nice presentation

2. MEASUREMENT OF BP

6. Learning objectives
• Classification of antihypertensives
• First line drugs + second line drugs
• Treatment of HT- Goal BP,
Which drug for whom?
Combinations
Contraindications
• HT emergency, urgency & in pregnancy

7. Classification
First line
ACEI / ARBs
CCB
Diuretics
Second line
α, β blockers
Both α& β
blockers
Central
sympatholytics
Dilators

8. • Captopril Enalapril
• Lisinopril Perindopril
• Ramipril Fosinopril
ACE inhibitors
• Losartan Candesartan
• Irbesartan Valsartan
• Telmisartan
ARBs
• Verapamil, Diltiazem,
• Nifedipine, Felodipine, Amlodipine,
Nitrendipine, etc
Calcium channel
blockers
• Propranalol, atenolol, metoprolol
β blockers
• Thiazide : Hydrochlorothiazide, Indapamide
Chlorthalidone
• Loop Diuretics : Furosemide
• K Sparing : Spironolactone; Amiloride
Diuretics

9. • Prazosin, Terazosin Doxazosin Phentolamine
Phenoxybenzamine
 Adrenergic
blockers
• Labetalol,Carvedilol
β +  Adrenergic
blocker
• Clonidine, Methyldopa
Central
Sympatholytics
• Arteriolar: Hydralazine, Minoxidil, Diazoxide
• Arteriolar+Venous: Sodium nitroprusside
Vasodilators

10. ACEI / ARBs
First line
Individually control 50%
With diuretics and β blocker 90%
Low dose diuretic is enough
Improves renal blood flow;
Retard diabetic nephropathy and regress LVH
Use: HT in diabetes, nephropathy,
LVH,CHF &post MI
ARBs are more widely used
Due to lack of allergic side effects.

11. ACE
Angiotensin I
Angiotensin II
Vasoconstriction
Sodium resorption
Aldosterone release
HYPERTENSION
Bradykinin
Inactive
peptides
Increased
Vascular
Permeability
Angioedema
ACEI
MECHANISM OF ACTION
Vasodilation

12. ADVERSE EFFECTS
ACEI
HYPERKALEMIA
ANGIOEDEMA
HYPOTENSION
RASHES
DRY COUGH

14. Cardioselective Betablockers
New Beta blockers Acting Exclusively At MyoCardium
Nebivolol
Betaxolol
Bisoprolol
Acebutolol
Esmolol
Atenolol
Metoprolol
Celiprolol
Vasodilator beta blockers (α +
β)
Labetolol, Carvedilol.
Celiprolol, Nebivolol, Betaxolol

17. Advantage
Low cost
Once daily
No postural
hypotension
No H2O & Salt
retention
Uses
Mild
Not a first line
drug
Post MI –
Prevent sudden
cardiac death.
Young non obese
HT with stable
CHF with ACEI
ADR
Loss of insulin
sensitivity
↑ TG;↓ HDL
↓ work
capacity
Loss of libido
Rebound
hypertension
Less effective in
preventing
stroke and CAD
Vasodilating β blockers –Less metabolic mischief
But expensive

18. α blockers
Prazosin, Terazosin, Doxazosin
MOA
Dilate Resistance &
Capacitance Vessels
TPR -  B.P
Advantages:
BPH – Symptomatic
improvement
Do not affect CHO & lipid
metabolism
ADR: Diarrhoea,
Postural hypotension
1st dose phenomenon
Tachycardia
Impaired ejaculation
Fluid retention (α 1)
Tolerance
Add diuretics
Phenoxybenzamine,
Phentolamine (α1 + α2)
Pheochromocytoma

19. Central sympatholytics

20. Clonidine
Imidazoline
derivative
Selective 2 agonist
 symp outflow
ADR
Sedation; Dry Mouth
Impotence; Bradycardia
Clonidine With Drawal
 BP, HR
USE:Hypertension -Rare
Opioid withdrawal
Analgesic – intrathecal/epidural
Menopausal hot flushes
Diabetic neuropathy for loose stool
Methyldopa
 - CH3 analogue of
DOPA  - methyl NA
 Central 2 agonist
False neurotransmitter
ADR: Like clonidine
Positive Coombs test
USE: Only for PIH

22. Uses
• First line
• Long acting DHP
mainly used –
amlodipine
• Quick acting
• Stroke preventing
potential
• Most useful in
cyclosporine
induced HT
ADR
• Hypotension
Headache
Constipation
Edema Tachycardia
CCF& GERD
Advantages
• Not contraindicated in
asthma,angina,pregnancy
• Do not affect renal
perfusion, physical activity
• Male sexual function.
• Uric acid and electrolyte
level

