This document provides an overview of cardiovascular medical training. It begins with an introduction to the cardiovascular system, including the heart, blood vessels, and blood. It then defines blood pressure and discusses blood pressure regulation through the autonomic nervous system, kidneys, and renin-angiotensin-aldosterone system. The document concludes by explaining hypertension and its complications, which can include damage to vessels, the heart, brain, and kidneys. Left uncontrolled, hypertension increases the risk of heart attack, stroke, heart failure, and other conditions.
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A Global Problem
HIGHLY LETHAL 5 yr Survival rate “50%”
More M.I. cases now survive More Incidence of CHF due to damaged myocardium
Better options than before now available to treat CHF
1 billion people worldwide have high blood pressure, and this number is expected to increase to 1.56 billion people by the year 2025
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. 2
Contents
• Introduction
• The Cardiovascular System
• What Is Blood Pressure?
• Primary Systems in Blood Pressure Regulation
• Hypertension and its Complications
3. 3
INTRODUCTION
• This module will provide the background you need to understand the role
of MS Pharma CVS Portfolio in controlling Cardiovascular risk and thus
minimizing the risks of cardiovascular disease.
• Left uncontrolled risks is a substantial contributor to the development of
cardiovascular disease and its associated manifestations, such as Myocardial
Infarction, Angina, Cerebrovascular accident (Stroke) and Congestive heart
failure.
7. Layers of heart:
-Heart lies a protective sac of tissue
called Pericardium
1. Epicardium.
2. Myocardium.
3. Endocardium.
-Septum is separates between
the right & left halves.
Heart
Basic Anatomy Of The Heart
8. Chambers of the heart:
• 2 chambers on the right side.
• 2 chambers on the left side.
Heart valves:
• The atrioventricular valves
(tricuspid,mitral)
• The semilunar valves
(pulmonic, aortic)
Heart
Basic Anatomy Of The Heart
9. SA node:
Heart’s pacemaker coz. It maintains heartbeat.
sends electrical impulses causing atria to contact.
AV node:
Network of muscles in heart wall.
Conducts impulses from atria to ventricles.
Bundle of HIS:
Conducting muscle fibers within the septum.
the impulses travel into left and right bundle branches.
4-Purkinje fibers:
Tiny fibers transmit impulses directly to muscles of ventricle
Heart
Function of the Heart Cardiac Conduction
11. Cardiac Output:
• Amount of blood pumped with each contraction of left ventricle in a minute.
CO = HR X SV
HEART RATE:
• No. of times the ventricles contract each min.
• Normal heartbeat 72/min.
Stroke volume (SV):
• is the amount of blood pumped with each contraction of the ventricle in one contraction.
• SV = EDV − ESV
Ejection fraction (EF)
• is the fraction of blood pumped out of a ventricle with each heartbeat.
• indicator of ventricular function It reflects the vigor of the heart’s pumping action
• Normal EF is approximately 65%
Heart
Function of the Heart
15. Artery Blood vessel carrying
oxygenated blood away from the
heart to body tissues
Arteriole Small artery that branches
into capillaries; the major resistance
vessel of the arterial system
Capillaries The smallest blood
vessels that connect arterioles and
venules; the site of gas exchange in
the tissue
Venule Small vein that leads from
capillaries to larger veins
Vein Blood vessel carrying
Deoxygenated blood
from body tissues
back to the heart
Aorta One of two major arteries
from the heart; exits from left
ventricle and carries blood to the
systemic circulation
Blood Vessels
Structure and function of Blood vessel
18. Is an important vascular regulatory organ and the largest organ in body.
The healthy endothelium maintains CV homeostasis.
Injury of endothelium promote oxidation of LDL >>>>>>> Atherosclerosis.
