Hypertension is defined as high blood pressure that is linked to increased long-term health risks. The document discusses guidelines for classifying blood pressure levels and outlines the prevalence, awareness, treatment, and control of hypertension worldwide. It also summarizes the risks and complications of hypertension if left untreated, including heart, brain, kidney, and eye damage, and emphasizes the importance of lifestyle modifications and drug therapy to reduce complications.
Definition of hypertension - prevalence- classification and varieties of hypertension - risk factors - clinical manifestation of hypertension -complication -diagnosis - management - treatment of hypertension and special cases
This lecture shows the recently updated guidelines for the management of hypertension in primary health care clinics. Moreover, it talks about secondary and resistant hypertension.
Hypertension is another name for high blood pressure. It can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Blood pressure is the force that a person's blood exerts against the walls of their blood vessels.
Definition of hypertension - prevalence- classification and varieties of hypertension - risk factors - clinical manifestation of hypertension -complication -diagnosis - management - treatment of hypertension and special cases
This lecture shows the recently updated guidelines for the management of hypertension in primary health care clinics. Moreover, it talks about secondary and resistant hypertension.
Hypertension is another name for high blood pressure. It can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Blood pressure is the force that a person's blood exerts against the walls of their blood vessels.
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.
HYPERTENSION introduction, recommendations for accurate measurements of BP, evaluation of patient with hypertension, management of patient with hypertension, resistant hypertension, hypertensive crisis, hypertensive emergencies
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.
this presentation have various hypertension management guidelines used in the Indian context, hypertension management algorithm, medication used and AYUSH interventions
HYPERTENSION- THE LATEST MANAGEMENT
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
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.
HYPERTENSION introduction, recommendations for accurate measurements of BP, evaluation of patient with hypertension, management of patient with hypertension, resistant hypertension, hypertensive crisis, hypertensive emergencies
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.
this presentation have various hypertension management guidelines used in the Indian context, hypertension management algorithm, medication used and AYUSH interventions
HYPERTENSION- THE LATEST MANAGEMENT
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention...Yogacharya AB Bhavanani
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention in patients of essential hypertension and cardiac autonomic function tests
This presentation consists of various approaches to treat hypertension depending on severity. It also include treatment according to international guidelines. Classification and brief description of each antihypertensive agent has been mentioned.
Understanding Hypertension - Info from Timberland Medical Centre, KuchingTimberlandMedicalCentre
For more information, visit https://www.timberlandmedical.com
Timberland Medical Centre is a private hospital that has been in operation since 1994. We are strategically located at the 3rd Mile roundabout on Jalan Rock, Kuching, Sarawak, East Malaysia. Our hospital is 10 minutes from the Kuching International Airport and 15 minutes from the Central Bus Terminal. We continually seek to improve and upgrade our services and facilities, as we strive to provide the best medical care for our patients and customers.
This lecture presents the 1-Updated recommendations regarding definition and proper diagnosis of HTN. 2-Updated guidelines for threshold of BP to start treatment and targets of treatment. 3- Updated recommendations on CV risk assessment and management. 4-Hypertension and comorbidities: updated guidelines
Epidemiology , diagnosis and treatment of Hypertension Toufiqur Rahman
Hypertension, Blood pressure, Systolic Hypertension, Diastolic Hypertension, Epidemiology, Classification of hypertention, Type of hypertension, aetiology of hypertension, Clinical features, complications of hypertension, ambulatory blood pressure monitoring, Resistant hypertension, anti hypertensives,
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
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
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.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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.
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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
3. Definition of Blood Pressure
The pressure exerted by blood against the artery
through which it flows
Blood pressure =
cardiac output X systemic vascular resistance
CO X SVR = BP
3
4. Hypertension is defined:
As the level of blood pressure
linked with a doubled increased
long-term risk for adverse events
OR
Hypertension is ... “the level of
blood pressure at which the
benefits of action (i.e. therapeutic
intervention) exceed those of
inaction.”
