over time, the combination of insulin resistance and beta-cell dysfunction leads to chronically high blood glucose levels and a diagnosis of type 2 diabetes. The document recommends that treatment of type 2 diabetes should target these underlying defects by addressing insulin resistance through medications like thiazolidinediones in addition to other antidiabetic agents.
This document outlines classifications for cranial neuralgias, central causes of facial pain, and other headaches that are not classified elsewhere in the International Classification of Headache Disorders. It defines and provides diagnostic criteria for specific conditions like trigeminal neuralgia, occipital neuralgia, central post-stroke pain, and burning mouth syndrome. Unclassified headaches and headaches where insufficient information is available to determine the type are also addressed.
Occipital neuralgia is a form of headache involving severe pain in the back of the head and scalp. It can be difficult to diagnose due to similarities with other headache types. Treatment may include nerve blocks, medications, nerve stimulation, or surgery. Nerve blocks using local anesthetics and steroids can help with diagnosis and pain relief. Surgical options like nerve decompression or rhizotomy may be considered if more conservative treatments are ineffective.
The document provides a detailed review of antibiotics, including:
1) It traces the history of antibiotics from sulfonamides in the 1930s to newer drugs developed in response to increasing bacterial resistance in the 1960s and onward.
2) It describes different classes of antibiotics like beta-lactams (penicillins and cephalosporins) and summarizes the characteristics, uses, and limitations of representative drugs within each class.
3) It discusses the ongoing challenge of bacterial resistance developing to existing antibiotics and the need for prudent antibiotic use and new drug development to address this threat.
Hypertension guidelines2008to2010updateDr P Deepak
This document provides guidelines for the management of hypertension in adults. It covers measuring and diagnosing hypertension, evaluating patients, lifestyle modification, assessing cardiovascular risk, drug treatment options, and long-term management. The guidelines were developed by an expert committee and endorsed by several organizations. It aims to help health professionals optimize the care of patients with hypertension.
This document discusses hypertension and provides guidelines for its diagnosis and treatment. Some key points:
1. Hypertension, defined as persistently elevated blood pressure, affects over 30% of Americans and is a major risk factor for cardiovascular disease.
2. The goal of treatment is to reduce blood pressure-related health risks through lifestyle modifications and medication. Treatment goals are under 140/90 mmHg for most patients, or under 130/80 mmHg for those with diabetes or kidney disease.
3. First-line drug treatment typically involves thiazide diuretics. Other drug classes like ACE inhibitors or ARBs may be used for compelling indications or patient characteristics. Multiple drug combinations are often needed to control blood
Artemisinin combination therapy (ACT) is recommended for treating uncomplicated Plasmodium falciparum malaria, combined with primaquine on day 2. Chloroquine is the treatment of choice for Plasmodium vivax malaria, with primaquine added for 14 days to prevent relapse. For severe P. falciparum malaria, intravenous artesunate or quinine should be promptly administered to prevent death, along with doxycycline or clindamycin once oral intake is possible. Chemoprophylaxis for short term exposure uses doxycycline while mefloquine is recommended for long term exposure.
Brian Strom discusses drug safety and the limitations of pre-marketing clinical trials in accurately detecting adverse drug reactions (ADRs). Post-marketing studies using pharmacoepidemiological methods are needed to further evaluate drug safety in large populations over long time periods. Pharmacoepidemiology applies epidemiological study designs like cohort studies and case-control studies to examine drug use and ADRs in real-world settings. However, drug safety research is challenging given issues like confounding factors, measurement of drug exposure, and potential conflicts of interest. Strom argues for increased focus on common ADRs rather than just rare events to better understand drug safety.
This document provides an introduction to pharmacoepidemiology methods. It discusses study designs like cohort studies and case-control studies. It also outlines different data sources that can be used including spontaneous adverse reaction reports, medical billing data, and medical records databases. The document concludes by discussing the future of pharmacoepidemiology, including new scientific developments like applications of epidemiology methods and studies of drug effectiveness, as well as new data sources and the role of genetics.
This document provides guidance on using ad hoc reporting tools in the MT Edition software. It defines ad hoc reporting as customizable reports that can be generated for specific data verification needs. It then covers how to create ad hoc reports by selecting data elements, setting filters, and formatting output. Reports can be exported in various formats and used to verify data within the MT Edition and against source data. Pre-made "state published" reports may also be accessed and customized. Filters can be organized into folders and shared with other users.
This document provides an introduction and table of contents to a course on cardiovascular pharmacology. It outlines topics that will be covered such as the autonomic nervous system, properties of cardiac cells, types of antidysrhythmic drugs, antihypertensive drugs, vasopressors, inotropic agents, thrombolytics, platelet inhibitors, and diuretics. It notes that continuing education hours may be available through qualifying boards. The document serves as an overview of the course content and organization.
