This document discusses resistant hypertension and its treatment. It defines resistant hypertension as blood pressure that remains above goal despite use of three antihypertensive agents from different classes including a diuretic. Treatment involves identifying and treating secondary causes, adjusting medications that raise blood pressure, monitoring blood pressure outside the office, making lifestyle changes, and using pharmacologic therapies like diuretics, aldosterone antagonists, and catheter-based renal denervation. While renal denervation showed promise in early trials, the SYMPLICITY HTN-3 trial found it did not significantly reduce blood pressure compared to a sham procedure.
Hypertension: New Concepts, Guidelines, and Clinical Management Hypertensio...MedicineAndFamily
This document summarizes guidelines for diagnosing and treating hypertension. It discusses the prevalence of hypertension and cardiovascular disease in the US population. It reviews risk factors for hypertension and cardiovascular events. It also summarizes findings from clinical trials demonstrating the benefits of treating hypertension, including reduced risks of stroke, heart failure, and myocardial infarction. Thiazide diuretics are recommended as first-line treatment based on their effectiveness and lower costs.
1) For stroke prevention, intensive blood pressure lowering is recommended, with the lower the better. The target is below 115/75 mmHg for those under 60 and below 140/90 mmHg for those over 60.
2) In patients with acute ischemic stroke, it is unnecessary to lower blood pressure in the first 7 days unless systolic blood pressure is over 220 mmHg.
3) In intracerebral hemorrhage patients, the target systolic blood pressure is below 140 mmHg. More aggressive lowering to 120 mmHg is not necessary.
Resistant hypertension is defined as uncontrolled hypertension despite treatment with at least 3 antihypertensive drugs. It is increasingly common in clinical practice. The document outlines its definition, epidemiology, pathogenesis, diagnosis, and management approaches including lifestyle modifications, identifying and treating secondary causes, additional drug therapies, and device-based interventions.
Resistant hypertension is defined as blood pressure that remains above goal despite treatment with three antihypertensive agents from different classes, with one being a diuretic. Approximately 10% of hypertensive patients have resistant hypertension. Pseudoresistance can occur due to factors like poor medication adherence or white coat effect. Evaluation of resistant hypertension involves assessing for secondary causes, target organ damage, and ensuring true treatment resistance by addressing pseudoresistance factors. Treatment focuses on lifestyle modifications, optimizing medication adherence, addressing secondary causes, and adding additional antihypertensive agents such as mineralocorticoid receptor antagonists.
This document discusses resistant hypertension. It defines resistant hypertension as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, including a diuretic. It notes that resistant hypertension affects 10-20% of hypertensive patients and is associated with increased risk of cardiovascular events. The document outlines various causes of resistant hypertension including primary factors, secondary causes like obstructive sleep apnea and primary aldosteronism, and lifestyle and medication factors that can contribute. It provides guidance on evaluating and managing patients with resistant hypertension through lifestyle changes, medication optimization, and consideration of device therapies if needed.
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
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.
Hypertension: New Concepts, Guidelines, and Clinical Management Hypertensio...MedicineAndFamily
This document summarizes guidelines for diagnosing and treating hypertension. It discusses the prevalence of hypertension and cardiovascular disease in the US population. It reviews risk factors for hypertension and cardiovascular events. It also summarizes findings from clinical trials demonstrating the benefits of treating hypertension, including reduced risks of stroke, heart failure, and myocardial infarction. Thiazide diuretics are recommended as first-line treatment based on their effectiveness and lower costs.
1) For stroke prevention, intensive blood pressure lowering is recommended, with the lower the better. The target is below 115/75 mmHg for those under 60 and below 140/90 mmHg for those over 60.
2) In patients with acute ischemic stroke, it is unnecessary to lower blood pressure in the first 7 days unless systolic blood pressure is over 220 mmHg.
3) In intracerebral hemorrhage patients, the target systolic blood pressure is below 140 mmHg. More aggressive lowering to 120 mmHg is not necessary.
Resistant hypertension is defined as uncontrolled hypertension despite treatment with at least 3 antihypertensive drugs. It is increasingly common in clinical practice. The document outlines its definition, epidemiology, pathogenesis, diagnosis, and management approaches including lifestyle modifications, identifying and treating secondary causes, additional drug therapies, and device-based interventions.