4
Evans and Rose Brit Med Bull
7. Definition of Hypertension
JNC - VII BHS
Normal <120/<80 Optimal <120/<80
Prehypertension 120-139/80-89 Normal <130/<85
Stage 1 140-159/90-99 High Normal 130-139/85-89
Stage 2 >160/>100 Hypertension
Chobnian JAMA 2003;289:2560 Grade 1 140-159/90-99
Grade 2 160-179/100-109
Grade 3 >180/>110
Isolated syst.
hypertension
Grade 1 140-159/<90
Grade 2 >160/<90
Williams BMJ 2004;328;634
7
8. What guidelines are used to
categorize HTN?
The Joint Committee on Prevention,
Evaluation, and Treatment of High
Blood Pressure (JNC 7) guidelines
provide the most current guidelines
http://www.nhlbi.nih.gov/hbp/detect/categ.htm
8
12. Prevalence
65 million Americans have hypertension
(HTN)
Of those diagnosed with HTN < 50%
have their blood pressure under control
Lack of treatment leads to serious
complications
12
13. High Prevalence of Hypertension Worldwide
60 55
Prevalence of hypertension (%)
49 49
47
42
38 38
40
28
20
0
USA Italy Sweden England Spain Finland Japan* Germany
Adults aged 35–64 y (data are age- and sex-adjusted), except* (adults aged ≥ 30 y)
Hypertension defined as BP ≥ 140/90 mmHg or on treatment
Wolf-Maier et al. JAMA. 2003;289:2363−2369;
13 Sekikawa, Hayakawa. J Hum Hypertens. 2004; 2004;18:911–912.
15. Awareness, Treatment and Control of
Hypertension is Rather Low Worldwide
Proportion of patients in the population (%)
Country Aware Treated Controlled*
Japan 16.0 – 4.1
England 35.8 24.8 10.0
Germany 36.5 26.1 7.8
Spain 38.9 26.8 5.0
Sweden 48.0 26.2 5.5
Italy 51.8 32.0 9.0
USA 69.3 52.5 28.6
* BP < 140/90 mmHg
Wolf-Maier et al. Hypertension. 2004;43:10–17; 15
15 Sekikawa, Hayakawa. J Hum Hypertens. 2004;18:911–912.
16. BP Control Rates
Trends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey,
Percent
II II
II (Phase 1) (Phase 2)
1976–80 1988–91 1991–94 1999–2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
16
19. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
19
20. Risk of CV Mortality Doubles With Each 20/10
mmHg BP Increase
• Meta-analysis of 61 prospective, observational studies
• 1 million adults aged 40–69 y with BP > 115/75 mmHg
• 12.7 million person-years
10
8-fold
8
relative CV risk
Fold increase in
6
4-fold
4
2-fold
2
1-fold
0
115/75 135/85 155/95 175/105
SBP/DBP (mmHg) 20
21. Each 2 mmHg Decrease in SBP
Reduces CV Risk by 7–10%
• Meta-analysis of 61 prospective, observational studies
• 1 million adults aged 40–69 y with BP > 115/75 mmHg
• 12.7 million person-years
7% reduction
in risk of IHD
and other
2 mmHg vascular disease
decrease in mortality
mean SBP
10% reduction
in risk of stroke
mortality
21
21 Lewington et al. Lancet. 2002;360:1903–1913.
22. CVD Risk
HTN prevalence ~ 50 million people in the United States.
The BP relationship to risk of CVD is continuous, consistent, and
independent of other risk factors.
Each increment of 20/10 mmHg doubles the risk of CVD across the
entire BP range starting from 115/75 mmHg.
Prehypertension signals the need for increased education to reduce
BP in order to prevent hypertension.
22
25. Factors contribute to the
development of primary HTN
1. Sympathetic nervous system
hyperactivity
2. Renin-angiotensin-aldosterone system
hyperactivity
3. Endothelial dysfunction
25
27. Types of HTN?
Primary Secondary
• ?? ‘essential’idiopathic • Caused by some other
• Most common type medical problem or
found in 90-95% of condition:
those with HTN • High-dose estrogen
• Cause not well • Renal artery stenosis
understood • Pregnancy (PET)
• Salt sensitive
• Cushing’s syndrome
• RAAS dependent
• pheochromocytoma
• Others?