Nln pharmacology study guide final 6 3-2013Dr P Deepak
This document provides guidance for studying for the NLN Pharmacology Exam. It outlines that the exam contains 100 multiple choice questions testing calculations, principles of medication administration, and medication effects. Approximately 1/3 of the exam focuses on calculations, so the guide emphasizes practicing dosage calculations and reviews common calculation methods. It also reviews key principles like the rights of medication administration, routes of drug administration, and definitions of important terms. The goal is to prepare nurses to demonstrate competency in safe medication administration.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
6122 htn lp_01.12.06
1. N98-269 PCP Kit
Hypertension Update:
Focus on Pharmacotherapy
Robert J. Straka, Pharm.D. FCCP
Associate Professor
University of Minnesota
College of Pharmacy
Minneapolis, Minnesota
strak001@umn.edu
Learning Objectives:
At the end of the presentation, learners should be able to:
1) Describe and define several basic facts about the epidemiology and
pathophysiology of hypertension
2) Describe and explain fully the goals and overall approach to
managing patients with hypertension with an emphasis on
pharmacotherapeutic issues
3) Discuss current JNC 7 issues and evidenced-based support for
their recommendations (and modifications based on recent studies)
4) Outline salient features of pharmacotherapeutic agents commonly
used to treat patients with hypertension and be able to develop a
rationale for their selection for specific patients
1
2. N98-269 PCP Kit
JNC 7 Guidelines for Hypertension
• Goal: To reduce CV morbidity and mortality through
prevention and management of hypertension
• JNC 7 Guidelines (2003)
Classification of Blood Pressure
Category
SBP (mm Hg)
DBP (mm Hg)
Normal
< 120
< 80
Prehypertension
120-139
80-89
Hypertension, Stage 1
140-159
90-99
Hypertension, Stage 2
≥ 160
≥ 100
Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.
Framingham Study - CV Events and BP
Optimal: <120 and <80,
Normal <130 and <85,
High normal 130-139 or 85-89)
(JNC VI)
130-139/
85-89 mmHg
Framingham Study - CV Events and BP
120-129/
88-84 mmHg
<120/80 mmHg
Vasan, RS, et al. N Engl J Med 2001;345:1291-7
2
3. N98-269 PCP Kit
BP Category and 1st Major CV Event
3
P<0.001
Hazard Ratio
2.5
P<0.05
Optimal
Normal
Hi Normal
2
1.5
1
0.5
0
Women
Men
Opt: <120/80
NL: 120-129/80-84
Vasan, RS, et al. N Engl J Med 2001;345:1291-7
High NL: 130-139/85-89
Age-Adjusted Relative Risk for
CHD Death
Multiple Risk Factor Intervention Trial
3
4. N98-269 PCP Kit
Estimated 10-Year Risk (%) of Coronary Artery Disease for
Various Combinations of Risk Factors for Men and Women
70
60
57.556.4
Men
Women
50
38 36.8
40
28.827.7
30
23.4
20
10
13.7
8.7
9.2
5.5
17
16.5
11.3
0
BP Systolic
Cholesterol
HDL -C
Diabetes
Cigarettes
LVH by ECG
120
220
50
-
160
220
50
-
160
260
50
-
160
260
35
-
160
260
35
+
-
160
260
35
+
+
-
160
260
35
+
+
+
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
MRFIT: Impact of Elevated SBP and Total Cholesterol
on CHD Mortality (N=316,099)
34
CHD Deaths/10,000 PatientYears
23
21
18
17
12
13
12
10
245+
8
9
6
4
221-244
203-220
182-202
Cholesterol Quintile
<182
(mg/dL)
14
8
8
6
6
17
11
6
6
3
3
<118
5
142+
132-141
125-131
118-124
Systolic BP Quintile
(mm Hg)
Neaton et al. Arch Intern Med. 1992;152:56-64.
4
5. N98-269 PCP Kit
Target Organ Damage in Hypertension
HYPERTENSION
LVH
CHD
CHF
Stroke
Retinopathy
Decreased arterial
compliance
Adapted from JNC V. Arch Intern Med. 1993;1563:154.
Renal
impairment
Lowering BP Is Imperative in Reducing
Cardiovascular Risk
In clinical trials, antihypertensive therapy has been
associated with reductions in:
Myocardial Infarction
Stroke
Heart Failure
20%-25%
35%-40%
>50%
JNC 7 Express. 2003. NIH Publication 03-5233.
Neal B et al. Lancet. 2000;356:1955-1964.
5
6. N98-269 PCP Kit
JNC - 7
The Seventh Report
of the
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of
High Blood Pressure
JAMA 2003; 289 (19): 2560-2572 May 21, 2003
Web Site
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
JNC 7 Highlights
• For patients older than 50 years, SBP >140 mm Hg is a more important
CVD risk factor than DBP
• Patients with pre-hypertension require health-promoting lifestyle
modifications to prevent CVD
• Thiazide-type diuretics should be used in drug treatment for most patients
with uncomplicated hypertension, either alone or in combination with
drugs from other classes
• High-risk conditions are compelling indications for the initial use of specific
antihypertensive drug classes
• Most patients will require 2 or more antihypertensive agents to reach their
goal blood pressure
• If BP is >20/10 mm Hg above goal, consideration should be given to
initiating therapy with 2 agents, one of which should usually be a thiazidetype diuretic
JAMA 2003; 289 (19): 2560-2572 May 21, 2003
The JNC 7 report. JAMA. 2003;289:2560-2572.
