1 billion people worldwide have high blood pressure, and this number is expected to increase to 1.56 billion people by the year 2025 Lets gear up to take on this future opportunity by offering Range of brands benefitting the patients Suffering from Hypertension

1. .
1 billion people worldwide have high blood pressure,
and this number is expected to increase to 1.56 billion
people by the year 2025
1out of every 4adults
Will be afflicted with hypertension

2. .
Lets gear up to take on this future opportunity by
offering
Range of brands benefitting the patients
Suffering from
Hypertension

3. .
Introducing

4. Anatomy of Heart

5.  Right and left atrium are the two
collecting chambers of the heart.
 Superior vena cava collects the blood
from head & upper extremities.
 Inferior vena cava collects the blood from
abdomen & lower extremities.
 Both the superior and inferior vena cava
will pour the deoxygenated blood to the
right atrium
 Aorta will supply the oxygenated blood to
all parts of the body.
Systemic Circulation

6.  The pulmonary circulation carries this
spent blood from the heart to the lungs.
 In the lungs, the blood releases its
carbon dioxide and gets oxygenated.
 This oxygenated blood then returns to
the heart before being transferred to the
systemic circulation.
Pulmonary Circulation

7. Blood Pressure
• Accurate Blood Pressure Measurement is the first step in treating
hypertension or high blood pressure.
• 30% done inaccurately
• Primary factor in 68% of heart attacks and 75% of strokes.
• Hypertension is one of the major modifiable risk factors for many
cardiovascular diseases

8.  Blood Pressure- measurement of the force exerted by blood against the
walls of the arteries
 Systolic blood pressure- the pressure in the large arteries when the heart
is contracted
 Diastolic Blood pressure- the pressure in the large arteries when the heart
is relaxed
 Hypertension- PERSISTENT elevation of either diastolic or systolic blood
pressure or both.
 Essential (primary) hypertension- high blood pressure with no identifiable
cause
 Secondary hypertension- high blood pressure with a known cause
Blood Pressure & Hypertension

9. Hypertension (HTN)
• High blood Pressure (BP)
– Systolic pressure > 140 mm Hg
– Diastolic pressure > 90 mm Hg
• Classification of Hypertension
– Primary
– Secondary

10. Pathophysiology of High BP
• Blood pressure – is the force of blood exerted on arteries as it
flows through them
Classification of BP Systolic Diastolic
(mm Hg) (mm Hg)
Normal <120 <80
Pre-hypertension 120-139 80-89
Stage 1 Hypertension 140-159 90-99
Stage 2 Hypertension >160 >100

11. Blood Pressure Control Mechanism
Blood Pressure
1. Depends on:
- Cardiac Output
- Contractility
- Fluid Volume
- Peripheral vascular resistance
2. Is affected by:
- Nervous system
- Kidney function
- Hormonal changes
- Capillary fluid shift

12. Causes of Hypertension
• Aging
• Smoking
• Obesity
• High sodium (salt) diet
• High cholesterol
• Lack of exercise
• Drinking
• Being insulin resistant

13. Risk Factors of HTN
• Smoking
• Age
– Women older than 65 years of age
– Men older than 55 years of age
• Obesity
• Diabetes
• Lack of Physical activity
• Chronic alcohol consumption
• Family history of cardiovascular disease
• Sex – men and postmenopausal women

14. Symptoms of Hypertension
• Prehypertension and Stage 1 HTN
– Usually none
• Stage 2 HTN
– If occurs rapidly – symptoms of Hypertensive Crisis
• Headache
• Visual disturbances
• Nausea & vomiting

15. Diagnosis of Hypertension
 Usually by routine doctor’s visit
 One high BP reading does not mean you have HTN
 Repeated BP reading to be done
 Complete physical, medical and family history will be performed
 Risk factors identified

16. Treatment of Hypertension
There are following steps in treating Hypertension
1. Lifestyle modification
2. First line treatment
3. Second line treatment
4. Third line treatment

17. Lifestyle Modification
• Weight reduction
• Reduction of sodium intake
• Decrease of alcohol intake
• Smoking cessation
• Increase in physical activity
• If inadequate, continue to first line treatment

18. First Line Treatment
• Continue with lifestyle modification
• Initial drug selection:
– Diuretic
– Beta-blocker
– If inadequate, continue to second line treatment

19. Second Line Treatment
• Adding drugs from the following categories
– Angiotensine Converting Enzyme (ACE) Inhibitor
– Calcium Channel Blocker
– Angiotensine II Receptor Blocker (ARB)
– α- blocker, α- and β-blocker
– If inadequate, continue to third line treatment

20. Third Line Treatment
• Increase drug dose, or
• Substitute another drug, or
• Add a second drug from another class
• If inadequate, may need to do further studies
• Serious organ damage may be present

