This document discusses combination drug therapy for treating hypertension. It notes that the majority of hypertensive patients require two or more drugs to control their blood pressure. Combination therapy is more effective than high doses of single drugs and has fewer side effects. Effective combinations include angiotensin receptor blockers or ACE inhibitors with diuretics or calcium channel blockers. Initial fixed-dose combination therapy improves medication adherence compared to free-drug combinations. Overall, rational combination therapy utilizing complementary drug classes is necessary to adequately control blood pressure for most hypertensive patients.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
Management of Hypertension and Diabetes in Aging People 2014Nemencio Jr
This module discusses the issues in the management and treatment goals for hypertension and diabetes in the older population based on the most recent guidelines
European Society of Hypertension 2013 Hypertension guidelines presentation in...JAFAR ALSAID
Summary of the European Society of Hypertension 2013 Hypertension Guidelines presented during the Eighth Hypertension and Cardiovascular highlight session in Bahrain on Sept. 11th 2013.
1. Resistant Hypertension, complications, Target organ damage2. newly diagnosed stage-1 hypertension, rationale of use of ARB and comparison of Azilsartan with other ARBs3. Hypertension with bronchial asthma 4. Hypertension with Diabetes Mellitus with proteinuria5. Hypertension , Diabetes and IHD6. Gestational Hypertension , rationale of use of drugs7. Hypertension , Diabetes , ACS8. Hypertension, Diabetes and Syndrome X9. Hypertension and special situations
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Nutritional therapy in hypertension and diabetes by SYED SHOAIB HUSSAINPARUL UNIVERSITY
hypertension and diabetes are common problems associated with improper diet habits, so diet therapy is a core management strategy to manage diabetes and hypertension
Comparative effectives of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers added to standard medical therapy for treating patients with stable ischemic heart disease and preserved left ventricular systolic function.
Management of Hypertension and Diabetes in Aging People 2014Nemencio Jr
This module discusses the issues in the management and treatment goals for hypertension and diabetes in the older population based on the most recent guidelines
European Society of Hypertension 2013 Hypertension guidelines presentation in...JAFAR ALSAID
Summary of the European Society of Hypertension 2013 Hypertension Guidelines presented during the Eighth Hypertension and Cardiovascular highlight session in Bahrain on Sept. 11th 2013.
1. Resistant Hypertension, complications, Target organ damage2. newly diagnosed stage-1 hypertension, rationale of use of ARB and comparison of Azilsartan with other ARBs3. Hypertension with bronchial asthma 4. Hypertension with Diabetes Mellitus with proteinuria5. Hypertension , Diabetes and IHD6. Gestational Hypertension , rationale of use of drugs7. Hypertension , Diabetes , ACS8. Hypertension, Diabetes and Syndrome X9. Hypertension and special situations
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Nutritional therapy in hypertension and diabetes by SYED SHOAIB HUSSAINPARUL UNIVERSITY
hypertension and diabetes are common problems associated with improper diet habits, so diet therapy is a core management strategy to manage diabetes and hypertension
Comparative effectives of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers added to standard medical therapy for treating patients with stable ischemic heart disease and preserved left ventricular systolic function.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Addressing hypertension to reduce the burden of stroke 19 feb2018 (1)Sudhir Kumar
Hypertension is the commonest risk factor for stroke. Management of hypertension is important in ensuring best outcomes for stroke patients. Adequate control of bP is also important to prevent stroke recurrence. This presentation looks at the role of high BP in stroke occurrence and antihypertensive agents that can be used to achieve target BP.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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. Hypertension (HTN) is a major public health concern, affecting
26% of adults worldwide1
Number of
people with HTN
worldwide in 20001
972 million
Increase in the
number of adults with
HTN globally by 20251
60%
Percent of all global
healthcare spending
attributable to high
blood pressure2
10%
Annual worldwide cost of
hypertension2 $370 billion
1.6 Billion
HTN patients estimated
by 2025
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The
global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.