6
7. N98-269 PCP Kit
JNC 7 Guidelines for Hypertension
• Goal: To reduce CV morbidity and mortality through
prevention and management of hypertension
• JNC 7 Guidelines (2003)
Classification of Blood Pressure
Category
SBP (mm Hg)
DBP (mm Hg)
Normal
< 120
< 80
Prehypertension
120-139
80-89
Hypertension, Stage 1
140-159
90-99
Hypertension, Stage 2
≥ 160
≥ 100
Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.
Benefits of Lowering BP
• In stage 1 HTN and additional CVD risk factors, achieving a
sustained 12 mmHg reduction in SBP over 10 years will
prevent 1 death for every 11 patients treated
Average Percent Reduction
Stroke Incidence
Myocardial Infarction
Heart Failure
35-40%
20-25%
50%
Adapted from the JNC 7 Slide Deck. Available at:
http://www.nhlbi.nih.gov.
7
8. N98-269 PCP Kit
Prevalence of Hypertension in the US
Aware
Treated
Controlled*
Hypertensive Patients (%)
80
70
73
60
50
70
68
59
55
51
54
40
30
34
31
29
27
20
10
10
0
NHANES II
(1976-1980)
NHANES III
(1988-1991)
[Phase I]
NHANES III
(1991-1994)
[Phase II]
NHANES
(1999-2000)
*Controlled BP = SBP <140 mm Hg and DBP <90 mm Hg.
Adapted from JNC 7. JAMA. 2003;289:2560-2572.
Patient Evaluation
Evaluation of patients with documented HTN has three
objectives
1. Assess lifestyle and identify other CV risk factors or
concomitant disorders that affects prognosis and guides
treatment
2. Reveal identifiable causes of high BP
3. Assess the presence or absence of target organ damage and
CVD
The JNC 7 report. JAMA. 2003;289:2560-2572.
8
9. N98-269 PCP Kit
Major CVD Risk Factors: JNC 7
Hypertension*
Cigarette smoking
Physical inactivity
Obesity (body mass index ³30 kg/m2)*
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 mL/min
Age (>55 years for men, >65 for women)
Family history of premature CVD (men aged <55 or
women aged <65 years)
*Components of the metabolic syndrome.
Yellow = modifiable, Underline = new from JNC 6
Identifiable Causes and Target Organ
Damage
Identifiable Causes:
• Sleep apnea, drug induced, chronic kidney disease, primary aldosteronism,
renovascular disease, chronic steroid therapy and Cushing’s syndrome,
pheochromocytoma, coarctation of the aorta, thyroid or parathyroid
disease.
Target Organ Damage:
• Heart: (LVH, Angina or prior MI, Prior revascularization, Heart failure)
• Brain: (Stroke or TIA)
• Chronic Kidney Disease
• Peripheral Arterial Disease
• Retinopathy
The JNC 7 report. JAMA. 2003;289:2560-2572.
9
10. N98-269 PCP Kit
Laboratory Tests
• Routine Tests:
– ECG
– UA
– Blood glucose, and hematocrit
– Serum Potassium, creatinine, or the corresponding estimated GFR and
Ca
– Lipid profile, after 9-12 hour fast, that includes HDL, LDL and TG
Optional Tests:
– Measurement of Urinary albumin excretion or albumin/creatinine ratio
– More extensive testing for identifiable causes not generally indicated
unless BP control is not achieved
Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.
Goals of Therapy
• Reduce CVD and renal morbidity and mortality
• Treat to BP < 140/90 mmHg or BP < 130/80 mmHg in patients
with diabetes or chronic kidney disease
• Achieve SBP goal especially in persons >50 years of age
Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.
10
11. N98-269 PCP Kit
JNC 7: Lifestyle Modification
Modification
Approximate SBP reduction (range)
Weight Reduction
5-20 mmHg/10Kg wt loss
Adopt DASH eating plan
8-14 mmHg
Dietary sodium reduction
2-8 mmHg
Physical activity
4-9 mmHg
Moderation of alcohol consumption
2-4 mmHg
.
Adapted from the JNC 7 Reference Card. Available at: http://www.nhlbi.nih.gov.
JNC 7 Algorithm for Treatment
Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov
11
12. N98-269 PCP Kit
JNC 7: Compelling Indications for
Individual Drug Classes
Compelling Indication
Recommended Drug Classes
Heart failure
THIAZ, BB, ACEI, ARB, ALDO ANT
Post-myocardial infarction
BB, ACEI, ALDO ANT
High CVD risk
THIAZ, BB, ACEI, CCB
Diabetes
THIAZ, BB, ACEI, ARB, CCB
Chronic kidney disease
ACEI, ARB
Recurrent stroke prevention
THIAZ, ACEI
.
Adapted from the JNC 7 Reference Card. Available at: http://www.nhlbi.nih.gov.