21.  Coronary artery disease (CAD), due to arteriosclerosis &
atherosclerosis of the coronary artery. This is manifested as angina
and myocardial infarction.
 Left ventricular hypertrophy.
 Nephropathy-proteinurea, renal insufficiency & kidney failure.
 Congestive heart failure.
 Stroke.
 Retinopathy.
Complications of Hypertension

22. Coronary Artery Disease
A narrowing of the small blood vessels that supply blood
and oxygen to the heart

23. Ischemia refers to LESS OXYGEN SUPPLY OR DEMAND OF OXYGEN.
Ischemia

24.  Chest pain usually caused by lack
of oxygen from restricted blood flow
to the heart (cardiac ischemia).
 Pain may also spread to the neck,
jaw, or arm. It is the primary
symptom of CAD.
Angina Pectoris

25.  Myocardial infarction (MI) means
that part of the heart muscle
suddenly loses it's blood supply.
 Without prompt treatment, this
can lead to damage to the
affected part of the heart.
 An MI is sometimes called a
heart attack or a coronary
thrombosis.
Myocardial Infarction

26. Left Ventricular Hypertrophy

27. Nephropathy
Damage to or disease of the kidney

28.  Congestive heart failure (CHF), in its
most strict sense, defines the
inability of the heart to deliver
adequate amounts of blood, nutrients
and oxygen to the body. Symptoms
of CHF include shortness of breath
and fatigue.
Congestive Heart Failure

29. Stroke
• Rapidly developing loss of brain function(s)
due to disturbance in the blood supply to the
brain.
• This can be due to ischemia (lack of blood
flow) caused by blockage (thrombosis, arterial
embolism), or a hemorrhage (leakage of
blood).
• The affected area of the brain is unable to
function, leading to inability to move one or
more limbs on one side of the body, inability to
understand or formulate speech, or an inability
to see one side of the visual field

30. Retinopathy
Non-inflammatory damage to the retina of the eye.
Frequently, retinopathy is an ocular manifestation of systemic disease

31. Hypertension Treatment

32. Drugs Used to Treat HTN
 Diuretics
Furosemide , Hydrochlorothizide
 Beta blockers
Atenolol , Propranolol
 ACE inhibitors
Captopril , Enalapril, Lisinopril
 ARB’s
Irbesartan, Losartan
 Calcium channel blockers
Diltiazem, Nifedipine , Amlodipine

33. Arterial Blood Pressure (BP)
The lateral pressure force generated by the pumping action of the heart
on the wall of aorta & arterial blood vessels per unit area.
OR = Pressure inside big arteries (aorta & big vessels).
• Measured in (mmHg), & sometimes in (cmH2O), where
1 mmHg = 1.36 cmH2O.
• Of 2 components:
Systolic … (= max press reached) = 110-130 mmHg.
Diastolic … (= min press reached) = 70-90 mmHg.
In normal adult  120/80 mmHg.

34. • Diastolic pressure is more important, because diastolic period is
longer than the systolic period in the cardiac cycle.
• Pulse pressure = Systolic BP – Diastolic BP.
• Mean arterial pressure = Diastolic BP + 1/3 Pulse press.

35. Factors affecting ABP
• Sex … M > F …due to hormones/ equal at menopause.
• Age … Elderly > children …due to atherosclerosis.
• Emotions … due to secretion of adrenaline & nor-adrenaline.
• Exercise … due to  venous return.
• Hormones … (e.g. Adrenaline, noradrenaline, thyroid H).
• Gravity …  Lower limbs > upper limbs.
• Race … Orientals > Westerns … ? dietry factors, or weather.
• Sleep …  due to  venous return.
• Pregnancy … due to  metabolism.

36. Blood Pressure Cardiac Output Total Peripheral
Resistance
l Beta-Blockers
l CCBs*
l Diuretics
l ACE Inhibitors
l ATII type 1 RBs
l CCBs
l Diuretics
l Sympatholytics
l Vasodilators
* = Non-dihydropyridine CCBs
Anti-Hypertensive Drugs : Site of Action

37. CALCIUM CHANNEL BLOCKERS
(Nifedipine 20mg SR)
(Amlodipine 5 mg & 10mg)

38.  Cardiac calcium channels
 L-type calcium channel
 ryanodine (RyR2) calcium channel
 located on the sarcoplasmic reticulum
 Critical for:
 conduction velocity (AV node)
 duration of depolarization
 cardiac muscle contraction
CALCIUM CHANNEL BLOCKERS

39.  Intrinsic ability of cardiac muscle
 Also called ‘Inotropism’ or ‘Inotropy’
 Related to the intracellular [Ca2+]
 Inotropic agents
 Positive: increase contractility
 Negative: decrease contractility
CARDIAC CONTRACTILITY

