Introduction Classification of BP Total Cardiovascular Risk Stratification Pre Hypertension stage Four main classes of medication Medication based on the comorbidity Combination Therapy Treatment of acute complications Conclusion

1. MODERN PRINCIPLES OF HYPERTENSION TREATMENT
DR. VERMA NISHU

2. TOPICS
1. Introduction
2. Classification of BP
3. Total Cardiovascular Risk
Stratification
4. Pre Hypertension stage
5. Four main classes of
medication
6. Medication based on the
comorbidity
7. Combination Therapy
8. Treatment of acute
complications
9. Conclusion
DR. VERMA NISHU 20XX 2

3. INTRODUCTION
Hypertensive is a hemodynamic
disorder.
Defined as blood pressure level
above which investigation and
treatment do good more than
harm
A patient said to be
hypertensive when his
SBP>140mmHg and DBP>
90mmHg provided that the
patient is not on
antihypertensive drugs.
Risk factor for MI, Stroke, ARF
etc
DR. VERMA NISHU 20XX 3

4. CLASSIFICATION OF BP FOR ADULT (ESH-ESC GUIDELINES. 2003)
DR. VERMA NISHU 20XX 4

5. TOTAL CARDIOVASCULAR RISK STRATIFICATION
DR. VERMA NISHU 20XX 5

6. PRE HYPERTENSION STAGE
 BP less or equal to 140/90 (any one (SBP/DBP) can be considered)
 Start of medication in pre-hypertension stage not controlled inspite of Lifestyle
modification:
 Low salt intake (Restricted to 5-6g/day)
 Moderate alcohol intake
 Quit smoking
 Regular exercise (more than 30min/day)
 Increase vegetables, fruit, low fat dairy intake
 Waist circumference should be less than 102cm for men and 88cm for women
DR. VERMA NISHU 20XX 6

7. FOUR MAIN CLASSES OF MEDICATION:
1. ACE inhibitor
2. Angiotensin receptor blocker (ARBs)
3. Thiazide Diuretics
4. Long-Acting calcium channel blockers (Dihydropyridine)
There is a lot of variability in terms of how individuals respond to different medications, so it’s important to follow up
to see how the medications are working.
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8. Initial Drug Choices
HTN without compelling indication
Grade 1 HTN:
Thaiazide
May conider ACE inhibitor, ARB, beta blockers, CCB or combination
Grade 1I and III HTN:
Combination for Most.
(Thaiazide and ACE inhibitor or ARB or beta blockers or CCB).
HTN with compelling indication Drugs for the compelling indication
•Other antihypertensive drugs (Diuretics, ACE inhibitor or ARB or beta blockers or CCB).
DR. VERMA NISHU 20XX 8

9. DR. VERMA NISHU 20XX 9
THE MEDICATION YOU SHOULD CHOOSE BASED ON THE
COMORBIDITY OF THE PATIENT.

10. HYPERTENSION WITH HEART FAILURE:
The treatment should include :
 ACE inhibitors or ARBs,
 diuretics,
 aldosterone antagonists and
 Beta Blocker
Bear in mind :
 Beta Blocker must be used with caution in decompensated heart failure
which is when heart failure rapidly worsens.
 That’s because of their ability to decrease heart rate and their negative
inotropic effect, meaning that they decrease the force of heart contraction.
DR. VERMA NISHU 20XX 10

11. HYPERTENSION WITH DIABETES MELLITUS
The optimum treatment is
 ACE inhibitors or ARBs,
 Diuretics (Thiazide),
 Long-acting Calcium channel blockers and
 Beta Blocker
Bear in mind :
 ACE inhibitors or ARBs are protective against diabetic nephropathy.
 when using Beta Blocker, hypoglycemia is the side effect to watch out for, as it may go unnoticed, since Beta
Blocker blunt the counter- regulatory effects and symptoms of catecholamines, like tachycardia and tremors.
That’s particularly dangerous for people with diabetes , who already take a bunch of other hypoglycemic
medications like insulin.
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12. HYPERTENSION WITH ASTHMA
The treatment should include:
 ACE inhibitors or ARBs,
 Diuretics (Thiazide),
 Long-acting Calcium channel blockers (Dihydropyridine)
 Cardio-selective Beta Blocker
Bear in mind :
 Here we should avoid here is ACE inhibitors, since their most common side effect is cough.
 Cardio-selective Beta Blocker, which also block beta2 receptors in the lungs, cause bronchoconstriction.
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13. HYPERTENSION WITH PREGNANCY
The treatment should include:
 Hydralazine
 Methyldopa
 Labetalol
 Nifedipine
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14. COMBINATION THERAPY
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Possible combinations of classes of antihypertensive
drugs.
 Green continuous lines: preferred combinations;
 green dashed line: useful combination (with
some limitations);
 black dashed lines: possible but less well tested
combinations;
 red continuous line: not recommended
combination.
 Although verapamil and diltiazem are sometimes
used with a beta-blocker to improve ventricular
rate control in permanent atrial fibrillation, only
dihydropyridine calcium antagonists should
normally be combined with beta-blockers.

15. Treatment of acute complications

16. Hypertensive Urgency Hypertensive Emergency
Adjustment of oral antihypertensive medication IV medication like Nitroprusside, Labetalol
No need to decrease BP acutely Decrease BP immediately
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17. CONCLUSION
• Patients with DM & CKD require more aggressive BP control.
• Most patients with hypertension will require two or more
antihypertensive medications to control blood pressure.
• The use of combination therapy is appropriate as initial treatment.
• Sustained antihypertensive efficacy may protect against the early
morning rise in blood pressure that leads to heightened risk of
cardiovascular events.
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18. THANK YOU
DR. VERMA NISHU