6. Historical Lessons on the Risks of Hypertension and
the Benefits of Treatment
CHD Incidence Rate/
1000 Person Years
50
40
30
20
10
0
Treatment Decreases
Morbidity and Mortality
Placebo Active
Treatment
Cumulative Fatal &
Nonfatal Endpoints
Hypertension Increases
Morbidity and Mortality
Normotension
Hypertension
The Framingham Study The Vet. Adm. Study II
Ann Intern Med. 1961; 55:33–50. JAMA. 1970; 213:1143–1152.
140
120
100
80
60
40
20
0
Men Women
7. Risk Factors for Cardiovascular Disease
• Smoking
• Hyperlipidaemia
• High salt intake
• Lack of exercise
• Obesity
• Diabetes
• Alcohol >4pints of beer/day
• Genetic
8.
9.
10. CV
mortality
risk
CV Mortality Risk Doubles With
Each 20/10 mm Hg BP Increment*
BP > 140/90 mmHg associated with:
69% of pts in the 1st heart attack
74% of pts with heart failure
77% of pts in the 1st stroke
SBP/DBP (mm Hg)
8
7
6
5
4
3
2
1
0
115/75 135/85 155/95 175/105
*Individuals aged 40-69 years, starting at BP 115/75 mm Hg.
CV, cardiovascular; DBP, diastolic blood pressure; SBP, systolic blood pressure.
Lewington S et al. Lancet. 2002;360:1903-1913.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
11. HTN leads to an increased risk of death from stroke and
heart disease
8x
4x
Systolic BP / Diastolic BP (mmHg)
2x
Cardiovascular Mortality Risk
CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2
Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913
12. BP Differences of 10 mmHg Are Associated With
Up to a 40% Effect on
CV Risk
• Meta-analysis of 61 prospective, observational studies
• 1 million adults
• 12.7 million person-years
30% reduction in
risk of IHD
mortality
10 mmHg
decrease in
mean SBP 40% reduction in
Lewington S et al. Lancet. 2002;360:1903–1913.
risk of stroke
mortality
13. Current Antihypertensive Therapy Reduces CV Events
Average Reduction in Events, %
0
–20
–40
–80
CV=cardiovascular.
Neal B et al. Lancet. 2000;356:1955–1964.
Major CV
Events
20%–30%
Stroke
30%–40%
CV Death
30%–40%
–60
–100
Can we do better?
14. Multiple Antihypertensive Agents
Are Needed to Achieve Target BP
Target BP (mm Hg)
Number of antihypertensive agents
Trial 1 2 3 4
ALLHAT SBP <140/DBP <90
UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
AASK MAP <92
IDNT SBP <135/DBP <85
DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.
Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
Lewis EJ et al. N Engl J Med. 2001;345:851-860.
Cushman WC et al. J Clin Hypertens. 2002;4:393-405.
15. ALLHAT study:
42,418 patients with hypertension
SBP >140mmHg and/or DBP >90 mmHg OR
Took medication for hypertension and had at least one additional risk factor for CHD
Age >55 years
Diuretics vs. ACEi
Stage 1 and 2
only 26% the BP controlled by single drug
30% required 3 drugs
The LIFE Trial
9,200 patients with hypertension
SBP 160 – 200 mmHg and/or DBP 95- 115 mmHg with LVH
ARBs vs. BB
Stage 2
90% had 2 drugs
50% BP achieved
19. Definition of resistant hypertension:
uncontrolled BP despite adherence to a
regimen with at least three antihypertensive
agents including a diuretic.
The percentage of patients in this category is
estimated at approximately 10–15% of the
hypertensive population.
20.
21.
22.
23.
24.
25.
26. Value of low dose combination treatment with blood pressure
lowering drugs: analysis of 354 randomized trials (2003 BMJ)
Objective To determine the average reduction in BP, prevalence of adverse effects,
and reduction in risk of stroke and IHD events produced by the five main categories
of antihypertensive drugs, singly and in combination.
Design Meta-analysis of 354 randomized double blind placebo controlled trials.
40 000 treated patients and 16 000 patients given placebo
Results All five categories of drug produced similar reductions in BP.
The standard dose average reduction was 9.1 mm Hg systolic and 5.5 mm Hg
diastolic .
