- Hypertension is defined as systolic blood pressure over 140 mmHg or diastolic over 90 mmHg. Options for blood pressure measurement include office, ambulatory, and home monitoring.
- Ambulatory blood pressure monitoring provides advantages like identifying white-coat hypertension but is more expensive. Home blood pressure monitoring is cheaper but lacks nocturnal readings.
- Uncontrolled hypertension despite three or more antihypertensive classes at maximum dose is defined as resistant hypertension. Causes include non-adherence, secondary causes, and volume overload.
1) The document compares the 2017 guidelines for hypertension from Hypertension Canada and the American Heart Association/American College of Cardiology.
2) There are some differences in definitions of elevated blood pressure and hypertension thresholds. Hypertension Canada guidelines are more evidence-based while AHA/ACC guidelines are more pragmatic.
3) Both emphasize accurate blood pressure measurement and recommend similar non-pharmacological interventions like weight loss, diet changes, and increased physical activity. However, they differ on when to initiate drug therapy and targets for specific patient groups.
The document outlines guidelines for the management of arterial hypertension from the 2018 ESC/ESH conference. It discusses definitions of hypertension, recommendations for blood pressure measurement, classifications of hypertension, screening and diagnosis, assessment of hypertension-mediated organ damage, and initiation of blood pressure-lowering treatment. Key points include defining hypertension as a blood pressure over 140/90 mmHg, outlining options for office and out-of-office blood pressure measurement, stratifying cardiovascular risk, and recommending prompt initiation of treatment for grade 2 or 3 hypertension or grade 1 hypertension with high risk or organ damage.
Hypertension 2018 Guidelines - prof. Tarek Medhat MNDU net
Hypertension guidelines have been updated with several key changes:
1. The definition of hypertension is now lower at 130/80 mmHg or higher which means more people will be classified as hypertensive.
2. The term "prehypertension" has been eliminated and replaced with "elevated blood pressure" for readings of 120-129/80 mmHg or lower.
3. More emphasis is placed on accurately measuring blood pressure at home or with ambulatory monitoring to detect white coat hypertension or masked uncontrolled hypertension.
4. Treatment goals for blood pressure are now lower, especially for those with cardiovascular disease.
This document discusses guidelines for the treatment of hypertension from multiple organizations and studies. It provides recommendations for treatment thresholds, goals, and initial drug choices. For the case patient, a 58-year-old African American woman with diabetes and dyslipidemia, the guidelines recommend a goal blood pressure of <140/90 mmHg and initial drug treatment with a thiazide diuretic or calcium channel blocker. Lifestyle modifications including dietary changes, exercise, weight control, and limiting alcohol and salt are also emphasized.
This document provides clinical practice guidelines for the management of hypertension. It defines hypertension and classifies it into various types including isolated systolic, isolated office, and masked hypertension. It recommends evaluating patients to identify secondary causes, target organ damage, and risk factors. Treatment involves non-pharmacological lifestyle changes as well as drug therapy. Special populations like those with diabetes, renal disease, or the elderly may require different treatment goals or strategies. The guidelines cover initial assessment, treatment options including various drug classes, management of resistant/refractory cases, and special groups.
Described the BP targets in Ischemic stroke with and without IV thrombolysis, with and without mechanic thrombectomy, Intra cerebral Heamorrhage, SAH and other Neurological emergencies with revised AHA/ ASA upated guidelines
ALSO showed different journal evidence of work on blood pressure management in acute ischemic and heamorrhagic stroke, BP tergets in SAH, PRES
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
1) The document compares the 2017 guidelines for hypertension from Hypertension Canada and the American Heart Association/American College of Cardiology.
2) There are some differences in definitions of elevated blood pressure and hypertension thresholds. Hypertension Canada guidelines are more evidence-based while AHA/ACC guidelines are more pragmatic.
3) Both emphasize accurate blood pressure measurement and recommend similar non-pharmacological interventions like weight loss, diet changes, and increased physical activity. However, they differ on when to initiate drug therapy and targets for specific patient groups.
The document outlines guidelines for the management of arterial hypertension from the 2018 ESC/ESH conference. It discusses definitions of hypertension, recommendations for blood pressure measurement, classifications of hypertension, screening and diagnosis, assessment of hypertension-mediated organ damage, and initiation of blood pressure-lowering treatment. Key points include defining hypertension as a blood pressure over 140/90 mmHg, outlining options for office and out-of-office blood pressure measurement, stratifying cardiovascular risk, and recommending prompt initiation of treatment for grade 2 or 3 hypertension or grade 1 hypertension with high risk or organ damage.
Hypertension 2018 Guidelines - prof. Tarek Medhat MNDU net
Hypertension guidelines have been updated with several key changes:
1. The definition of hypertension is now lower at 130/80 mmHg or higher which means more people will be classified as hypertensive.
2. The term "prehypertension" has been eliminated and replaced with "elevated blood pressure" for readings of 120-129/80 mmHg or lower.