Blood Vessels
Endothelium
19. Role of the Healthy Endothelium in Cardiovascular Homeostasis:
► Vasoconstriction/Vasodilatation
► Growth promotion/Growth inhibition
► Promotes fibrinolysis
► Inhibits thrombosis
► Mediates inflammatory mechanisms
► Inhibits platelet aggregation
► Influence lipid oxidation
► Regulates vascular permeability
Blood Vessels
Endothelium
21. Vasoconstrictors Released by the Endothelium
Endothelin
Angiotensin II
Thromboxane A2
Blood Vessels
Endothelium-derived Vasoconstrictors
22. The endothelium releases a number of factors that promote vasodilatation.
Vasodilators send a message to the smooth muscle cells of the artery wall to relax, inducing
vasodilatation.
Vasodilators Released by the Endothelium
• Nitric oxide
• Prostacyclin
• Bradykinin
• Endothelium-derived hyperpolarizing factor
Blood Vessels
Endothelium-derived vasodilators
23. The most important vasodilator known and proliferation of smooth muscle >>>>>
prevent hypertrophy &hyperplasia.
Have antithrombotic effect and inhibits >>>>> the development Atherosclerosis.
Stimulating production of nitric oxide, so vasodilatation.
Another vasodilator but less potent than NO.
Blood Vessels
Endothelium-derived vasodilators
29. The therapeutic control of arterial hypertension is still a global
challenge
According to the World Health Organization (WHO) almost 600 million people
worldwide suffer from this disease
Ref. world health organization / international society of hypertension: guidelines for the management of
hypertension (1999). Journal of hypertension 1999; 17 (1): 151-183
Defining blood pressure
Hypertension prevalence
30. 0
5
10
15
20
infectious
disease
CVD cancer Other
Ref peter A Meredith, Henry L Elliott, William B white ; hypertension & related
Disorders 2003 Elsevier, Moby Rapid reference
Cardiovascular disease is the second leading cause of mortality worldwide
Defining blood pressure
Hypertension prevalence
31. 100
50
25
12.5
87.5
Ref. world health organization / international society of hypertension: guidelines for the management of hypertension
(1999). Journal of hypertension 1999; 17 (1): 151-183
WHO worldwide blood pressure control %
Defining blood pressure
Hypertension prevalence
32. Hypertension can be sub-classified into seven categories:
Essential hypertension
Secondary hypertension
Isolated systolic hypertension
Pseudo hypertension
White coat hypertension
Accelerated hypertension
Malignant hypertension
Defining blood pressure
Blood Pressure Subclassification
33. Essential hypertension
• is the most common form of elevated blood pressure and may be defined as an elevation
of arterial BP
Secondary hypertension
• usually defined as persistent Hypertension which can be attributed to a definable
Underlying disorder
Defining blood pressure
Blood Pressure Subclassification
34. White coat hypertension
Some patients exhibit elevated blood pressure when measurements are made in the clinic or
office environment. In contrast, when blood pressure is assessed a way from the clinical
environment, usually by ambulatory recording, pressure is considered to fall within normal range
Defining blood pressure
Blood Pressure Subclassification
35. Pseudo hypertension
When BP measured by cuff is falsely elevated compared to reference standard because of
hardened calcific arterial walls
• Pathophysiology
• arterial calcification as opposed to atherosclerosis/collagen deposition*
• Associations
• Age
• Hypertension
• Atherosclerosis
• Scleroderma
• Prevalence
• 1.7% and 2.5% but poorly studied*
Defining blood pressure
Blood Pressure Subclassification
* Zuschke et al, Pseudohypertension, Southern Medical Journal 1995, 88:1185-90
36. Isolated Systolic Hypertension (ISH)
• Isolated Systolic blood pressure continuous to rise with age because loss of elasticity in the large
Capacitance arteries
• ISH is largely associated with westernized or industrialized populations and is not observed in more
primitive societies
Pulse Pressure
• The difference between SBP and DBP is the pulse pressure.
• It increases slowly from age 50 to 59 and more rapidly thereafter, as SBP increases and DBP
decreases.
• In the elderly, pulse pressure is an independent predictor of cardiovascular disease.