The half standard dose was 7.1 mm Hg systolic and 4.4 mm Hg diastolic (20% lower)
The BP lowering effects of different categories of drugs were additive.
Symptoms attributable to thiazides, BB, and CCB were strongly dose related; but by
ACEi (mainly cough) were not dose related. ARBs caused no excess of symptoms.
The prevalence of symptoms with two drugs in combination was less than additive.
Adverse metabolic effects (such as changes in cholesterol or potassium) were
negligible at half standard dose.
Conclusions Combination low dose drug treatment increases efficacy
and reduces adverse effects. From the average blood pressure in people
who have strokes (150/90 mm Hg) three drugs at half standard dose are
estimated to lower blood pressure by 20 mm Hg systolic and 11 mm Hg
diastolic and thereby reduce the risk of stroke by 63% and IHD events by
46% at age 60-69.
27.
28. Rational of combination therapy
1. The heterogeneity of the hypertensive population.
2. Initial falls in BP from monotherapy are also opposed by reflex responses in
counter-regulatory mechanisms that are activated following BP reduction.1
3. Combining selected classes of antihypertensive therapy with different
modes of action.
4. RAAS blockers tolerability is the best in comparison.
5. ARBs or ACEi + duiretics reduce the incidence of hypokalemia
6. ARBs or ACEi + CCB reduce the incidence and severity of edema
1. Sever P, Messerli FH. Eur Heart J 2011;32:2499-506.
2. Law M et al. BMJ 2003;326:1427-31.
3. Alan Grdman. Current opinion nephrol hyoetens 2012,21:486-491
29.
30. Drug combination (AHS)
Preferred :
ARBs/diuretics
ARBs/CCB
ACEi/diuretics
ACEi/CCB
Acceptable:
BB/diuretics
Thiazide/K+ sparing
CCB/diuretics
CCB/BB
BB/diuretics
Less effective:
ACEi/BB
ARB/BB
CCB(nondihydropyridine)/BB
Central acting agent/BB
1. Reduces risk of hypokalemia
2. Ameliorates diuretic-induced activation
of RAAS
3. Ameliorates CCB edema
4. Reduction of mortality
5. Option for CKD
1. BB ameliorate thiazide-induced activation
of RAAS
2. Side effect sexual dysfunction and
glucose intolerance
3. BB less effect as anti-HTN
4. Carvedilol
1. BB with CCB increase the risk of
bradycardia and heart block
2. the combination of ACE inhibitor/CCB
was associated with a 20% reduction in
major CV endpoints compared with ACE
inhibitor/HCTZ. (ACCOMPLISH)
3. Abrupt discontinuation cause
hypertensive crisis
New combinations
Valsartan/amlodipine/HCT
Olmesartan/amlodipine/HCT
Aliskiren/amlodipine/HCT
35. Initial Fixed-Dose Combination Therapy
ADVANTAGES
• 2 drugs needed for control of Stage 2 BP
• Low (therapeutic) dose of 2 drugs
– more effective than higher dose of single drug
– usually well tolerated
– adverse effects can be reduced
• Simplified treatment regimen: adherence improved by 26% compare to free
combination
• and potential for improved outcomes
• Economic benefits
– Fewer copayments
– health care costs reduced
– fewer office visits
36.
37.
38. Reduced discontinuation of antihypertensive treatment by two-drug
combination as first step. Evidence from daily life practice
OBJECTIVES:
To measure persistence with antihypertensive drug therapy in patients
initiating treatment with mono or combination therapy.
METHODS:
Data were limited to patients aged 40-80 years who received their first
antihypertensive drug prescription (n = 433,680 and 41,199, respectively)
CONCLUSION:
Initiating treatment with a combination of two drugs is associated with a
reduced risk of treatment discontinuation.
Corrao G1, et al, J Hypertens. 2010 Jul;28(7):1584-90.