3. More emphasis is placed on accurately measuring blood pressure at home or with ambulatory monitoring to detect white coat hypertension or masked uncontrolled hypertension.
4. Treatment goals for blood pressure are now lower, especially for those with cardiovascular disease.
This document discusses guidelines for the treatment of hypertension from multiple organizations and studies. It provides recommendations for treatment thresholds, goals, and initial drug choices. For the case patient, a 58-year-old African American woman with diabetes and dyslipidemia, the guidelines recommend a goal blood pressure of <140/90 mmHg and initial drug treatment with a thiazide diuretic or calcium channel blocker. Lifestyle modifications including dietary changes, exercise, weight control, and limiting alcohol and salt are also emphasized.
This document provides clinical practice guidelines for the management of hypertension. It defines hypertension and classifies it into various types including isolated systolic, isolated office, and masked hypertension. It recommends evaluating patients to identify secondary causes, target organ damage, and risk factors. Treatment involves non-pharmacological lifestyle changes as well as drug therapy. Special populations like those with diabetes, renal disease, or the elderly may require different treatment goals or strategies. The guidelines cover initial assessment, treatment options including various drug classes, management of resistant/refractory cases, and special groups.
Described the BP targets in Ischemic stroke with and without IV thrombolysis, with and without mechanic thrombectomy, Intra cerebral Heamorrhage, SAH and other Neurological emergencies with revised AHA/ ASA upated guidelines
ALSO showed different journal evidence of work on blood pressure management in acute ischemic and heamorrhagic stroke, BP tergets in SAH, PRES
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
Ten commandments of the 2018 esc guidelines on hypertension in adultsDavid Arias
The document summarizes key points from the 2018 European Guidelines for the treatment of hypertension. It defines hypertension as a systolic BP of 140 mmHg or higher and/or a diastolic BP of 90 mmHg or higher. It recommends screening all adults for high BP at least every 5 years. It advises initiating drug treatment for adults under 80 with grade 1 hypertension if lifestyle changes do not control their BP and immediately for those with higher grades of hypertension or who are high risk. It provides targets for lowering BP through lifestyle changes and medications.
New 2017 aha acc hypertension guidelinesgisa_legal
The new Hypertension Guideline lowers the threshold for diagnosing hypertension from 140/90 mm Hg to 130/80 mm Hg. This means nearly half of American adults now have hypertension based on the new definition. The guideline provides new treatment recommendations including lifestyle changes and BP-lowering medications. It also emphasizes accurate BP measurement and self-monitoring by patients at home.
This document provides guidance on managing patients with hypertension. It begins with 3 practice questions on hypertension management goals and treatment options. The main points covered include defining hypertension and its importance, diagnostic criteria requiring multiple measurements, classification of primary vs secondary hypertension, lifestyle modifications and drug treatment options. Target blood pressure is outlined as <130/80 mmHg with considerations for elderly patients. First-line drug options include thiazide diuretics, calcium channel blockers, ACE inhibitors and ARBs. Combination therapy may be needed to control high blood pressure.
Actilyse_E2E_IV thrombolysis in high-risk AIS patients_V2.pptxRahulJankar4
This document discusses intravenous thrombolysis with alteplase in high-risk acute ischemic stroke patients. It begins by reviewing the evidence from major clinical trials that established alteplase as the standard of care for stroke thrombolysis within 4.5 hours of symptom onset. It then examines the evidence for thrombolysis in several high-risk patient profiles, including those with cardioembolic stroke, recent myocardial infarction, baseline hyperglycemia, and hypertension. For hypertension, it discusses management to control blood pressure before and after thrombolysis to reduce hemorrhagic risks while maintaining cerebral perfusion. The document concludes that alteplase is effective and safe for thrombolysis in acute ischemic stroke patients with baseline blood
This document discusses updates to NICE guidelines for managing hypertension. Key changes include recommendations for using ambulatory or home blood pressure monitoring to confirm diagnoses, treating stage 1 hypertension only for those over age 80 or with other risk factors, aiming for lower blood pressure targets, and considering new drug classes like direct renin inhibitors or higher diuretic doses for resistant hypertension. The guidelines emphasize shared decision making and culturally appropriate care and communication.
This document provides an overview of hypertension including definitions, staging, types, risk factors, complications, testing, treatment and management. It defines normal, elevated, stage 1 and stage 2 hypertension based on blood pressure readings. It also discusses white coat and masked hypertension. Treatment involves nonpharmacological and pharmacological approaches. Drugs like thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers are first-line treatment options. Resistant hypertension and hypertension in special groups like pregnancy are also addressed.
This document defines hypertension and provides classifications and terminology. It discusses the epidemiology, aetiology, evaluation, and management of hypertension. Some key points:
- Hypertension is defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg.
- Causes of hypertension include essential (95% of cases), secondary to conditions like CKD or Cushing's syndrome.
- Evaluation involves history, exam, urine/blood tests, ECG to assess target organ damage.
- Treatment involves lifestyle changes and medication. Goals are SBP <140 mmHg and DBP <90 mmHg.