Resistant hypertension is defined as blood pressure that remains above goal despite treatment with three antihypertensive agents from different classes, with one being a diuretic. Approximately 10% of hypertensive patients have resistant hypertension. Pseudoresistance can occur due to factors like poor medication adherence or white coat effect. Evaluation of resistant hypertension involves assessing for secondary causes, target organ damage, and ensuring true treatment resistance by addressing pseudoresistance factors. Treatment focuses on lifestyle modifications, optimizing medication adherence, addressing secondary causes, and adding additional antihypertensive agents such as mineralocorticoid receptor antagonists.
This document discusses resistant hypertension. It defines resistant hypertension as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, including a diuretic. It notes that resistant hypertension affects 10-20% of hypertensive patients and is associated with increased risk of cardiovascular events. The document outlines various causes of resistant hypertension including primary factors, secondary causes like obstructive sleep apnea and primary aldosteronism, and lifestyle and medication factors that can contribute. It provides guidance on evaluating and managing patients with resistant hypertension through lifestyle changes, medication optimization, and consideration of device therapies if needed.
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
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.
This document discusses hypertension in patients with chronic kidney disease. It begins by noting that hypertension and diabetes are leading causes of end-stage renal disease. It then discusses how poorly controlled hypertension can cause or accelerate renal failure. The document provides an overview of diseases attributable to hypertension and outlines the paradigm shift in hypertension therapy to focus on more than just lowering blood pressure. It also discusses lifestyle modifications, target organ damage, left ventricular hypertrophy, dipping patterns, morbidity and mortality related to hypertension, and approaches to hypertension treatment and management.
2022 Guideline for the Management of Heart Failure Clinical Update.pptxsubhankar16
This document summarizes guidelines from the 2022 AHA/ACC/HFSA for the diagnosis and management of heart failure. It defines the stages of heart failure from A to D and discusses evaluation, causes, biomarkers, imaging, and invasive testing. Key recommendations include using biomarkers like BNP and NT-proBNP to diagnose and manage HF. Transthoracic echocardiography is recommended for initial evaluation, and cardiac MRI, CT, or nuclear imaging if echo is inadequate. Invasive procedures are not routinely recommended but may help in select cases. Remote monitoring can benefit some patients with advanced HF.
This document discusses heart failure, including its increasing prevalence globally, definitions, classifications, management, and new strategies. Some key points:
- Heart failure prevalence is increasing worldwide and mortality remains high, around 50% within 5 years of diagnosis.
- The universal definition characterizes heart failure as a clinical syndrome caused by structural or functional cardiac abnormalities, accompanied by typical symptoms and signs.
- Management focuses on guideline-directed medical therapies (GDMT) including ACE inhibitors, ARBs, beta-blockers, and MRAs, though utilization remains suboptimal.
- The PARADIGM-HF trial showed the ARNI drug sacubitril/valsartan reduced cardiovascular death and heart failure
Hypertension is very common in patients with chronic kidney disease (CKD), affecting 67-92% of patients. Control of hypertension is important for slowing the loss of kidney function and reducing the risk of further kidney damage. The document discusses several risk factors for hypertension in CKD patients including older age, African descent, overweight or obesity, and concurrent diabetes or heart disease. It also reviews guidelines for treating hypertension in CKD, which generally recommend a target blood pressure under 140/90 mmHg and use of renin-angiotensin system blocking agents along with monitoring of kidney function and potassium levels.
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
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.
The document discusses hypertension in several special situations. It describes how hypertension commonly co-exists with conditions like diabetes, cerebrovascular disease, renal disease, and congestive heart failure. It provides guidelines on evaluating and managing blood pressure in these situations. For example, it recommends that antihypertensive therapy aims to reduce stroke risk in cerebrovascular disease and slow renal disease progression when hypertension is present with renal problems. The document also examines hypertension among different demographic groups like women, pregnant women, and the elderly.
Secondary hypertension - Etiopathogenesis, Clinical features, Advances in Man...Chetan Ganteppanavar
Secondary hypertension can be caused by renal or endocrine disorders. Renal causes include renal parenchymal diseases like glomerulonephritis which account for 2-5% of secondary hypertension cases. Renovascular hypertension from atherosclerosis or fibromuscular dysplasia is responsible for 1-3% of cases. Primary aldosteronism is an uncommon but important endocrine cause that can present with hypokalemic hypertension and is diagnosed through elevated aldosterone to renin ratio and saline suppression testing. Imaging and adrenal vein sampling are used to determine unilateral vs bilateral disease.
1) Cardiorenal syndrome commonly occurs in patients with acute decompensated heart failure and is associated with poor outcomes. It involves a complex interaction between hemodynamic alterations and activation of neurohormonal systems that affects both the heart and kidneys.