MILANO ITALY
39. Strategies for Combination Therapy in Hypertension
Conclusion
Combination therapy is necessary in
approximately 75% of patients with
hypertension. Rational combination therapy
begins with the selection of two-drug
combinations that exhibit additive BP
reduction, excellent tolerability and a
demonstrated ability to reduce CV endpoints
in long-term clinical trials. The latter include
ACE inhibitors, ARBs, CCBs and low-dose
diuretics. More than 25% of patients need at
least three drugs. Strategies for clinical use of
combination therapy continue to evolve.
Current guidelines recommend routine initiation
of a combination in patients with Stage 2
hypertension. More recent studies suggests a
potential for hastening goal attainment and
improving long-term outcomes through the
use of initial combination therapy in a
broader spectrum of patients with
hypertension.
• In a meta-analysis of nine studies comparing
administration of SPCs or their separate
components, the adherence rate was
improved by 26% in patients receiving SPCs
• initial combination treatment consistently
reduces the time taken to reach target BP
compared with initial monotherapy. After 8
weeks, 48% of patients achieved their target
compared with 75% begun on a combination.
• Initial combination therapy was associated
with a 33% reduction in major CV events
compared with patients initiated on
monotherapy and later switched to a
combination treatment by their treating
physician.
• Initial combination treatment should be used
sparingly in frail or very elderly patients (the
presence of orthostatic hypotension)
Alan H. Gradman, Curr Opin Nephrol Hypertens. 2012;21(5):486-491
40. Initial Fixed-Dose Combination Therapy
DISADVANTAGES
• BP may be controlled with 1 drug in some patients
– However, majority of patients require 2 drugs
• Combination ‘too potent’ causing hypotension
– Benefit risk profile for each combination should be assessed in appropriate
patient population
– Individualize therapy
• Additive risk for dose independent adverse effects
– However, mono components likely to be taken as part of a multi drug regimen
– Balance against risk of dose dependent side effects with high dose monotherapy
and risk of inadequate BP control (stroke, heart failure and MI)
• If adverse effects
– must discontinue both drugs:
– more office visits
– more lab tests
41. Cost-effectiveness analysis of cardiovascular disease prevention
with a multidrug regimen
Sanz G and Fuster V (2008) Fixed-dose combination therapy and secondary cardiovascular prevention: rationale,
selection of drugs and target population
Nat Clin Pract Cardiovasc Med doi:10.1038/ncpcardio1419
43. 1.5 Initiating and monitoring antihypertensive drug treatment, including blood pressure
targets
Initiating treatment
1.5.1 Offer antihypertensive drug treatment to people aged under 80 years with stage 1
hypertension who have one or more of the following:
target organ damage
established cardiovascular disease
renal disease
diabetes
a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011]
1.5.2 Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.
[new 2011]
1.5.3 For people aged under 40 years with stage 1 hypertension and no evidence of target organ
damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation
of secondary causes of hypertension and a more detailed assessment of potential target organ
damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime
risk of cardiovascular events in these people. [new 2011]
44. .6 Choosing antihypertensive drug treatment
1.6.1 Where possible, recommend treatment with drugs taken only once a day. [2004]
1.6.2 Prescribe non-proprietary drugs where these are appropriate and minimise cost. [2004]
1.6.3 Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more)
the same treatment as people with both raised systolic and diastolic blood pressure. [2004]
1.6.4 Offer people aged 80 years and over the same antihypertensive drug treatment as people
aged 55–80 years, taking into account any comorbidities. [new 2011]
1.6.5 Offer antihypertensive drug treatment to women of child-bearing potential in line with the
recommendations on Management of pregnancy with chronic hypertension and Breastfeeding in
'Hypertension in pregnancy' (NICE clinical guideline 107). [2010]
Step 1 treatment
1.6.6 Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting
enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE
inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB.
[new 2011]
1.6.7 Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011]
1.6.8 Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people
aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is
not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure
or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011]
1.6.9 If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as
chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or
2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide
or hydrochlorothiazide. [new 2011]
45. Display Settings:
•Abstract
A2absb0trasctt (rteaxtc) t
J Hypertens. 2010 Jul;28(7):1584-90. doi: 10.1097/HJH.0b013e328339f9fa.
Reduced discontinuation of antihypertensive treatment by two-drug combination as first step. Evidence
from daily life practice.