• In the SHEP study, pulse pressure predicted stroke and total mortality more strongly than did SBP
or DBP.
Defining blood pressure
Blood Pressure Subclassification
37. Defining blood pressure
Blood Pressure Subclassification
Accelerated hypertension
• is the terminology applied in severe hypertension with Blood pressure around 200/120
mmHg and above, when Significant target organ damage is present, usually in
Association with advancing renal insufficiency and Fundoscopic hemorrhages, but in
the absence of Papilloedema or a medical emergency
Malignant hypertension
may be defined as severe hypertension in association With one or more of the
following:
• Papilloedema
• Pulmonary oedema
38. Circadian Rhythm
Blood pressure fluctuates according to a predictable pattern during the day. Blood pressure
is usually lower at night, but in the early morning hours, it rises along with pulse rate.
Defining blood pressure
Circadian Rhythm
41. The autonomic nervous system itself is divided into two components:
The sympathetic nervous system:
▪ Thereby increasing total peripheral resistance.
▪ It also markedly increases the activity of the heart, both increasing
▪ The heart rate and enhancing the strength of pumping.
The parasympathetic nervous system:
▪ Conversely, stimulation of the parasympathetic (vagus) nerves which reduce heart rate and
slightly decrease heart muscle contractility, thereby reducing CO and blood pressure.
Primary System in Blood Pressure Regulation
Vasomotor center
42. Primary System in Blood Pressure Regulation
The Autonomic Nervous System
43. Baroreceptors (or baroceptors):
• In the human body detect the pressure of blood flowing
through them and can send messages to the central
nervous system to increase or decrease total
peripheral resistance and cardiac output.
• Baroreceptors can be divided into two categories:
a. high pressure arterial Baroreceptors
b. low pressure Baroreceptors (also
c. known as cardiopulmonary receptors).
Nervous System in Blood Pressure Regulation
Baroreceptors
46. The kidneys maintain homeostasis by regulating the balance between excretion
and intake of water and electrolytes.
The kidneys perform their excretory function by constantly filtering large
quantities of blood and removing substances at varying rates, depending on the
needs of the body.
The Kidneys in Blood Pressure Regulation
Role of Kidneys in Homeostasis
47. Glomerular filtration rate:
• The rate of excretion of substances from the kidneys.
• regulate the fluid volume.
• The major function of this AuToReGuLaTiOn in the kidneys is to maintain
a relatively constant GFR and allow control of renal excretion of water and
solutes.
The Kidneys in Blood Pressure Regulation
GFR and Auto regulation
48. The long-term regulation of BP (dominant role):
The primary mechanism by which the kidneys influence long term control of blood
pressure is by regulating the fluid volume of the body.
• Pressure diuresis.
• Pressure natriuresis
The short-term regulation of BP:
via the production of vasoactive substances or substances such as Renin
The Kidneys in Blood Pressure Regulation
The role of kidneys in Blood Pressure
49. If blood pressure does become elevated and remains persistently elevated, the
kidneys are adversely affected. (hypertensive nephrosclerosis)
Hypertension + diabetes
is a particularly damaging combination for the kidneys. An early sign of kidney
damage related to hypertension and/or diabetes is microalbuminuria, Proteinuria, or
the presence of excess protein in urine, indicates the presence of renal damage or
disease.
The Kidneys in Blood Pressure Regulation
The role of kidneys in Blood Pressure
51. 51
Angiotensinogen
(syn. By liver)
AI AII
Renin
arteries
kidneys
adrenal glands
vasoconstriction
Na+ Na+
Cough,
Angioedema
Aldosterone
Bradykinin Inactive
Fragments
ARBs
The Renin-Angiotensin-Aldosterone System
52. AT1
• Vasoconstriction
• ↑ Cell growth (Vascular and myocardial
hypertrophy)
• Increase Na and water reabsorption
• Increase intraglomerular pressure
• Positive Inotropic & chronotropic effect
• Arrhythmogenic effect
AT2
• Potent vasodilatation
• Increase renal blood flow
• Increase sodium and
water excretion
• Inh. Of cell growth.