Compelling Indications for
Individual Drug Classes: JNC 7
Compelling Indication
Recommended
Heart failure
DIUR, BB, ACEI, ARB, ALDOANT
Post-myocardial
infarction
BB, ACEI, ALDO ANT
Clinical Trial Basis
ACC/AHA Heart Failure Guideline,
MERIT-HF, COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE, ValHEFT,
RALES, CHARM
ACC/AHA Post-MI
Guideline, BHAT, SAVE, Capricorn,
EPHESUS
ALLHAT, HOPE, ANBP2, LIFE,
CONVINCE
High CAD risk
DIUR, BB, ACE, CCB
Adapted from Chobanian et al. JAMA. 2003; Vol 289, No 19: 2560-2572.
12
14. N98-269 PCP Kit
Treatment Diabetes:
Diabetes Care 29;S4-S42:2006
• Initial drug therapy for those with a blood pressure
>140/90 should be with a drug class demonstrated to
reduce CVD events in patients with diabetes (ACE
inhibitors, ARBs, β-blockers, diuretics, calcium channel
blockers). (A)
– All patients with diabetes and hypertension
should be treated with a regimen that includes
either and ACE inhibitor or ARB (E)
Hypertension Management in Adults with Diabetes (Diabetes Care, Vol 29 S4-S42,
Supplements Jan 2006)
Treatment Cont.
• If ACE inhibitors or ARBs are used, monitor renal function and
serum potassium levels. (E)
• While there are no adequate head-to-head comparisons of ACE
inhibitors and ARBs, there is clinical trial support for each of the
following statements:
– In patients with type 1 diabetes with hypertension and any degree of albuminuria, ACE
inhibitors have been shown to delay the progression of nephropathy. (A)
– In patients with type 2 diabetes, hypertension, and microalbuminuria, ACE inhibitors and
ARBs have been shown to delay the progression to macroalbuminuria. (A)
– In those with type 2 diabetes, hypertension, macroalbuminuria (>300 mg/day), and renal
insufficiency, an ARB should be strongly considered. (A)
Hypertension Management in Adults with Diabetes (Diabetes Care, Vol 29, S4-S42, Jan 2006)
14
15. N98-269 PCP Kit
Diagnostic Criteria for Albuminuria
• Standard urine dipsticks are not sensitive enough to
detect microalbuminuria
Albuminuria
Spot
Specimen
(mcg/mL)
Spot
Specimen
(mcg/mg Cr)
24-hr Timed
Specimen
(mg)
Normo-
< 20
< 30
< 30
Micro-
20-200
30-299
30-299
Macro-
> 200
≥ 300
≥ 300
ADA Clin Practice Guidelines; Diabetes Care. 2002;25(1):S85-S89.
JNC 7: Goals for Prevention and
Management of Hypertension
• Reduce morbidity and mortality by least intrusive means
possible
– SBP <140 mm Hg and DBP <90 mm Hg (<130/80 for
diabetics)
– SBP/DBP below these levels if treatment is tolerated
– Control other modifiable risk factors
The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. May 21, 2003. JAMA 2003; 289
(19): 2560-2752
15
16. N98-269 PCP Kit
Follow-up and Monitoring
• Patients should return for follow-up and adjustment of
medications until the BP goal is reached
• More frequent visits for stage 2 HTN or with complicating
comorbid conditions
• Serum potassium and creatinine monitored 1-2 times per year
• After BP at goal and stable, follow-up at 3-6 month intervals
• Comorbidities, such as heart failure, associated diseases, such
as diabetes, and the need for laboratory tests influence the
frequency of visits
HOT: Cardiovascular Events in Diabetes
Patients and DBP Level
≤90 mm Hg DBP
≤85 mm Hg DBP
≤80 mm Hg DBP
Events per 1000
Patient-years
20
P=.016
15
15.9 15.5
11.1 11.2
10
5
0
9.1
7.5
9.0
7.0 6.4
4.3
MI
3.7
3.7
Stroke
CV Mortality
All Mortality
Hansson et al. Lancet. 1998;351:1755-1762.
16
17. N98-269 PCP Kit
Additional Considerations in
Antihypertensive Drug Choices
• Potential favorable effects:
– Thiazide diuretics useful in slowing demineralization in
osteoporosis
– BBs useful in the treatment of atrial
tachyarrhythmias/fibrillation, migraine, thyrotoxicosis
(short term), essential tremor, or periopertative HTN
– CCBs useful in Raynaud’s syndrome and certain
arrhythmias
– Alpha-blockers useful in prostatism.