27
30. What are the Symptoms?
Symptoms may or may not be present
• Dizziness (unsteadiness)
• Early morning headache
activity tolerance
• Malaise, fatigue
• Blurring of vision
• Spontaneous nosebleed
• Palpitations, angina, dyspnea
• Early signs/symptoms are often missed
30
34. BP measurement
Physical assessment • Proper size cuff
• Height & weight applied 1 inch above
• Blood pressure brachial artery
Measuring BP • Inflate cuff to 30
accurately: mmHg above initial
• No smoking or caffeine radial pulse check If
30 minutes before BP elevated, wait 2
• Rest for 5 minutes prior minutes, recheck
to BP
• Check BP in other arm
• Apply cuff to bare arm
34
35. BP Measurement Techniques
Method Brief Description
In-office Two readings, 5 minutes apart, sitting
in chair. Confirm elevated reading in
contralateral arm. 140/90
Ambulatory BP Indicated for evaluation of “white-
monitoring coat” HTN. Absence of 10–20% BP
decrease during sleep may indicate
increased CVD risk. 130/80
Self-measurement Provides information on response to
therapy. May help improve
adherence to therapy and evaluate
“white-coat” HTN. 135/85
35
40. Key Messages
For persons over age 50, SBP is a more important than DBP as CVD risk
factor.
Starting at 115/75 mmHg, CVD risk doubles with each increment of
20/10 mmHg throughout the BP range.
Persons who are normotensive at age 55 have a 90% lifetime risk for
developing HTN.
Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be
considered prehypertensive who require health-promoting lifestyle
modifications to prevent CVD.
40
41. Key Messages (Continued)
Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
Certain high-risk conditions are compelling indications for other drug
classes.
Most patients will require two or more antihypertensive drugs to
achieve goal BP.
If BP is >20/10 mmHg above goal, initiate therapy with two agents,
one usually should be a thiazide-type diuretic.
41
42. Key Messages (Continued)
The most effective therapy prescribed by the careful clinician will control
HTN only if patients are motivated.
Motivation improves when patients have positive experiences with, and
trust in, the clinician.
Empathy builds trust and is a potent motivator.
The responsible physician’s judgment remains paramount.
42
43. Complications of HTN
The higher the BP and the longer an
individual has hypertension, the higher
the risk of complications which include:
• Hypertensive heart disease
• Cerebrovascular disease
• Peripheral vascular disease
• Kidney disease
• Retinal damage
43
48. Complications of Hypertension
Peripheral vascular Kidney disease
disease
• vessels less elastic
• Aortic aneurysm or
decreased
dissection
perfusion renal
Retinal damage
failure
• damage to blood
vessels of the eye
48
49. Acute Complications
Hypertensive Sx: papilledema,
Crisis: progressive renal
Severe and abrupt failure,
elevation of BP encephalopathy
Diastolic over Most common
120mm hg cause is untreated
hypertension
High Mortality
Goal: slowly
decrease BP
49
50. Classifications Hypertensive Crisis
Hypertensive crisis is Hypertensive urgency:
categorized by the BP is elevated but there
degree of organ damage is no evidence of target
Hypertensive organ damage
emergency:
BP is severely elevated
and there is evidence of
target organ damage
• Especially brain
50
51. GOAL: Reduce Complications
JNC 7 guidelines
recommend a target
BP of less than
140/90
Patients with renal
disease or diabetes
need BP less than
130/80
51
52. What Reduces Risk of
Complications?