- Classes of medications for treatment include diuretics, ACE
High blood pressure (BP) is a major cause of death worldwide. Non-pharmacological management of hypertension includes weight loss and following the DASH diet. Pharmacological treatment should be initiated when BP is above 140/90 mmHg or 150/90 mmHg for those over 60, and targets are not met within 1 month additional medication should be added. For hypertensive emergencies associated with end organ damage, BP should be reduced up to 25% within the first hour. Calcium channel blockers and combining drugs at lower doses are preferable for elderly patients.
This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.
This document discusses diagnostic challenges and treatment dilemmas related to arterial hypertension. It covers topics such as accurate blood pressure measurement methods, diagnosing hypertension using out-of-office assessments like ambulatory blood pressure monitoring and home monitoring, assessing overall cardiovascular risk, evaluating for secondary causes of hypertension like renovascular disease and hyperaldosteronism, and the role of echocardiography in hypertension management.
The document summarizes key points from the 2017 ACC/AHA hypertension clinical practice guidelines. It outlines a new blood pressure classification system with lower targets for managing hypertension. It emphasizes accurate blood pressure measurement, lifestyle modifications like weight loss and reducing sodium intake, and initial treatment with thiazide diuretics, calcium channel blockers, or ACE inhibitors/ARBs. The guidelines recommend developing a specific care plan to achieve and sustain blood pressure control through reducing cardiovascular risk factors and social determinants of health.
This document provides information about hypertension management through a series of questions and presentations. It begins with 3 multiple choice questions about hypertension management goals, recommended first-line drugs, and blood pressure staging. The subsequent presentations define blood pressure, discuss white coat hypertension, screening recommendations, hypertension classification, etiology, duration and incidence. It also covers hypertension evaluation, secondary causes, treatment approaches including lifestyle modifications and pharmacotherapy, special patient considerations, and resistant hypertension.
Management of hypertensive condition in 2020 according to AHA/ASA guidelines. We will discuss the presentation, clinical assessment, investigations, and management of hypertension along with major randomized controlled trials and guidelines.
A hypertensive crisis is a sudden spike in blood pressure to 180/120 mmHg or higher, which is a medical emergency that could lead to organ damage or be life-threatening. Symptoms include headaches, confusion, chest pain, nausea, and weakness. Causes include non-compliance with medications, high salt/fat diets, certain drugs, kidney disease, and hormone imbalances. Treatment involves reducing blood pressure in the ICU over hours to days depending on any organ damage present. Nursing care focuses on monitoring, medication administration, lifestyle changes, and education to prevent future crises.
Management of hypertension in acute strokeSudhir Kumar
Hypertension is an important and common risk factor for brain stroke- both ischemia and hemorrhagic subtypes. Appropriate management of blood pressure is crucial for good recovery rom acute stroke, and prevent recurrence of stroke. This presentation looks at the role played by hypertension in causing first ever and recurrent strokes. The current guidelines are also discussed.
The document discusses hypertension, including its definition, prevalence, risk factors, categories, and guidelines for assessment and treatment. Some key points:
- Hypertension is defined as BP ≥140/90 mmHg. It affects over 1 billion people globally with a prevalence of 30-45% in adults.
- Common risk factors include diabetes, dyslipidemia, obesity, and chronic kidney disease.
- Categories range from normal BP to grade 3 hypertension based on systolic and diastolic BP levels.
- Risk assessment uses the SCORE system to estimate 10-year fatal CVD risk based on factors like age and cholesterol.
- Out-of-office BP measurements via home monitoring or amb
This document discusses the evaluation and management of hypertension. It covers definitions of hypertension, reasons for treating it due to health risks like stroke and heart disease. It discusses causes like behaviors and genetics. It outlines diagnosing hypertension through various blood pressure measurements and assessing cardiovascular risk. Treatment involves lifestyle changes and medication, with goals of controlling blood pressure to reduce health risks. It addresses treatment-resistant cases and improving medication adherence.
This document provides guidelines for the treatment of hypertension. It discusses the definition and classification of hypertension according to the JNC 7 report. Evaluation of patients involves measuring blood pressure accurately, assessing risk factors, checking for target organ damage, and identifying secondary causes. Treatment goals depend on patient population, with the general goal being under 140/90 mmHg. Initial drug therapy involves thiazide diuretics, ACE inhibitors, ARBs, or CCBs. Lifestyle modifications including salt restriction, moderation of alcohol, regular exercise, weight control, and smoking cessation are also recommended.
This document summarizes death audit data from the MICU, ward, and total for September 2023. It shows that there were 22 total deaths, with 9 from the ward and 13 from the MICU. The leading causes of death were central nervous system issues (6 deaths), gastrointestinal/hepatobiliary issues (5 deaths), and respiratory system issues (3 deaths). It also provides more detailed information on each death, including diagnosis, length of stay, and ICD code. There were no deaths reported from infectious diseases, PLHIV, or snake bites.