Additional Considerations in
Antihypertensive Drug Choices
• Potential unfavorable effects:
– Thiazide diuretics should be used cautiously in gout or
history of significant hyponatremia
– BBs should be generally avoided in patients with asthma,
reactive airway disease or second or third-degree heart
block
– ACEIs and ARBs are contraindicated in pregnant women
or those likely to be come pregnant
– ACEIs should not be used in individuals with a history of
angioedema
– Aldosterone antagonists and K-sparing diuretics can cause
hyperkalemia
17
18. N98-269 PCP Kit
Selected Side Effects With
Hypertensive Medications
Beta Blockers
Calcium Channel Blockers*
• Bronchospasm
• Edema of the ankle
• Cough (common)
• Bradycardia
• Flushing
• Angioedema (rare)
• Heart failure
• Headache
• Hyperkalemia (rare)
• May mask insulin-
• Gingival hypertrophy
• Rash (rare)
induced hypoglycemia
ACE Inhibitors
ARBs
• Angioedema
(very rare)
• Hyperkalemia
• Loss of taste (rare)
Less Serious:
• Leukopenia (rare)
• Impaired peripheral
circulation
• Insomnia
• Fatigue
• Decreased exercise
tolerance
• Hypertriglyceridemia†
*Dihydropyridine
†
Except agents with intrinsic sympathomimetic activity
JNC VI. Arch Intern Med. 1997;157:2413-2446.
Multiple Antihypertensive Agents
Are Often Needed to Achieve Target BP
•Trial
•Target BP (mm Hg)
No. of antihypertensive agents
1
UKPDS1
MAP ≤92
HOT4
DBP ≤80
AASK5
•MAP ≤92
IDNT6
SBP ≤135/DBP ≤85
ALLHAT
4
DBP <75
MDRD3
3
DBP <85
ABCD2
2
SBP ≤140/DBP ≤90
7
DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.
5. Kusek JW et al. Control Clin Trials. 1996;16:40S-46S.
1. UKPDS 38. BMJ. 1998;317:703-713.
2. Estacio RO et al. Am J Cardiol. 1998;82:9R-14R. 6. Lewis EJ et al. N Engl J Med. 2001;345:851-860.
3. Lazarus JM et al. Hypertension. 1997;29:641-650. 7. ALLHAT. JAMA. 2002;288:2998-3007.
4. Hansson L et al. Lancet. 1998;351:1755-1762.
18
19. N98-269 PCP Kit
Benefits of Combination Therapy
• Combinations of low-dose agents from different classes have
been shown:
– to provide additional antihypertensive efficacy1,2
– to minimize the likelihood of dose-dependent adverse
events2,3
• Patient adherence is better with once-daily dosing2
1. Dollery CT. Ann Rev Pharmacol Toxicol. 1977;17:311-323. JNC VI. Arch Intern Med.
1997;157:2413-2446.
3. Skolnik NS et al. Am Fam Physician. 2000;61:3049-3056.
Antihypertensive Drug Classes
• Diuretics
• Adrenergic inhibitors (β-blockers, α-blockers, central
α-agonists, combined α-β blockers, peripheral agents)
• Direct vasodilators
• CCBs (dihydropyridines, nondihydropyridines)
• ACE inhibitors
• Angiotensin II receptor antagonists
• Drug combinations
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. November 1997. NIH publication 98-4080.
19
20. N98-269 PCP Kit
Diuretics
• Well studied: Class of agents for HTN (SHEP, ALLHAT etc), useful
in CHF
• Low acquisition cost
• Proven Mortality benefit (HTN) (SHEP Study)
• MOA:Decrease PVR in the long term
• Monitor for: Hypokalemia, hyperuracemia, hyperglycemia,
hypercalcemia, Lipids, gynecomastia (spirionlactone) etc.
• Which Agent?
•
ClCr > 30 ml/min thiazide (all probably work equally well)
•
ClCr < 30 ml/min loop diuretics or combination
Diuretics in Patients With Hypertension
Advantages
Disadvantages
• Clinical trials showed decr. in • Require monitoring for adverse
effects on serum
cardiovascular morbidity and
potassium/glucose/lipids
mortality
• Efficacious in white and
African American patients
• Cost-effective
•
In high doses, incr. risk for
hyperglycemia/other metabolic
abnormalities
GFR= glomerular filtration rate.
20
21. N98-269 PCP Kit
β -Blockers for Hypertension
•
Mechanism: reduce cardiac work by negative inotropic, negative
chronotropic and hypotensive (central and renin blocking) effects
•
Pharmacologic Issues: High first pass, modest half-life, variable
protein binding, cardioselectivity (dose dependent), intrinsic
sympathomimetic activity, alpha-blockade
•
Monitor: SE’s are extension of pharmacologic effects, bradycardia,
hypotension, CHF, depression, abrupt withdrawal, impotence,
diabetes (Signs and Symptoms) lipid effects (decrease HDL, incr.
trigs), reactive airway disease
•
Outcomes: Several studies on outcomes in the area of Hypertension
with/without diuretics or other agents (STOP-hypertension) and with
post AMI, in CHF etc.
Beta Blocking Agents
Non-Selective
Selective*
With
Alpha-Blocking
Activity
- ISA
+ ISA
Nadolol
Pindolol
Propranolol Carteolol
Timolol
Penbutolol
- ISA
Atenolol
Metoprolol
Esmolol
Betaxolol
Bisoprolol
+ ISA
Acebutolol Labetalol
Carvedilol
*Beta-1
Cardioselective
21
22. N98-269 PCP Kit
β-Blockers in Patients With Hypertension
Advantages
Disadvantages
• Clinical trials have showed
cardiovascular morbidity and
mortality reductions in nonelderly
•
Insulin sensitivity; may lead to
glucose intolerance masking
signs/symptoms of hypoglycemia
•
Non-ISA b-blockers incr.
triglycerides
•
Contraindicated in patients with
asthma, COPD, or 2°/3° heart
block’
• Non-ISA b-blockers risk of reinfarction/sudden death in
post-MI patients has been
demonstrated to be reduced
•
Meta-analysis: Lindholm Lancet
2005;345:1545-53 comparing betablockers with other
hypertensives: Risk of stroke was
16% higher than other
antihypertensives (sign)
National High Blood Pressure Education Program Working Group. Hypertension.