40.  Increased intracellular [Ca2+]
 Increased heart rate
 Cardiac glycosides (e.g. Digoxin)
 Stimulation of β1-adrenergic receptor
 Sympathomimetic agents
 Catecholamines
FACTORS INCREASING CONTRACTILITY
 Chronotropy
 Rate of contraction
 Also affected by intracellular [Ca2+]
 Dromotropy
 Rate of impulse conduction
 Noted particularly at AV node

41. Calcium channel blockers comprise three chemical groups, all of them bind the L-type
Ca++ channel, but each class binds to different binding sites of the same channel -
Phenilalkylamines
Verapamil is the only drug in this group, it binds to the V binding site.
Benzothiazepines
Diltiazem binds to the D binding site in the L-type Ca++ channel. It shows
cardiovascular effects similar to those of Verapamil.
Dihydropyridines
The prototype agent in this group is Nifedipine, a first generation dihydropyridine
that binds to the N binding site.
Second generation agents include Isradipine, Nicardipine and Felodipine.
Amlodipine is considered a third generation dihydropyridine.
CLASSIFICATION OF CALCIUM CHANNEL BLOCKERS

42. CLASSIFICATION OF CALCIUM CHANNEL BLOCKERS

43. CALCIUM CHANNEL BLOCKERS – MECHANISM OF ACTION
* Total Peripheral Resistance
Drugs: Nifedipine , Amlodipine
Site of Action- Vascular smooth muscle
Mechanism of Action Blocks Ca++ channel
decreases/prevents
contraction
Effect on
Cardiovascular system
Vascular relaxation
Decreased TPR*

44. Calcium channel antagonists block the inward movement of calcium by
binding to the L-type calcium channels in the heart and in smooth
muscle of the peripheral vasculature.
CCB’s dilate coronary arteries and peripheral arterioles, but not veins.
They also decrease cardiac contractility (negative inotropic effect),
automaticity at the SA node and conduction at the AV node.
Dilation of the coronary arteries increases myocardial oxygen supply.
CALCIUM CHANNEL BLOCKERS – MECHANISM OF ACTION

45. Trusted Anti-hypertensive

46. PRODUCT
Nifedipine extended release tablets 20 mg
PACK
10 X 10s

47. MECHANISM OF ACTION
Inhibits calcium ion from entering the “slow channels” or select voltage-
sensitive areas of vascular smooth muscle and myocardium during
depolarization, producing a relaxation of coronary vascular smooth
muscle and coronary vasodilation.
Increases myocardial oxygen delivery in patients with vasospastic
angina
Also reduces peripheral vascular resistance, producing a reduction in
arterial blood pressure.

48. • Prophylaxis and treatment of vasospastic angina
and chronic stable angina,
• Management of hypertension.
INDICATIONS
DOSAGE:
Once a day or as recommended by the Physician
Prescription potential
1Rx = 1 pack

49. STRATEGY :
• Highlight the benefits of Sustained release formulation over plain
nifedipine brands
No. OF DOCTORS SELECTED : 10
TARGET AUDIENCE :
• Consulting Physician
• Cardiologists
• General Practitioners
• Hospital consultants

50. POSITIONING:
Trusted Anti-hypertensive
COMMUNICATION PLATFORM :
• Sustained release formulation produces a gradual increase in plasma Nifedipine
concentration sustained over a 24-hour period and causing a gradual onset of
vasodilatation.
• Inhibits vascular remodeling and improve vascular function by selective activation of
PPAR gamma (peroxisome proliferator-activated receptor)through the activation of
Cu/ZnSOD in hypertension
• Reduces functional arterial stiffness and improves heart rate recovery by altering
the autonomic activity balance in hypertensive patients.

51. PROMOTIONAL INPUTS
• VA - 1 Page
• Print
- Leave behind literature ( Cardiac Range)
• Samples
• 3D Chart on Hypertension
• CME on Anti-hypertensives

53. PRODUCT
Amlodipine 5mg
Amlodipine 10mg
PACK
10 X 10s

54. MECHANISM OF ACTION

55. BENEFITS
• Predictable BP control - 24 hour B.P. reduction after single dose
• Prevent early morning ischemia
• Aids patient compliance
– OD dosing ,Favorable safety profile
– Effective as monotherapy and in combination with diuretics, ACEIs
and beta blockers
– Useful in hypertensive patients of all ages with concomitant
diseases viz. asthma, hyperlipidemia, diabetes, CHD and renal
disease

56. INDICATIONS
DOSAGE:
Hypertension : 5-10mg OD
Elderly, hepatic failure : 2.5mg OD
Prescription potential
1Rx = 1 pack
• Management of Hypertension
• Coronary artery disease in patients with heart failure

57. COMPETITORS
Amlodip (Pharmabase)
Norvasc (Pfizer)
Amaday (Ranbaxy)

58. STRATEGY :
No. OF DOCTORS SELECTED : 10
TARGET AUDIENCE :
• Consulting Physician
• Cardiologists
• General Practitioners
• Hospital consultants
• Position Amlostar as a choice antihypertensive in treating
Hypertension and CAD
•Target existing prescribers of Amlodipine