AT3
• unknown.
AT4
• act as a renal
vasodilator &
stimulates
plasminogen
activator
inhibitor-1.
The Renin-Angiotensin-Aldosterone System
53. The circulating RAAS exerts acute (short-term) control of BP.
The local RAAS exerts long-term effects on BP.
The long-term effects of the tissue RAAS may contribute to path physiological condition.
Blood vessels
• vascular hypertrophy which
makes Hypertension.
• Thrombus which makes
Atherosclerosis.
Heart
• increase force of contraction
make heart failure.
• Ventricular hypertrophy
makes Arrhythmias.
• Vasoconstriction of coronary
make Angina + MI.
Kidney
• Intraglomerular hypertension
make Proteinuria.
• Glomerular hypertrophy
makes Nephropathy.
The Renin-Angiotensin-Aldosterone System
Circulating RAAS &Tissue RAAS
58. Types of hypertension
Primary hypertension
Secondary hypertension
Role of regulatory system
Sympathetic nervous system
The RAAS
Angiotensin II receptors
61. PVR
In lumen due to wall thickness
or vasoconstriction
Change structure
Vascular Hypertrophy
( in the size of vascular smooth
muscle)
Pressure-related consequences of hypertension
Vascular hypertrophy and remodeling
65. 65
Pressure-related consequences of hypertension
Cardiovascular continuum*
*Adapted from Dzau V, Braunwald E. Am Heart J. 1991;121:1244-1263.
66. OXIDATION
INGESTED ! CHOLESTROL-
RICH OXIDIZED LDL
DIE
LARGE LIPID CORE
COVERED BY A THIN
FIBROUS .
rupture
Adhere to site
of trauma
Pressure-related consequences of hypertension
Atherosclerosis
69. 69
Weber M.A. et al., Rev Cardiovasc Med 2004
Correlation with CV events
Pressure-related consequences of hypertension
The circadian pattern of BP
70. Severe ischemia more than 20 min, commonly known as a heart attack.
If more than 30 min. damage to myocardial tissue can result.
Symptoms:
Burning, aching or pressure in ! Center of ! Chest .
Also pain or aching in the jaw or neck.
Pressure-related consequences of hypertension
Myocardial Infraction
Angina:
chest discomfort association with myocardial ischemia.
Symptoms are tightness or fullness which may radiated to Neck, shoulder
or left arm.
Classified to:
Stable angina.
Unstable angina.
72. HF is the inability of the Heart, specifically the Left ventricle to pump blood
into the Circulation.
CHF(congestive heart failure):
When heart is pump blood into ! Aorta as fast as ! Venous system.
Returns blood from ! Lung, the pressure Backs up into ! lung & other
tissues causing SWELLING or EDEMA.
Pressure-related consequences of hypertension
Heart Failure
73. ❑ Shortness of breath (dyspnea).
❑ Angina, Fatigue and fluid buildup (Edema).
❑ NYHA (the New York Heart Association):
Pressure-related consequences of hypertension
Heart Failure; Assessment of HF status
74. Ischemia can alter ! Electrical function of ! heart, leading to an irregular
heartbeat.
Arrhythmias themselves may not be life threating, but they can precipitate
major cardiovascular events, as stroke and sudden cardiac death.
Pressure-related consequences of hypertension
Arrhythmias
76. Ischemic stroke occurs when blood supply to ! Brain becomes blocked by atherosclerotic
plaque or blood clot which travels to ! Brain from another organ such as carotid artery.
Transient ischemic attack (TIA):
also called MINISTROKE.
caused by transient constriction of a small brain vessels or small clot.
Hemorrhagic strokes
caused by rupture of an artery in ! Brain.
risk of stroke in ISH 2-4 > HT ptn.