1994;23:275-285.
Meta-analysis: Diuretics and
β-Blockers in Older Patients
Outcome
First Drug
No. of
Trials
Cerebrovascular Events
Diuretics
8
β-Blockers
2
Stroke Mortality
Diuretics
7
β-Blockers
2
Coronary Heart Disease
Diuretics
8
β-Blockers
2
Cardiovascular Mortality
Diuretics
7
β-Blockers
2
All-Cause Mortality
Diuretics
7
β-Blockers
2
Active
Control Events/
Treatment Events/
No. of
No. of Patients
Patients
222/5876
79/1521
412/6661
178/2678
69/5838
25/1521
122/6618
57/2678
365/5876
115/1521
531/6661
197/2678
332/5838
130/1521
510/6618
230/2678
681/5838
227/1521
Odds Ratio and
95% CI
907/6618
384/2678
Messerli et al. JAMA. 1998;279:1903-1907.
0.4
0.6
0.8
1.0
1.2
1.4
22
23. N98-269 PCP Kit
CCBA’s for Hypertension
• Mechanism: reduce cardiac work by negative chronotropic,
negative inotropic and systemic (as well as coronary)
vasodilation
• Pharmacologic Issues: relative effects on conduction system,
negative inotropism, vasodilatation
• Monitor: EKG intervals, HR, BP, PK-PD interactions with
drugs
• Issues: Edema with higher doses of Dihydropyridines,
CYP3A4 inhibition of verapamil/diltiazem?
• Outcomes: Several studies (Syst-EUR, Syst-China, HOT,
ASCOT-BPL) favoring CCBAs of dihydropyridine type over
placebo for ISH, however others (AASK, IDNT may call to
question benefits in specific patient populations)
Calcium Channel Blockers
in Patients With Hypertension
Advantages
Disadvantages
• Clinical trials with long-acting
DHP CCB showed reduced CV
morbidity/mortality in ISH
• Cardiac conduction
abnormalities more common
with non-DHP CCBs
• Antianginal efficacy
(long-acting CCBs)
• Non-DHP CCBs may have
negative effect in heart failure
• Useful in pts with contraindications • Short-acting CCBs should not
be used in hypertension
(COPD, gout) to other drug classes
• DHP (and sometimes all) CCBs
• Effective in white and African
in higher doses may likely cause
American patients
edema
• ALLHAT- Amolodipine had similar
primary outcome to Chlorthalidone ALLHAT –Amlodipine had more
CHF than Chlorthalidone
and superior to beta-blockers and
diuretics? (ASCOT-BPL)
Staessen et al. Lancet. 1997;350:757-764. National High Blood Pressure Education Program Working
Group. Hypertension. 1994;23:275-285. McMurray and Murdoch. Lancet. 1997;349:585-586.ALLHAT:
JAMA 2002;288:2981-2997
23
24. N98-269 PCP Kit
CCBA’S Chemical Classification
• Benzothiazepines
– Diltiazem (Cardizem™, Dilacor™, Tiazac™ , Others)
• Phenylalkylamines
– Verapamil (Calan™, Isoptin™, Covera-HS™, others)
• Dihydropyridines
– Nifedipine (Procardia™, Adalat™)
– Nicardipine (Cardene™) Felodipine (Plendil™)
– Isradipine (DynaCirc™)
Nimodipine (Nimotop™)
– Amlodipine (Norvasc™)
Bepridil (Vascor™)
– Nisoldipine (Sular™)
ACE Inhibitors in Patients
With Hypertension
Advantages
Disadvantages
• Preferred in hypertensive
patients with
• Cough, especially in
women and elderly
– Heart failure due to
systolic dysfunction
– Diabetes (1+2?)+
proteinuria (see notes)
• Hyperkalemia, rash,
reversible acute renal
failure relatively
infrequent
• Useful after MI with low
ejection fraction
• Decr. efficacy in older
African Americans
24
25. N98-269 PCP Kit
ACE Inhibitors
Practical Notes:
- Initiate with small doses
- continue for > 2-4 wks before assessing benefit
- may take 3-6 months before max. benefit (CHF)
but 1-2 months for HTN
SE's – Hypotension (monitor BP)
- Renal Insufficiency (monitor Scr)
- Potassium retention (monitor K)
- Cough
Contraindicated with RAS, angioedema
Conclusions:
- ACE I's represent a significant opportunity for
CHF, post-AMI, diabetic nephropathy and HTN
ACE Inhibitors
Non-renin
ANGIOTENSINOGEN
Renin
Angiotensin I
Bradykinin
ACE
Non-ACE
ANGIOTENSIN II
ACEI
AT1
AT2
Inactive
peptides
ATn
25
27. N98-269 PCP Kit
Classification of Angiotensin II Receptors
AT1
AT2
Sensitive to blockade by:
Losartan, Valsartan, etc.