2) There are five types of cardiorenal syndrome classified based on the inciting cardiac or renal event and the affected secondary organs. Type 1 is acute cardiorenal syndrome due to acute worsening of cardiac function leading to kidney injury.
3) Loop diuretics are the mainstay of treatment for congestion in heart failure but aggressive diuresis may worsen kidney function. Other therapies discussed include inotropic agents, vasopressin antagonists
This document discusses the diagnosis and investigation of secondary hypertension. It describes various reversible and irreversible causes of secondary hypertension including renal, endocrine, vascular, and drug-related factors. It provides guidance on screening investigations including plasma and urine tests. It also outlines specialized tests that may be used to investigate particular causes such as renal artery stenosis, Conn's syndrome, phaeochromocytoma, and renal artery stenosis. These involve tests such as renal artery duplex ultrasound, CT/MRI scans, renal vein sampling, and MIBG scans.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
Guideline for the management of heart failureIqbal Dar
This document provides guidelines for the management of heart failure. It defines heart failure and outlines the stages from A to D. It recommends obtaining a thorough history and physical exam, diagnostic tests including biomarkers, and noninvasive cardiac imaging for initial and serial evaluation of heart failure patients. Invasive hemodynamic monitoring is recommended for selected patients with acute heart failure and impaired perfusion. Invasive coronary angiography is reasonable when ischemia may be contributing to heart failure.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document summarizes guidelines for treating hypertensive emergencies and urgencies. It defines hypertensive crisis as a severe elevation in blood pressure (>180/120 mmHg) and differentiates between emergencies and urgencies based on whether there is evidence of impending or progressive target organ dysfunction. The goal in treating hypertensive urgencies is to reduce mean arterial pressure by 10-15% within hours using oral medications. Hypertensive emergencies require more rapid blood pressure reduction, typically using intravenous medications, to prevent or limit end-organ damage. Lifestyle modifications and initial drug choices are outlined based on blood pressure levels and patient risk factors.
Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. It has a prevalence of 0.5-24.7% depending on the population. Causes include nonadherence, lifestyle factors like obesity and sleep apnea, secondary causes like primary aldosteronism and renal artery stenosis, and drug interactions. Evaluation involves assessing medication adherence, lifestyle behaviors, screening for secondary causes with tests like the aldosterone-renin ratio, and imaging of the kidneys and arteries. Management consists of optimizing lifestyle modifications, adjusting medications like adding mineralocorticoid receptor antagonists, and treating any identified
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
The document discusses resistant hypertension, defined as blood pressure above goal despite treatment with 3 or more antihypertensive drugs including a diuretic. Resistant hypertension affects up to 20% of hypertensive patients and increases cardiovascular risk. Causes include primary factors like age and secondary factors like primary aldosteronism. Pseudo-resistance can occur if measurements are inaccurate. Diagnosis requires excluding pseudo-resistance and investigating for reversible causes. Treatment involves lifestyle changes, adding additional drugs like spironolactone, or device therapies such as renal denervation or baroreflex activation. Target organ damage is common and includes left ventricular hypertrophy and kidney disease.
This document provides guidance on guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). It discusses initiation and titration of therapies including angiotensin receptor-neprilysin inhibitors, beta-blockers, sacubitril-valsartan, ivabradine, SGLT2 inhibitors, ACE inhibitors, ARBs, loop diuretics, and aldosterone antagonists. Key points include initiating therapies individually based on patient status, up-titrating doses every 2 weeks to maximize benefits, assessing for response using echocardiograms and biomarkers, and continuing GDMT even if ejection fraction improves to prevent heart failure events. Transcat
This document discusses hypertensive emergencies, which are severe cases of high blood pressure that result in acute organ damage. It defines categories of hypertensive states and provides details on etiology, pathophysiology, presentation, workup, and treatment of hypertensive emergencies. Treatment involves identifying the affected organ system and gradually lowering blood pressure over hours to days to prevent further organ injury, using intravenous medications like nitroprusside, labetalol, or nicardipine depending on the situation. Specific guidance is provided for rapidly lowering blood pressure in conditions like hypertensive encephalopathy, intracerebral hemorrhage, and ischemic stroke.