Atherosclerotic consequences of hypertension
Stroke (occlusion)
78. HTN can damage the glomeruli of ! Kidneys ▬▬▬► can be permeable to
proteins in ! Urine ▬▬► leads to Micro_& Macroalbuminuria (PROTEINURIA)
Atherosclerosis may occur in ! Artery renal arteries causing vessels obstruction
,ischemia & death of renal tissue ▬▬►chronic renal failure.
HTN & Atherosclerosis may lose their ability to remove waste products from the
blood, causing UREMIA.
Atherosclerotic consequences of hypertension
Damage of kidneys
79. AT 2
AT1
Afferent
Efferent
Ag II
ACE inh
Normal
ARBs
PROTEINURIA
Microalbuminuria, Macroalbuminuria
Intraglomerular
pressure
vasoconstriction
Vasodilatation
Vasodilatation
Atherosclerotic consequences of hypertension
PROTEINURIA
81. Increase BP causing hemorrhage, exudates & edema in ! Eyes.
Retinal ischemia ▬▬▬▬►thicken of wall.
Atherosclerotic consequences of hypertension
Damage to the Eyes
86. Turkey 24%
UAE 19%
Tunisia 13%
2
3
Egypt
Algeria
8%
6%
4
5
1
0 10 20 30 40(%)
Erem C et al. Prevalence of prehypertension and hypertension and associated risk factors among Turkish adults:
Trabzon Hypertension Study. J Public Health (Oxf). 2008 Sep 30.
The problem
Control Rates
88. The problem
24% of Saudi Population Hypertensive in 2007
0
10
20
30
40
50
60
70
80
SBP < 130 DBP < 80 SBP<130 & DBP<80
32%
74%
24%
Al Nozha et al, S Med J, 2007.
90. Poor Efficacy
Poor Compliance
REF; Chobanian AV, Bakris GL, Black HR, et al. the seventh report of the joint National Committee on prevention,
detection , report. JAMA 2003 May; 289 (19): 2560-722
The problem
Factors Related to the Result in Poor Control Rates
91. 91
‘‘Drugs don’t work in patients who don’t take them’’
C. Everett Koop, MD
Osterberg and Blaschke. N Engl J Med 2005;353:487–97
The problem
The Importance of Medication Compliance
92. 92
More Than 70% of Physicians Suspect Poor Compliance as the
Reason For Antihypertensive Treatment Failure
0
20
40
60
80
100
UK France Italy
Poor patient compliance
Products not effective
Side effects
Ménard and Chatellier. J Hum Hypertens 1995;9:S19–S23;
Andrade et al. Arq Bras Cardiol 2002;79:375–84
Doctors
citing
reason
(%)
*
* In patient surveys, side effects are a major reason for poor compliance
The problem
Factors Related to the Result in Poor Control Rates
94. 1. The patient should be
relaxed and the arm
must be supported.
Ensure no tight clothing
constricts the arm.
2. The cuff must be level with
the heart. If arm circumference
exceeds 33 cm, a large
cuff must be used. Place
stethoscope diaphragm over
the brachial artery.
3. The column of mercury must
be vertical. Inflate to occlude the
pulse. Deflate at 2 to 3 mm/sec.
Measure systolic (first sound)
and diastolic (disappearance)
to nearest 2 mm Hg.
Evaluation of blood pressure
Office monitoring of blood pressure
97. The standard components of the evaluation of a patient with
suspected hypertension are the medical history, the physical
examination, laboratory tests, and other diagnostic procedures.
Initial workup for patients with hypertension
Office monitoring of blood pressure
98. Initial workup for patients with hypertension
Classification of blood pressure
109. State the treatment goals for patients with hypertension
Tailoring treatment to fit the patient's global risk
110. State the treatment goals for patients with hypertension
Non-pharmacological Therapy
111. State the treatment goals for patients with hypertension
Pharmacological Therapy
112. State the treatment goals for patients with hypertension
JNC7 Recommendations for drug therapy
Stage I Hypertension
Stage II Hypertension
Initial combination drug therapy
More frequent follow up visit.