Corrao G1, Parodi A, Zambon A, Heiman F, Filippi A, Cricelli C, Merlino L, Mancia G.
Author information
•1Department of Statistics, Unit of Biostatistics and Epidemiology, University of Milano-Bicocca, Milan, Italy.
giovanni.corrao@unimib.it
Abstract
OBJECTIVES:
To measure persistence with antihypertensive drug therapy in patients initiating treatment with mono or
combination therapy.
METHODS:
Data analysis was based on two cohorts of patients, that is, a cohort derived from the registration of drug
prescriptions in all residents of the Lombardy region receiving Public Health Service and a cohort of patients
followed by general practitioners throughout the Italian territory. Data were limited to patients aged 40-80 years
who received their first antihypertensive drug prescription (n = 433,680 and 41,199, respectively) in whom
persistency of treatment was examined over 9 months. A proportional hazards model was fitted to estimate the
association between the pattern of initial antihypertensive drug therapy and risk of treatment discontinuation. Data
were adjusted for available potential confounders.
RESULTS:
Taking patients starting with diuretic monotherapy as reference, the adjusted risk of treatment discontinuation was
progressively lower in patients starting with monotherapy other than a diuretic, a two-drug combination, including a
diuretic and a two-drug combination without a diuretic. No significant difference in the risk of discontinuation was
seen between extemporaneous and fixed dose combinations, including a diuretic, that is, the only combination
reimbursable by Public Health Service and, thus, available in the database. Data were similar for the two cohorts.
CONCLUSION:
Initiating treatment with a combination of two drugs is associated with a reduced risk of treatment discontinuation.
46.
47.
48.
49.
50.
51.
52.
53.
54. There is great concern over the impact of patients not achieving BP goals. Poor BP control is
associated with a marked increase in the risk of CV fatal and non-fatal events.1 A meta-analysis
of 1 million patients in 61 prospective studies demonstrated that the relationship
between BP and cardiovascular disease events is continuous, consistent and age-dependent
– each 20 mmHg increase in SBP or 10 mmHg increase in DBP is associated with at least a
twofold increase in the risk of death from stroke, ischaemic heart disease or other vascular
cause.2
The US study using NHANES III data (Third National Health and Nutrition Examination
Survey) highlighted in this slide shows that uncontrolled and untreated hypertension is
associated with an increased risk of total and CV mortality in the general hypertensive
population.3 Relative to treated controlled hypertensive patients, treated uncontrolled
patients had a 57% and 74% increased risk of all-cause and CVD mortality, with untreated
hypertensives having a 34% and 37% increased risk, respectively. This association was
persistent and remained significant after excluding subjects with hypertension co-morbidities
at baseline.3
1. Grassi G et al. Eur Heart J 2011;32:218-25.
2. Lewington S et al. Lancet 2002;360:1903-13.
3. Gu Q et al. Am J Hypertens 2010;23:38-45.
55. 69% 1st heart attack
74% Heart failure
77% 1st stroke
Too low BP may leads to cardiac events
The J-CurvThe J-curve effect describes an inverse relation
between low blood pressure (BP) and cardiovascular
complications. This effect is more pronounced in
patients with preexisting coronary artery disease (CAD),
hypertension or left ventricular hypertrophy (LVH). e
phenomenon The recent large clinical outcomes trials
have observed a J-curve effect between a diastolic BP of
70-80 mmHg as well as a systolic BP <130 mmHg. The J-curve
phenomenon does not appear in stroke or renal
disease. This is because the coronary arteries are
perfused during diastole, but the cerebral and renal
perfusion mainly occurs in systole. Therefore, caution
should be taken to maintain the diastolic blood pressure
(DBP) at minimum of 70 mmHg and possibly to maintain
the DBP between 80-85 mmHg in patients with severe
LVH, CAD or vascular diseases. BP control in high-risk
elderly patients should be carefully done as undergoing
aggressive therapy to lower the systolic blood pressure
below 140 mmHg can cause cardiovascular
complications due to the severely reduced DBP and
increased pulse pressure.