REDUCING MODIFIABLE RISK
FACTORS IS A KEY INTERVENTION
Goal = Patient teaching to reduce risk
factors
Drug therapy is initiated if lifestyle
changes are not effective to control BP
52
53. Management of Hypertension
Depends on risk group
Lifestyle modifications
Drug therapy is initiated if lifestyle
modifications do not achieve goal
Add or change drugs if goal not achieved
53
54. TREATMENT: Lifestyle
Modification
Lose excess weight
Cut back on salt
Exercise regularly
Cease alcohol intake
Adopt the DASH eating plan to decrease
cholesterol intake
STOP smoking
54
58. Drug Therapy for HTN
Diuretics Beta adrenergic
• Flush excess water blockers
and sodium from the Three classes:
body
• Cardioselective
• Thiazide diuretics
• Non-selective
• Loop diuretics:
• Combined alpha-
furosemide (Lasix)
beta-blockers
• Potassium sparing:
Aldactone
58
59. The Majority of Hypertensive Patients Need
Combination Therapy to Achieve BP Goals
Trial (SBP achieved)
ASCOT-BPLA (137 mmHg)
ALLHAT (138 mmHg)
IDNT (138 mmHg)
RENAAL (141 mmHg)
UKPDS (144 mmHg)
ABCD (132 mmHg)
MDRD (132 mmHg)
HOT (138 mmHg)
AASK (128 mmHg)
1 2 3 4
Bakris et al. Am J Med. 2004;116(5A):30S–38S;
Average number of antihypertensive medications
59 Dahlöf et al. Lancet. 2005;366:895–906.
60. Pharmacologic Management
of Hypertension
Alpha-adrenergic blockers
• Suppress nerve impulses to blood vessels, which
allows blood to pass more easily so BP goes ↓
• prazosin (Minipress)
Calcium channel blockers
• decrease the influx of Ca++ into muscle cells
• Act on vascular smooth muscles (primary arteries) to
decrease spasm and promote vasodilation
• Amlodipine (Norvasc); felodipine (Plendil)
60
61. Pharmacologic Management
of Hypertension
Angiotensin Angiotensin II
converting enzyme receptor blockers
(ACE) inhibitors (ARB)
• Decrease effect of • Prevent action of
RAA system: angiotensin II and
Capoten, Lisinopril produce vasodilation
• Diabetes mellitus • losartan (Cozaar)
w/proteinuria, heart
failure
61
62. Pharmacologic Management of
Hypertension
Vasodilators Alpha-receptor
• Direct arterial agonists
vasodilation • Clonidine
• Sodium nitroprusside • Acts on central
(Nipride) nervous system
• Often used in • Lowers peripheral
hypertensive crisis vascular resistance
62
63. Why don’t some patients respond
to therapy?
Non-adherence to Drug related causes
therapy Other conditions
• Patients don’t take
Secondary
their HTN meds →
complications!!!
hypertension
• Cost, inadequate Volume overload
teaching, side effects,
inconvenient dosing
63
64. Causes of
Resistant Hypertension
Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
• Inadequate doses
• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN 64
65. Summary Key Points
Two types of HTN: primary & secondary
Inadequate BP control leads to serious
complications including STROKE
Key point: risk factor modification
Treatment focuses on lifestyle
management and drug therapy
JNC 7 provides the most current
treatment guidelines for hypertension
65
66. Identifiable
Causes of Hypertension
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
66
67. Pheochromocytoma
0.01-0.1% of HTN population
• Found in 0.5% of those screened
M=F
3rd to 5th decades of life
Rare, investigate only if clinically suspicion:
• Signs or Symptoms
• Severe HTN, HTN crisis
• Refractory HTN (> 3 drugs)
• HTN present @ age < 20 or > 50 ?
• Adrenal lesion found on imaging (ex. Incidentaloma)
67
68. Pheo: Signs & Symptoms
The five P’s:
• Pressure (HTN) 90%
• Pain (Headache) 80%
• Perspiration 71%
• Palpitation 64%
• Pallor 42%
• Paroxysms (the sixth P!)