Dr. Anitha M. S and Dr. Shubham sabne discussed the case of a 17-year-old male brought to the emergency department with abdominal pain, inability to sit up or open his mouth widely. After examining the patient and reviewing his history of a nail prick injury 15 days prior, tetanus was suspected. Laboratory tests and imaging were unremarkable. The patient was given tetanus immunoglobulin, magnesium sulfate, diazepam, metronidazole, and ceftriaxone. Tetanus causes muscle spasms through neurotoxins that block inhibition in the spinal cord. Proper wound care and vaccination are important to prevent this potentially fatal disease.
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Ten commandments of the 2018 esc guidelines on hypertension in adultsDavid Arias
The document summarizes key points from the 2018 European Guidelines for the treatment of hypertension. It defines hypertension as a systolic BP of 140 mmHg or higher and/or a diastolic BP of 90 mmHg or higher. It recommends screening all adults for high BP at least every 5 years. It advises initiating drug treatment for adults under 80 with grade 1 hypertension if lifestyle changes do not control their BP and immediately for those with higher grades of hypertension or who are high risk. It provides targets for lowering BP through lifestyle changes and medications.
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The new Hypertension Guideline lowers the threshold for diagnosing hypertension from 140/90 mm Hg to 130/80 mm Hg. This means nearly half of American adults now have hypertension based on the new definition. The guideline provides new treatment recommendations including lifestyle changes and BP-lowering medications. It also emphasizes accurate BP measurement and self-monitoring by patients at home.
This document provides guidance on managing patients with hypertension. It begins with 3 practice questions on hypertension management goals and treatment options. The main points covered include defining hypertension and its importance, diagnostic criteria requiring multiple measurements, classification of primary vs secondary hypertension, lifestyle modifications and drug treatment options. Target blood pressure is outlined as <130/80 mmHg with considerations for elderly patients. First-line drug options include thiazide diuretics, calcium channel blockers, ACE inhibitors and ARBs. Combination therapy may be needed to control high blood pressure.
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This document discusses intravenous thrombolysis with alteplase in high-risk acute ischemic stroke patients. It begins by reviewing the evidence from major clinical trials that established alteplase as the standard of care for stroke thrombolysis within 4.5 hours of symptom onset. It then examines the evidence for thrombolysis in several high-risk patient profiles, including those with cardioembolic stroke, recent myocardial infarction, baseline hyperglycemia, and hypertension. For hypertension, it discusses management to control blood pressure before and after thrombolysis to reduce hemorrhagic risks while maintaining cerebral perfusion. The document concludes that alteplase is effective and safe for thrombolysis in acute ischemic stroke patients with baseline blood
This document discusses updates to NICE guidelines for managing hypertension. Key changes include recommendations for using ambulatory or home blood pressure monitoring to confirm diagnoses, treating stage 1 hypertension only for those over age 80 or with other risk factors, aiming for lower blood pressure targets, and considering new drug classes like direct renin inhibitors or higher diuretic doses for resistant hypertension. The guidelines emphasize shared decision making and culturally appropriate care and communication.
This document provides an overview of hypertension including definitions, staging, types, risk factors, complications, testing, treatment and management. It defines normal, elevated, stage 1 and stage 2 hypertension based on blood pressure readings. It also discusses white coat and masked hypertension. Treatment involves nonpharmacological and pharmacological approaches. Drugs like thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers are first-line treatment options. Resistant hypertension and hypertension in special groups like pregnancy are also addressed.
This document defines hypertension and provides classifications and terminology. It discusses the epidemiology, aetiology, evaluation, and management of hypertension. Some key points:
- Hypertension is defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg.
- Causes of hypertension include essential (95% of cases), secondary to conditions like CKD or Cushing's syndrome.
- Evaluation involves history, exam, urine/blood tests, ECG to assess target organ damage.
- Treatment involves lifestyle changes and medication. Goals are SBP <140 mmHg and DBP <90 mmHg.
- Classes of medications for treatment include diuretics, ACE
High blood pressure (BP) is a major cause of death worldwide. Non-pharmacological management of hypertension includes weight loss and following the DASH diet. Pharmacological treatment should be initiated when BP is above 140/90 mmHg or 150/90 mmHg for those over 60, and targets are not met within 1 month additional medication should be added. For hypertensive emergencies associated with end organ damage, BP should be reduced up to 25% within the first hour. Calcium channel blockers and combining drugs at lower doses are preferable for elderly patients.
This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.
This document discusses diagnostic challenges and treatment dilemmas related to arterial hypertension. It covers topics such as accurate blood pressure measurement methods, diagnosing hypertension using out-of-office assessments like ambulatory blood pressure monitoring and home monitoring, assessing overall cardiovascular risk, evaluating for secondary causes of hypertension like renovascular disease and hyperaldosteronism, and the role of echocardiography in hypertension management.