59. POSITIONING:
Controls Hypertension, Improves lifestyle
COMMUNICATION PLATFORM :
• Long-acting, vasoselective calcium antagonist .
• Once-daily treatment with Amlostar in the dose range of 5 to 10 mg is
effective in improving exercise capacity and reducing anginal attack rate in
patients with chronic stable angina pectoris and also those with
vasospastic angina.
• Effective and well tolerated in controlling hypertension in the elderly
population

60. Calcium Channel Blockers Vs Beta blocker & Diuretics
Calcium channel blockers are associated with fewer strokes as compared
with beta-blockers or diuretics.

61. PROMOTIONAL INPUTS
• VA - 2 Pages
• Print
- Leave behind literature ( Cardiac Range)
• Samples
• 3D Chart on Hypertension
• CME on Anti-hypertensives

63. ACE Inhibitors
Angiotensin I
ACE
Angiotensin II
1. Potent vasoconstrictor
- increases BP
2. Stimulates Aldosterone
- Na+ & H2O reabsorbtion
RAAS

64. Renin-Angiotensin Aldosterone System
• Angiotensin II = vasoconstrictor
• Constricts blood vessels & increases BP
• Increases SVR or after load
• ACE-I blocks these effects decreasing SVR & after load

65. ACE Inhibitors
• Aldosterone secreted from adrenal glands cause sodium & water
reabsorption
• Increase blood volume
• Increase preload
• ACE-I blocks this and decreases preload

66. • Incompletely absorbed from GI tract.
• Protein binding is 25%
• Primarily excreted unchanged in urine.
• Half life is 12 hours
PHARMACOKINETICS

67. PRODUCT
PACK
10 X 10 s
Lisinopril 5mg
Lisinopril 10mg

68. MECHANISM OF ACTION
• Suppresses the renin-angiotensin-aldosterone system and prevents
conversion of angiotensin 1 to angiotensin II a potent
vasoconstrictor
• Decreases plasma angiotensin II ,increases plasma renin activity
and decreases aldosterone secretion.
• Reduces peripheral arterial resistance ,BP, afterload,preload.
• In heart failure patients, increases cardiac output and exercise
tolerance time.

69. INDICATIONS
DOSAGE:
Hypertension
Adults : 10mg /day
Elderly: 2.5 to 5mg /day
Heart Failure
2.5 to 5mg /day
Post MI
2.5 to 5mg /day
PRESCRIPTION POTENTIAL
1 Rx = 1 Pack
• Treatment of Hypertension
• Congestive heart failure
• Acute myocardial infarction
• Hypertensive diabetic patients

70. COMPETITORS (Prices and Packs to be added)
Ranopril (Ranbaxy)
Gapril (Pharmabase)
Lisioril (Ipca)

71. STRATEGY :
No. OF DOCTORS SELECTED : 10
TARGET AUDIENCE :
• Consulting Physician
• Cardiologists
• General Practitioners
• Hospital consultants
• Establish recall for Stripril
• Target top selling Lisinopril brands

72. POSITIONING:
For Effective BP control
COMMUNICATION PLATFORM :
• Names change ..Essence remains. Hipril – Trusted anti-hypertensive is now
Stripril.
• Early treatment with Stripril (within 24 hours of symptom onset) for 6 weeks
improves survival and reduces cardiovascular morbidity in patients with
myocardial infarction, and confers ongoing benefit after drug withdrawal.
• Reduces mortality in diabetic patients after myocardial infarction and also
improves neuropathy associated with diabetes.
• Well tolerated by patients

73. Beta blockers might not be tolerated
by persons with asthma, congestive
heart failure, depression or
underlying fatigue
STRIPRIL (ACE inhibitor) Vs Beta blocker
• ACE inhibitors have protective effects for the
kidney in persons with diabetes or in persons
with early kidney damage
• In Congestive heart failure patients, ACE
inhibitors may prolong survival.
• In left ventricular hypertrophy (LVH)
ACE inhibitors may be more effective than
other classes of medications
• ACE inhibitors are the blood pressure medication
of choice in persons with scleroderma, a disease
which can be associated with severe blood
pressure elevation and kidney failure
• ALLHAT Trial (Antihypertensive and Lipid Lowering
Treatment to Prevent Heart Attack)
In Diabetic patients , ACE inhibitors should be
used after diuretics and beta-blockers

74. PROMOTIONAL INPUTS
• VA - 2 Pages
• Print
- Leave behind literature ( Cardiac Range)
• Samples
• 3D Chart on Hypertension
• CME on Anti-hypertensives

85. Lets Spread the benefits to
MORE& MOREPatients …..