The Classical Triad:
• Pain (Headache), Perspiration, Palpitations
• Lack of all 3 virtually excluded diagnosis of pheo in a series of
> 21,0000 patients
68
69. Pheo: Paroxysms, ‘Spells’
10-60 min duration
Frequency: daily to monthly
Spontaneous
Precipitated:
• Diagnostic procedures, I.A. Contrast (I.V. is OK)
• Drugs (opiods, unopposed β-blockade, anesthesia induction,
histamine, ACTH, glucagon, metoclopramide)
• Strenuous exercise, movement that increases intra-abdo
pressure (lifting, straining)
• Micturition (bladder paraganlgioma)
69
70. Pheo: ‘Rule of 10’
10% extra-adrenal (closer to 15%)
10% occur in children
10% familial (closer to 20%)
10% bilateral or multiple (more if
familial)
10% recur (more if extra-adrenal)
10% malignant
10% discovered incidentally 70
71. Plasma Metanephrines
Not postural dependent: can draw
normally
Secreted continuously by pheo
SEN 99% SPEC 89%
False Positive: acetaminophen
Assay not widely available yet
71
72. Localization: Imaging
CT abdomen
• Adrenal pheo SEN 93-100%
• Extra-adrenal pheo SEN 90%
MRI
• > SEN than CT for extra-adrenal pheo
MIBG Scan
• SEN 77-90% SPEC 95-100%
72
77. Typical clinical scenarios
Difficult hypertension with hypokalaemia,
on polypharmacy- referred to
endocrinologist for exclusion of 2ary
hypertension
Coincidentaloma of adrenal with
hypertension, on polypharmacy
Which drugs are permissible, and after how
much delay should there be before
investigation?
77
78. Mineralocorticoid hypertension- in
whom should it be suspected?
Diagnosis should be suspected in patient with
hypertension, spontaneous hypokalaemia
(<3.5mmol/l), and alkalosis.
Severe hypokalaemia (<3.0) on diuretics
Investigate patient hypertension refractory to
conventional therapy, or adrenal coincidentaloma
Recent onset of hypertension
Normokalaemia present in >35% patients on low
salt diet
78
79. Clinical features of
hyperaldosteronism
Mild to severe hypertension
Sodium retention + intravascular vol exp
→mineralocorticoid escape
Resetting of osmostat (thirst provoked at higher [Na+])
K+ loss (kaliuresis) +/- low serum K+ (unprovoked: rule out
diuretics, laxatives, vomiting, herbal supplements)
Suppression of renin generation (rule out drugs,excessive
dietary sodium intake)
Polyuria, nocturia,fatigue,cramps, Mg++↓
Exclude liquorice abuse / carbenoxolone therapy
NB minor mineralocorticoids DOC, compound B
79
80. Imaging in 1ary hyperaldosteronism
High resolution CT scanning with thin (2-3mm)
slices
Bilateral adrenal venous catheter (measure cortisol,
adrenaline + aldosterone) remains gold standard –
operator dependent: right adrenal notoriously
difficult to cannulate. Give iv ACTH (2μg/min)
during sampling to magnify difference between
tumour and non-tumorous side
Non-tumorous side PAC = peripheral value
because of suppressed PRA
80
81. Glucocorticoid remediable
hyperaldosteronism GRA (FH1)
Due to aberrant expression of chimeric gene
formed by unequal recombination of promoter
and initial parts of CYP11B1 and section of
CYP11B2 with aldosterone synthase activity
Aldosterone under ACTH control
Autosomal dominant: FH of early onset BP↑ with
CVA ,K+↓
High levels of 18-hydroxy and 18-oxocortisol
Rx : chronic administration of low dose GC,
spironolactone, or amiloride
81
82. Liddle syndrome
Familial BP↑, unprovoked K+↓, PRA↓, and
undetectable PAC
Autosomal dominant, caused by constitutive
activation of distal renal epithelial sodium
channel (β,γ C-terminal subunit mutations
prevent trafficking of channel)
Treated by amiloride
82
83. Liddle's – low renin, low aldo
Licorice and SAME -- low renin, low aldo
Renal artery stenosis and renin-secreting
tumors -- high renin, high aldo
Adrenal hyperfunction -- low renin, high
aldo
83
84. Renin Aldo
Liddle low low
Licorice low low
RAS high high
Conn’s low high
84
85. Renin-Angiotesnin-
Aldosterone System
A drop in BP or blood Stimulates adrenal
volume causes kidneys to glands to release
secrete renin, a
renin aldosterone
precursor to This prompts the
angiotensin I kidneys to retain sodium
Angiotensin-converting and water
enzyme turns The increased volume
angiotensin I into and vasoconstriction
angiotensin II, a potent raise BP
vasoconstrictor
85