The document summarizes key points from the 2017 ACC/AHA hypertension clinical practice guidelines. It outlines a new blood pressure classification system with lower targets for managing hypertension. It emphasizes accurate blood pressure measurement, lifestyle modifications like weight loss and reducing sodium intake, and initial treatment with thiazide diuretics, calcium channel blockers, or ACE inhibitors/ARBs. The guidelines recommend developing a specific care plan to achieve and sustain blood pressure control through reducing cardiovascular risk factors and social determinants of health.
This document provides information about hypertension management through a series of questions and presentations. It begins with 3 multiple choice questions about hypertension management goals, recommended first-line drugs, and blood pressure staging. The subsequent presentations define blood pressure, discuss white coat hypertension, screening recommendations, hypertension classification, etiology, duration and incidence. It also covers hypertension evaluation, secondary causes, treatment approaches including lifestyle modifications and pharmacotherapy, special patient considerations, and resistant hypertension.
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A hypertensive crisis is a sudden spike in blood pressure to 180/120 mmHg or higher, which is a medical emergency that could lead to organ damage or be life-threatening. Symptoms include headaches, confusion, chest pain, nausea, and weakness. Causes include non-compliance with medications, high salt/fat diets, certain drugs, kidney disease, and hormone imbalances. Treatment involves reducing blood pressure in the ICU over hours to days depending on any organ damage present. Nursing care focuses on monitoring, medication administration, lifestyle changes, and education to prevent future crises.
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Hypertension is an important and common risk factor for brain stroke- both ischemia and hemorrhagic subtypes. Appropriate management of blood pressure is crucial for good recovery rom acute stroke, and prevent recurrence of stroke. This presentation looks at the role played by hypertension in causing first ever and recurrent strokes. The current guidelines are also discussed.
The document discusses hypertension, including its definition, prevalence, risk factors, categories, and guidelines for assessment and treatment. Some key points:
- Hypertension is defined as BP ≥140/90 mmHg. It affects over 1 billion people globally with a prevalence of 30-45% in adults.
- Common risk factors include diabetes, dyslipidemia, obesity, and chronic kidney disease.
- Categories range from normal BP to grade 3 hypertension based on systolic and diastolic BP levels.
- Risk assessment uses the SCORE system to estimate 10-year fatal CVD risk based on factors like age and cholesterol.
- Out-of-office BP measurements via home monitoring or amb
This document discusses the evaluation and management of hypertension. It covers definitions of hypertension, reasons for treating it due to health risks like stroke and heart disease. It discusses causes like behaviors and genetics. It outlines diagnosing hypertension through various blood pressure measurements and assessing cardiovascular risk. Treatment involves lifestyle changes and medication, with goals of controlling blood pressure to reduce health risks. It addresses treatment-resistant cases and improving medication adherence.
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3) Treatment involves initiating antihypertensive drug therapy with lifestyle modifications and titrating medications to achieve a blood pressure target of less than 130/80 mm Hg for most patients.
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Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Thinking of getting a dog? Be aware that breeds like Pit Bulls, Rottweilers, and German Shepherds can be loyal and dangerous. Proper training and socialization are crucial to preventing aggressive behaviors. Ensure safety by understanding their needs and always supervising interactions. Stay safe, and enjoy your furry friends!
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This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
Physiology and chemistry of skin and pigmentation, hairs, scalp, lips and nail, Cleansing cream, Lotions, Face powders, Face packs, Lipsticks, Bath products, soaps and baby product,
Preparation and standardization of the following : Tonic, Bleaches, Dentifrices and Mouth washes & Tooth Pastes, Cosmetics for Nails.
2. • Hypertension is defined as systolic blood pressure (SBP) of 140
mmHg or greater, diastolic blood pressure (DBP) of 90 mmHg or
greater, or taking antihypertensive medication.
3. BLOOD PRESSURE MEASUREMENT
• Options
- Office BP measurement
- Out of office BP measurement
1. • mbulatory Blood Pressure Monitoring ( BPM)
2. • Home Blood Pressure Monitoring (HBPM)
4. Office Blood Pressure monitoring
• Most widely performed
• Easy, cost effective
• Most of the studies use office BP
5. Office Blood Pressure monitoring
• Between-arm SBP difference of >15 mmHg is suggestive of
atheromatous disease and is associated with an increased CV risk.
• If a between-arm difference in BP is recorded, then it is
recommended that all subsequent BP readings use the arm with the
higher BP reading.
2018 ESC/ESH Guidelines
6. ABPM: Ambulatory BP monitoring
Advantages
• Can identify white-coat and masked hypertension
• Stronger prognostic evidence
• Night-time readings
• Measurement in real-life settings
• Abundant information from a single measurement session, including
short-term BP Variability
• Detect postural and postprandial hypotension
• Evaluation of resistant hypertension
• ssessment of symptoms of hypotension
during course of treatment
• Evaluate considerable variability of office BP
7. ABPM: Ambulatory BP monitoring
Disadvantages
• Expensive and sometimes limited availability
• Can be uncomfortable
8. HBPM: Home BP monitoring
Advantages
• Can identify white-coat and masked
hypertension
• Cheap and widely available
• Measurement in a home setting, which may
be more relaxed than the doctor’s office
• Patient engagement in BP measurement
• Easily repeated and used over longer periods
to assess day-to-day BP variability
9. HBPM: Home BP monitoring
Disadvantages
• Only static BP is available
• Potential for measurement error
• No nocturnal readings
10. Scope of Out-of-office BP
Out-of-office BP (i.e. ABPM or HBPM) is specifically recommended for a
number of clinical indications, such as
• identifying white coat and masked hypertension,
• Quantifying the effects of treatment, and
• identifying possible causes of side effects (e.g. symptomatic
hypotension).