24. Diuretics
• Mild Na and water deficit ↓t.p.r
• More effective in elderly. Mild & Moderate HT
• Action starts gradually over 2-3 weeks
• Salt intake is increased Action lost
MOA
• Hypokalaemia
• Erectile dysfunction
• Precipitation of diabetes.
• Hyperuricaemia
ADR
• Thiazides- Chlorthlidone& Indapamide. In elderly
• Furosemide. Weaker anti HT (since short acting)
• Combined in CHF, renal failure or with
vasodilators to counteract edema
• Spironolactone with thiazides; Refractory HT
Use

25. Vasodilators
Hydarlazine
K channel opener
Arteriolar dilator
ADR: Flushing Headache
Tachycardia
Fluid retention SLE
Postural hypotension
USE: PIH
HT emergency
CHF
Minoxidil
Similar to
hydralazine
Risk of angina& MI
are high
Not for HT
2% cream for
aloepaecia
Diazoxide:
Rapid iv
HT emergency
Na
Nitroprusside
NO generated by RBC &
endothelial cells
It is different from nitrates.
So no tolerance devlops
Rapid acting only iv
Arterio & veno dilator
iv bottle to be covered by black
paper
Converted to thiocyanate
excreted slowly
ADR: Lactic acidosis; psychosis
Use:HT emergency
CHF Pump failure
Acute MR
All cause reflex tachycardia ,
angina and MI→ β blockers
Fluid retention. → diuretics

26. 1. When to start drugs?
2. How much BP reduction is needed?
Goals Of Therapy

27. Classifying BP by Readings
Blood Pressure Category
Systolic
(mm Hg)
Diastolic
(mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
High: Stage 1 140-159 90-99
High: Stage 2 160 -179 100 -109
Severe
≥180 ≥110

28. Avoid alcohol

29. General population aged 60 years or older
SBP ≥150 mmHg
Or
DBP ≥ 90mmHg
Goal of Treatment
SBP <150 mmHg
OR
DBP of < 90mmHg.
Initiate Treatment at
General population < 60 years, + DM, + CKD
Initiate Treatment at
DBP ≥ 90mmHg
SBP ≥ 140 mmHg
DBP of < 90mmHg.
SBP of < 140 mmHg
Goal of Treatment

30. STEPPED CARE APPROACH
Step 1 <55 yrs ACEI/ARB
>55 CCB or diuretic
Step 2 ACEI/ARB + CCB or diuretic
Step 3 ACEI/ARB + CCB+ Diuretic
Step 4 ACEI/ARB + CCB+ Diuretic +
Aldo antagonist/ ↑ thiazide or
β blocker /α blocker
Vasodilating β
blocker
preferred
Avoid β
blocker &
Diuretic.
↑Diabetes

32. Combination
Rational
↑RAAS
(A,C,D&vasodilators)
&↓RAAS (β blocker
,sympatholytics )
Drugs causing fluid
retention-vasodilators
with diuretics
Vasodilators &β
blocker
Avoided
Sympathetic blocker &
clonidine
Hydralazine & DHP CCB
Methyl dopa & clonidine
Verapamil & β blocker
ACEI & ARB

33. Hypertension in Pregnancy
• BP > 140/ 90 mm Hg
• Labetalol β& α blocker. Widely used
• Nifedipine : To be stopped before labour.
• May weeken utrine contraction
•
• Methyl DOPA : Longest Record. Coombs test + ve
• Hydarlazine Not favoured Now
• CONTRAINDICATED
• ACEI, ARB, Diuretics
• Non selective Beta blockers
• Na nitroprusside in ecclampsia

34. Hypertensive crises
BP > 220/120
Goal: not more than 25% or BP 160/100 mm of Hg
Emergency- End organ damage
Reduce within minutes; parentral drugs
1. Nicardipine
2.Sod. Nitroprusside
3. Nitroglycerin( GTN)
4. Labetalol
5. Esmolol
6. Phentolamine
7.Hydralazine
8. Frusemide
Urgency
In hours
Oral drugs
1.Labetalol
2.Amlodipine
3.Captopril

35. Logical combinations in diseases
CCF
• D ,  Blockers,
• ACE I / ARB, spironolactone
DM -
• ACE I / ARB
BPH -
• 1 Blockers
MIGRA
INE
•  Blockers
ISOLATED
SYSTOLIC
• D & CCB