Sensitive to blockade by:
CGP 42112A, PD123177
•Vasoconstriction
•Vasodilation
•Aldosterone
•Antiproliferation
Release
•Cardiac Inotropic Effect
•Vasopressin Release
•Increase SNS Activity
•Decrease Renin Release
•Renal Na+ & H2O Reabsorption
•Cell Growth & Proliferation
•Apoptosis
•Bradykinin
•Nitric
Release
Oxide Release
Angiotensin II Receptor Blockers
Drug
% Bioavailable
Effect of
Food
T½
(hrs)
Protein
Bound
Cozaar®
33
No
2
99%
-
9
99%
Valsartan
Diovan®
25
50%
6
95%
Irbesartan
Avapro®
60
No
15
90%
Candesartan
Atacand®
40
No
-
-
-
9
99%
Losartan
Brand
Name
(Metabolite E-3174)
-
(Metabolite CV-11974)
Telisartan
Micardis®
50
20%
13
99%
Eprosartan
Teveten®
13
25%
9
98%
27
28. N98-269 PCP Kit
Angiotensin II Receptor Blockers
Drug
Losartan
Brand
Name
% Bioavailable
Effect of
Food
Cozaar®
No
50%↓
T1/2 Protei
(hrs)
n
Bound
2
99%
9
99%
6
95%
Valsartan
Diovan®
33
25
Irbesartan
Avapro®
60
No
15
90%
Candesartan
Atacand®
No
20%↓
9
13
99%
99%
25%↓
9
98%
(Metabolite E-3174)
Telmisartan
Micardis®
40
50
Eprosartan
Teveten®
13
(Metabolite CV-11974)
Angiotensin II Receptor Blockers (ARBs)
• Losartan (Cozaar® Merck, 25 + 50 mg tabs qd-bid)
• Valsartan (Diovan®,Novartis, 80 and 160 mg caps qd)
• Irbesartan (Avapro® BMS, 150-300mg/d tabs qd)
• Telmisartan (Micardis® Boehring Ing, Glaxo Welcome, 20-80mg tabs qd )
• Candesartan (Atacand ®,Astra Merck, 4, 8,16,32mg tabs (qd-bid))
• All of available agents are approved for hypertension
– Hyzaar® is losartan 50 mg/HCT 12.5 mg tablet
– Diovan HCT ® is valsartan + HCT 80/12.5 or 160/12.5 capsules
– Avilide ® is irbesartan + HCT 12.5 or 25mg tablets
28
29. N98-269 PCP Kit
Angiotensin II Receptor Blockers (ARBs)
•
Similar anti-HTN efficacy to ACE inhibitors and atenolol
(perhaps less SE’s and D/C rates)
•
Advantages may be in reduced incidence of cough and
angioedema (vs. ACE inhibitors) although angioedema has
been reported
•
Apparently no effects on lipids, fasting glucose although
have a significant uricosuric effect
•
Hyperkalemia can occur to comparable level as with ACE
inhibitors
Angiotensin II Receptor Blockers in Patients
With Hypertension
Advantages
Disadvantages
• Decr. incidence of cough vs.
ACE inhibitors
• Limited data on long-term
efficacy/safety in clinical
practice
• Alternative for ACE intolerant
patients
• Sign. Uricosuric effect
• Benefits in Type 2 Diabetics
• Benefit in CHF patients
(CHARM)
• Questions remain about
efficacy vs ACE’s in heart
failure (ELITE II, Val-HeFT,
CHARM)
• Similar to ACE inhibitors wrt
K+ sparing
29
30. N98-269 PCP Kit
Cough: ARBs vs Enalapril
Percent of patients experiencing cough
16
16
15.1*
16
12
8
4
2.5
0
Patients (%)
Patients (%)
Patients (%)
13.1*
12
8
4
3.0
8
4.3
4
0.7
0
Enalapril Irbesartan
n = 61
n = 121
12
0
Enalapril Losartan
n = 199 n = 200
Enalapril Valsartan
n = 60
n = 137
Tikikanen I, et al.
J Hypertens. 1995;13:1343.
Holwerda NJ, et al.
J Hypertens. 1996;14:1147.
* P < .01
Larochelle P, et al. Am J Hypertens.
1997;10:131A.