11. Gangrene of the
Heart Left Ventricular
Hypertrophy
Lower Extremities
Aortic
Aneurysm
Failure Myocardial
Infarction
Coronary Heart
Disease
HYPERTENSION
Hypertensive
Blindness
Chronic
Kidney
Failure
Stroke Preeclampsia/
Eclampsia
encephalopathy
Cerebral
Hemorrhage
12. HYPERTENSION GUIDELINES͙..
• Indian Guidelines on Hypertension IV- 2019
LATEST
• American College of Cardiology (ACC)/American Heart Association
(AHA)-2017
• European Society of Cardiology (ESC)/European Society of
Hypertension (ESH)-2018
• American Society of Hypertension(ASH)-2014
• WHO classification/International Society of Hypertension(ISH)-2014
• Joint National Committee (JNC 8)- merica’s -2014
• Canadian Hypertension Education Program (CHEP) guidelines-2015
13. HYPERTENSION GUIDELINES
• The lengthy delay in producing revision reflects vulnerability of the
guideline process?
• What to follow?
14. change in definition of HTN
• ACC/ AHA guidelines were released in November, 2017. They have
changed the definition of hypertension from 140/90 to 130/80 mm
Hg.
• This change was primarily on the basis of interpretation of the SPRINT
(Systolic Blood Pressure Intervention Trial) study which was published
in November, 2015.
• The ACC/ AHA have categorised the BP levels as normal, elevated,
stage 1 and stage 2 HTN.
• ESC/FSH guidelines have refined the previous categories of HTN as
optimal, normal, high normal, grade l, 2, and 3 HTN and isolated
systolic hypertension (ISH)
15. change in definition of HTN͙But͙.?
• The latest Canadian guidelines 2017 and the Australian
guidelines 2016 were both released after the SPRINT study but
they have retained the original definition of 140/90 mm Hg.
• The European Society of Hypertension and European Society of
Cardiology (ESH/ESC) have recently come out with their 2018
guidelines and are the most recent ones. They also did not change
the original definition of 140/90 mm Hg.
• Thus, most experts are not ready to change the definition of
hypertension as has been done in the ACC/ AHA guidelines
17. ACC/AHA guidelines: perfect?
• It is well known that with increasing levels of BP the
target organ damage is higher. Two patients—one with a
BP of 144/90 mmHg and other with a BP of 190/110mmHg—will
be stamped and diagnosed as stage 2 H TN according to
the ACC/ AHA guidelines which pretty much down sizes
the magnitude of the problem in the second patient.
• The ACC/ AHA also does not give much importance to the well-
known entity of ISH which is very common in the elderly
and which mandates special attention
• ACC/AHA have clubbed all such patients also the same entity of stage 2
HTN.
18. Guidelines in India
• The latest Indian guidelines on hypertension (Indian Guidelines on
Hypertension (IGH) IV) from the Association of Physicians of India
(API), were released in October 2019.
• Definition : Remains same
20. HYPERTENSIVE EMERGENCIES (MALIGNANT HYPERTENSION)
• BP >180/120 mmHg, complicated by evidence of impending or progressive target
organ dysfunction.
• Examples :Hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left
ventricular failure with pulmonary edema, unstable angina pectoris, aortic dissection,
or eclampsia.
• IV nitroglycerine is generally used, recommended dose is initially 5mcg/min, then
titrate by 5 mcg/min at 3 to 5 minute intervals, upto 10 mcg/min.
• IV Labetalol is also being used in hypertensive emergencies in a bolus dosage of 2-10
mg and infusion of 2.5-30 mcg/kg/min.
• IV enalaprilat is useful in presence of heart failure.
• IV esmolol has been shown to be specially useful for peri-operative HE
• IV nitroprusside is required rarely, in situations like dissection of aorta and
subarachnoid haemorrhage with very high blood pressure.
• Sublingual captopril can also be used when less rapid reduction is required.
21. HYPERTENSIVE URGENCIES (ACCELERATED HYPERTENSION)
• BP >180/120 mmHg without progressive target organ dysfunction.
Examples :upper levels of stage II hypertension associated with severe
headache, shortness of breath, epistaxis, or severe anxiety.
• Aim should be safe, prompt and gradual lowering of blood pressure
with oral medication over a period of 1-3 days. In most urgencies,
blood pressure can be controlled with rapidly acting oral medications
like calcium channel blockers and ACEI/ARB.