Treatment regimen may require 3 drugs with very high doses of
some agents.
113. 50% of patient achieve the goal blood pressure with monotherapy.
Basic of combination therapy is to combine drugs from different
classes to take advantage of their complementary modes of
action.
State the treatment goals for patients with hypertension
Combination therapy
114. provides convenient dosing and makes it possible to use low doses of
both agent to
Maximum effect.
Minimizing the risk of adverse effect.
Improving patient compliance.
State the treatment goals for patients with hypertension
Fixed Combination therapy
115. Diuretics
Alpha1 blockers
Beta blockers
Alpha beta blockers
Calcium channel blockers
ACE inhibitors
ARBs
State the treatment goals for patients with hypertension
Major Classes of Antihypertensive Drugs
119. Overview of Antihypertensive Agents
Homodynamic effects of Antihypertensive agents
Different, but complementary mechanism of action
=
=
Total
peripheral
resistance
β-blockers CCBs
Diuretics ARBs ACEIs
X
Stroke
volume
Heart rate X
Cardiac
output
Venous
pressure
BP
Arterial
pressure
142. 142
Clinical trials & evidence-based medicine
Introduction
• Clinical trials are experiments done in clinical research. Such prospective biomedical or
behavioural research studies on human participants is designed to answer specific
questions about biomedical or behavioural interventions, including new treatments
(such as novel vaccines, drugs, dietary choices, dietary supplements, and medical
devices) and known interventions that warrant further study and comparison.
• Clinical trials generate data on safety and efficacy. They are conducted only after they
have received health authority/ethics committee approval in the country where
approval of the therapy is sought.
143. 143
Clinical trials & evidence-based medicine
Introduction
• There is abundant evidence that links hypertension with increased risk of
cardiovascular disease.
• A large body of evidence also shows that lowering blood pressure reduces
the risk of these complications.
149. 149
Randomized
Participants are randomly (i.e., by chance) assigned to one of two or
more treatment arms of a clinical trial.
Minimizes the differences among groups by equally distributing
people with particular characteristics among all the trial arms.
Clinical trials & evidence-based medicine
Trial design
150. 150
Clinical trials & evidence-based medicine
Trial design
Controlled
Studying a group of treated patients not in isolation but in comparison to other groups
of patients.
I.Placebo controlled
Compare the test group to placebo.
II.Double dummy
• Patients are given both placebo and active doses in during the study.
• Additional insurance against bias or placebo effect.
III.Active control.
The study would compare the 'test' treatment to standard-of-care therapy.
151. 151
Clinical trials & evidence-based medicine
Blind vs Open label
I. Open label
• Both the researcher and the patient know the full details of the treatment.
• They do nothing to overcome the placebo effect or the bias.
• Sometimes they are unavoidable like surgery
II. Blind
• The researcher knows the details of the treatment, but the patient does not.
• They eliminate the placebo effect but not the bias.
• The researcher might give extra care to the placebo group
III. Double blind
• Neither the researcher nor the patient knows about the treatment.
• They eliminate both the bias and the placebo effect.
152. 152
• Age
• Sex
• Type of disease
• Stage of disease(severity)
• Treatment history
Clinical trials & evidence-based medicine
Inclusion and exclusion criteria
153. 153
CI
• Quantifies the uncertainty in measurement.
• They are used to indicate the reliability of an estimate.
• It is usually reported as a 95% CI
• It is the range of values within which we can be 95% sure that the true value for
the whole population lies.
Clinical trials & evidence-based medicine
Confidence interval
154. 154
• Results are said to be statistically significant if it is unlikely to have occurred by
chance.
• A statistically significant difference" simply means there is statistical evidence that
there is a difference; it does not mean the difference is necessarily large.
Clinical trials & evidence-based medicine
Statistical Significance
155. 155
• The smaller the p-value, the more significant the result is said to be.
• P value< 0.05 is usually accepted to be statistically significant.
Clinical trials & evidence-based medicine
P- Value