Irbesartan Safety Profile: Comparable to
Placebo
Selected adverse events often associated with antihypertensive therapy
occurring in more than 1% of patients in placebo-controlled trials
20
Patients (%)
16.7
15
Placebo (n = 641)
Irbesartan (n = 1,965)
12.3
10
6.6 6.6
5
5.0 4.9
2.7 2.8
2.8
2.1
2.3
1.5
0
Headache Musculo- Dizziness
skeletal
Data on file.
pain
Cough
Nausea/
vomiting
Edema
30
31. N98-269 PCP Kit
α1-Blockers in Patients
With Hypertension
•
Agents: Doxazosin (Cardura®), Prazosin (Minipress®), Terazosin (Hytrin®), Tamsulosin
(Flomax®)
•
Advantages
•
Useful in patients with dyslipidemia: neutral or beneficial effect on lipids
•
Useful in patients with hypertension and benign prostatic hypertrophy
•
Disadvantages
•
Can produce 1st dose syncope
•
Common SEs (5-20%): Dizziness, headache, lethargy, palpitations
•
Orthostatic hypotension can occur
•
Early termination of doxazocin arm of ALLHAT due to negative outcome (higher HF,
stroke, CVD risk) of doxazocin vs. chlorthalidone (JAMA 2000:283;1967-75)
α-Blockers in Patients
With Hypertension
Agents: Doxazosin (Cardura®), Prazosin (Minipress®), Terazosin (Hytrin®), Tamsulosin
(Flomax®)
Advantages
Disadvantages
• Useful in patients with
dyslipidemia: neutral or
beneficial effect on lipids
• Common SEs (5-20%): Dizziness,
headache, lethargy, palpitations
• Useful in patients with
hypertension and benign
prostatic hypertrophy
• Orthostatic hypotension can occur
• Can produce 1st dose syncope
• Doxazocin appears inferior compared
to chlorthalidone (ALLHAT) Early
termination of doxazocin arm of
ALLHAT (JAMA 2000:283;1967-75)
.
31
32. N98-269 PCP Kit
Centrally acting α2-Agonists in Patients
With Hypertension
•
Agents: Clonidine (Catapress®), Guanabenz , Guanfacine, Methyldopa (Aldomet®)
•
Advantages
–
Clonidine has a very quick onset and useful for hypertensive urgencies
–
Clonidine also has a patch form that is applied once a week improving adherence to therapy for
select patients
–
Methyldopa is a useful antihypertensive during pregnancy
•
Disadvantages
–
Many frequent (5-40%) SEs limit the use of these agents (e.g. Dry mouth, drowsiness,
dizziness, constipation, weakness, nausea & vomiting, agitation, orthostatic
hypotension)
–
Abrupt withdrawal of therapy results in a rapid (24-48hr) rebound hypertension
Peripherally Acting Adrenergic Blockers
•
Agents: Guanadrel, Guanethidine, Reserpine
•
Advantages
•
•
Reserpine is generally well tolerated at low doses
Low Cost
Disadvantages
•
Common SEs (5-40%) for Guanadrel, Guanethidine : significant
orthostatic hypotension, syncope, diarrhea, drowsiness, fatigue,
decreased ejaculation, peripheral edema, nasal stuffiness, cough,
palpitations, SOB, leg cramps
•
Reserpine SEs: Nasal congestion, activation of PUD Avoid in
PUD patients. Dose related depression Avoid in patients with
depression history
32
33. N98-269 PCP Kit
Direct Vasodilators
•
Agents: Hydralazine, Minoxidil
•
Advantages
–
Both are potent vasodilators
–
Hydralazine IV is a safe choice for eclampsia
–
Minoxidil could be added to a regimen in case of a resistant
hypertension
•
Disadvantages
–
Minoxidil SEs: Hirsutism, transient ECG (T wave) changes
–
Hydralazine common SEs: Headache, nausea / vomiting, diarrhea,
–
Reflex tachycardia and RAAS activation for both
Combination Drug Therapy
Rational for the use of combination agents:
1. Maximize antihypertensive efficacy
utilizing different pharmacologic agents
block opposing actions of each entity
2. Minimize side effects
block the predictable side effects from the single entity buy
using dual therapy
3. Rarely cost more than individual agents (reduces co-pay)
4. Improves compliance (less # of drugs to take)
33
34. N98-269 PCP Kit
Summary by Drug Class
• Diuretics:
- Supported by JNC 7 and evidence (SHEP, STOP-HTN ALLHAT etc.)
• Beta-Blockers
- Supported by JNC VI and evidence (SHEP, STOP-HTN etc.)
- Supported by evidence of co-morbidities (AMI, CHF)
• ACE Inhibitors:
- Supported by ADA Guidelines (general for Diabetics) and Evidence
(HOPE, AASK)
• Calcium Channel Blockers
- Supported by Evidence (Syst-Eur, Syst- China, ASCOT-BPL)
• ARBs:
- Supported by guidelines (ADA for type 2 diabetics with
microalbuminuria-IDNT, IRMA 2, RENAAL), Alternative to ACE inhibitors
for CHF (if intolerant to ACE I’s, some comparative HTN data with bblockers-LIFE)
• Others:
- alpha blockers (not for HTN only- ALLHAT)
Essentials of Hypertension:
Summary
• Fundamental basis for aggressive management of blood
pressure is established
• Guidelines for selection of drug classes must be considered as
guide for most patients
• Special populations (eg. Diabetics) may require specific
approaches with multiple drugs
• Too many patients are less than optimally managed for
hypertension and other risk factors for CVD
34