• Sublingual nifedipine should not be used in hypertensive crises as it
can cause precipitous fall in blood pressure, reflex tachycardia and
may precipitate renal, cerebral or coronary hypoperfusion.
22. RESISTANT HYPERTENSION : DEFINITION
Uncontrolled BP in spite of concurrent use of 3 anti hypertensive
agents of different classes in which are at maximum tolerated dose.
24. Resistant hypertension :Causes
• Secondary causes of
hypertension
• - Chronic kidney disease
• - Coarctation of the aorta
• - Non-specific aortoarteritis
• - Cushing syndrome and other
glucocorticoid excess states
including chronic steroid therapy
• - Obstructive uropathy
• - Pheochromocytoma
• - Primary aldosteronism and
other mineralocorticoid excess
states
• - Renovascular hypertension
• - Obstructive sleep apnea
syndrome
•-Thyroid or parathyroid disease
25. Initiation of therapy IGH-IV
• Stage I hypertension
lifestyle modification
repeat readings within 2-3 weeks
Pharmacotherapy after 1 month.
• stage II hypertension & Stage III hypertension
shorter waiting period . ie,repeat readings after few hours will be
desirable.
26. Initiation of therapy IGH-IV
• BP needs to be recorded in both arms and in lying and standing
before initiation of pharmacotherapy
• In patients who have evidence of ASCVD and HMOD,
pharmacotherapy should be started early.
• DBP is a more potent cardiovascular risk factor than SBP until age 50;
thereafter, SBP is more important
• SBP is a major risk factor for CVDs. The rise in SBP continues
throughout life while Diastolic hypertension predominates before 50
years of age, .
27. ASCVD Risk Calculator
• http://static.heart.org/riskcalc/
app/index.html#!/baseline-risk
• The purpose of the ASCVD Risk
Calculator is to estimate a
patient’s 10-year ASCVD risk at
an initial visit to establish a
reference point.
• More than 10% is significant.
28. ACC / AHA Initiation of therapy
Hypertension: stage 1
Assess the 10-year risk for heart disease and stroke using
the atherosclerotic cardiovascular disease (ASCVD) risk calculator
• If risk is less than 10%, start with healthy lifestyle recommendations and
reassess in 3-6 months
• If risk is greater than 10% or the patient has known clinical cardiovascular
disease (CVD), diabetes mellitus, or chronic kidney disease, recommend
lifestyle changes and BP-lowering medication (1 medication); reassess in
1 month for effectiveness of medication therapy
-- If goal is met after 1 month, reassess in 3-6 months
-- If goal is not met after 1 month, consider different medication
or titration
-- Continue monthly follow-up until control is achieved
29. ACC / AHA Initiation of therapy
Hypertension: stage 2
Recommend healthy lifestyle changes and BP-lowering medication (2
medications of different classes) reassess in 1 month for effectiveness
• If goal is met after 1 month, reassess in 3-6 months
• If goal is not met after 1 month, consider different medications or
titration
• Continue monthly follow-up until control is achieved
31. GOAL
The first objective of treatment should be to lower BP to <140/90 mmHg in all patients
And if well tolerated
<65 years <130/80
>65 years <140/80
32. GOAL
Clinical Condition(s)
BP Goal,
mm Hg
General
Clinical CVD or 10-year SCVD risk ≥10%
No clinical CVD and 10-year ASCVD risk <10%
Older persons (≥65 years of age͖ noninstitutionalized, <130/80
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus
Chronic kidney disease
Chronic kidney disease after renal transplantation
Heart failure <130/80
Stable ischemic heart disease
Secondary stroke prevention
Secondary stroke prevention (lacunar)
Peripheral arterial disease
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.
33. • Lose weight, if overweight
• Increase physical activity :30-45 minutes of brisk walking or swimming at
least 3-4 times a week could lower SBP by 7-8 mm Hg.
Isometric exercises such as weight lifting should be avoided
• Daily intake of salt should be restricted to 6gms (amounting to 3-4 gms of
sodium)
1 tsp of salt (flattened) = 5g of salt. A hypertensive patient should eat not more that 5 g of salt in a day.
• Stop smoking. E cigarettes are also harmful
• Limit intake of foods rich in fats and cholesterol
• Increase consumption of fruits and vegetables
• Alcohol consumption should be limited to no more than 2 drinks per day
(24oz beer, 10oz wine, 3oz 80-proof whiskey)
37. ACC/AHA-2017 comments on antihypertensive
When initiating antihypertensive drug
therapy, use first-line agents that include
• Thiazide diuretics
• Calcium channel blockers
• ACE inhibitors or ARBs
38. ACE inhibitors
Do not use in combination with ARBs or direct
renin inhibitor
•
Increased risk of hyperkalemia, especially in
patients with chronic kidney disease or in those
on K+ supplements, or K+ sparing drugs
•
May cause acute renal failure in patients with
severe bilateral renal artery stenosis
•
Do not use if history of angioedema with ACE
inhibitors
39. ACE inhibitors
ACE inhibitors are first line agents in patients with diabetes, individuals
with other metabolic risk factors, post-MI and patients with heart
failure. In diabetes mellitus, they retard the onset and progression of
renal disease (patients with microalbuminuria and early CKD).
40. ARBs
Do not use in combination with ACE/direct renin
inhibitors
•
Increased risk of hyperkalemia in chronic kidney disease
or in those on K+ supplements or K+ sparing drugs
•
May cause acute renal failure in patients with severe
bilateral renal artery stenosis
•
Do not use if history of angioedema with ARBs.
patients with a history of angioedema with an ACE
inhibitor can receive an ARB beginning 6 weeks after ACE
inhibitor discontinued
41. ARBs
• In the recent randomized double blind ROADMAP89 trial involving
4,447 diabetic patients with olmesartan (40 mg OD), the onset of
microalbuminuria has been shown to be delayed in patients with type
2 diabetes.
• Monitoring eGFR change and serum potassium should be added.
This monitoring should be after 1 week of initiating this therapy and
after each dose increase.
42. CCB—dihydropyridines
•
Avoid use in patients with heart failure with reduced ejection
fraction
•
But amlodipine or felodipine may be used in the presence of
congestive heart failure if required as no effect on heart rate
and cardiac contractility, hence safe even
•
Associated with dose-related pedal edema.
43. Thiazide or
thiazide-like diuretics
Chlorthalidone preference based on prolonged half-life and proven trial
reduction of CVD
•
Monitor for hyponatremia and hypokalemia, uric acid and calcium
levels (CI in Gout). Steroids can worsen hypokalemia due to diuretics.
•
Use with caution in patients with history of acute gout unless patient is
on uric acid-lowering therapy
44. Diuretics—loop
•
Preferred diuretics in patients with symptomatic heart
failure
•
Preferred over thiazides in patients with moderate-to-
severe chronic kidney disease (eg:GFR <30 mL/min)
45. Diuretics—potassium sparing
•
Monotherapy agents minimally effective
antihypertensives
•
Combination therapy of potassium-sparing diuretic
with a thiazide can be considered in patients with
hypokalemia on thiazide monotherapy
•
Avoid in patients with significant chronic kidney disease
(eg, GFR <45 mL/min)
46. Diuretics—aldosterone antagonists
•
Preferred agents in primary aldosteronism and resistant
hypertension
•
Spironolactone associated with greater risk of gynecomastia
and impotence compared to eplerenone
•
Common add-on therapy in resistant hypertension
•
Avoid use with K+ supplements, other K+-sparing diuretics
or significant renal dysfunction
•
Eplerenone often requires twice daily dosing for adequate
BP lowering
47. β-Blockers—cardioselective
β-Blockers are not recommended as first-line agents
unless the patient has ischemic heart disease or
heart failure
• Preferred in patients with bronchospastic airway
disease requiring a β-blocker
• Bisoprolol and metoprolol succinate preferred in
patients with heart failure with reduced ejection
fraction and in IHD
• Avoid abrupt cessation
48. Direct renin inhibitor
•
Do not use in combination with ACE inhibitors or ARBs
•
Aliskiren is very long acting
•
Increased risk of hyperkalemia in chronic kidney disease or in those on K+
supplements or K+-sparing drugs
•
May cause acute renal failure in patients with severe bilateral renal artery stenosis
•
Avoid in pregnancy
49. α1-blockers
•
Associated with orthostatic hypotension, especially in older adults
•
May consider as second-line agent in patients with concomitant benign
prostatic hyperplasia
50. Central α1-agonist and other centrally acting
drugs
•
Generally reserved as last-line due to significant central nervous system
adverse effects, especially in older adults
•
Avoid abrupt discontinuation of clonidine, which may induce
hypertensive crisis; clonidine must be tapered to avoid rebound
hypertension
51. TYPE 2 DM + HTN: SGLT2 inhibitors ͙͙?
• Empagliflozin, Canagliflozin and Dapagliflozin have been
evaluated recently amongst diabetic patients in three large
trials (EMPA-REG, CANVAS Program and DECLARE-TIMI 58).
These agents have significant CV benefits and reduce blood
pressure. They reduce BP significantly in patients of diabetes
or hypertension irrespective of the level of BP.
• There is significantly reduced progression of kidney disease
and renal events with these agents.
55. *GDMT beta blockers for BP control or relief of angina include carvedilol,
metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and
timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta
blocker
†If needed for BP control.
56. Treatment of hypertension in patients with CKD
BP goal <130/80 mm Hg
(Class I)
Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)
Yes No
ACE inhibitor Usual “first-line”
(Class IIa) medication choices
ACE inhibitor
intolera nt
Yes No
ARB* ACE inhibitor*
(Class IIb) (Class IIa)
57. Maintenance and Follow-up of
Therapy : IGH-IV
• At least once in a fortnight, blood pressure should be
measured at the clinic or at home