Resistant hypertension is defined as high blood pressure that remains above goal despite treatment with three or more antihypertensive medications, including a diuretic. Patients with resistant hypertension are at high risk for cardiovascular events and are more likely to have a secondary, potentially reversible cause of their hypertension. Treatment involves identifying and treating any underlying causes, optimizing medication regimens, lifestyle modifications, and specialist management. Recommended medication regimens include an ACE inhibitor or ARB, calcium channel blocker, and thiazide diuretic, with the addition of spironolactone or other agents if needed to achieve blood pressure control.
Hypertension, or high blood pressure, is classified as either primary (essential) or secondary. Primary hypertension accounts for 90% of cases and has no identifiable cause, while secondary hypertension is caused by an underlying condition like renal disease. Treatment involves lifestyle modifications and medication, with thiazide diuretics often used as initial therapy. Other common drug classes for treatment include ACE inhibitors, calcium channel blockers, beta blockers, and alpha blockers. Multiple drug therapy is usually required to control hypertension.
This document discusses hypertension in patients with chronic kidney disease. It begins by noting that hypertension and diabetes are leading causes of end-stage renal disease. It then discusses how poorly controlled hypertension can cause or accelerate renal failure. The document provides an overview of diseases attributable to hypertension and outlines the paradigm shift in hypertension therapy to focus on more than just lowering blood pressure. It also discusses lifestyle modifications, target organ damage, left ventricular hypertrophy, dipping patterns, morbidity and mortality related to hypertension, and approaches to hypertension treatment and management.
2022 Guideline for the Management of Heart Failure Clinical Update.pptxsubhankar16
This document summarizes guidelines from the 2022 AHA/ACC/HFSA for the diagnosis and management of heart failure. It defines the stages of heart failure from A to D and discusses evaluation, causes, biomarkers, imaging, and invasive testing. Key recommendations include using biomarkers like BNP and NT-proBNP to diagnose and manage HF. Transthoracic echocardiography is recommended for initial evaluation, and cardiac MRI, CT, or nuclear imaging if echo is inadequate. Invasive procedures are not routinely recommended but may help in select cases. Remote monitoring can benefit some patients with advanced HF.
This document discusses heart failure, including its increasing prevalence globally, definitions, classifications, management, and new strategies. Some key points:
- Heart failure prevalence is increasing worldwide and mortality remains high, around 50% within 5 years of diagnosis.
- The universal definition characterizes heart failure as a clinical syndrome caused by structural or functional cardiac abnormalities, accompanied by typical symptoms and signs.
- Management focuses on guideline-directed medical therapies (GDMT) including ACE inhibitors, ARBs, beta-blockers, and MRAs, though utilization remains suboptimal.
- The PARADIGM-HF trial showed the ARNI drug sacubitril/valsartan reduced cardiovascular death and heart failure
Hypertension is very common in patients with chronic kidney disease (CKD), affecting 67-92% of patients. Control of hypertension is important for slowing the loss of kidney function and reducing the risk of further kidney damage. The document discusses several risk factors for hypertension in CKD patients including older age, African descent, overweight or obesity, and concurrent diabetes or heart disease. It also reviews guidelines for treating hypertension in CKD, which generally recommend a target blood pressure under 140/90 mmHg and use of renin-angiotensin system blocking agents along with monitoring of kidney function and potassium levels.
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
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.
The document discusses hypertension in several special situations. It describes how hypertension commonly co-exists with conditions like diabetes, cerebrovascular disease, renal disease, and congestive heart failure. It provides guidelines on evaluating and managing blood pressure in these situations. For example, it recommends that antihypertensive therapy aims to reduce stroke risk in cerebrovascular disease and slow renal disease progression when hypertension is present with renal problems. The document also examines hypertension among different demographic groups like women, pregnant women, and the elderly.
Secondary hypertension - Etiopathogenesis, Clinical features, Advances in Man...Chetan Ganteppanavar
Secondary hypertension can be caused by renal or endocrine disorders. Renal causes include renal parenchymal diseases like glomerulonephritis which account for 2-5% of secondary hypertension cases. Renovascular hypertension from atherosclerosis or fibromuscular dysplasia is responsible for 1-3% of cases. Primary aldosteronism is an uncommon but important endocrine cause that can present with hypokalemic hypertension and is diagnosed through elevated aldosterone to renin ratio and saline suppression testing. Imaging and adrenal vein sampling are used to determine unilateral vs bilateral disease.
1) Cardiorenal syndrome commonly occurs in patients with acute decompensated heart failure and is associated with poor outcomes. It involves a complex interaction between hemodynamic alterations and activation of neurohormonal systems that affects both the heart and kidneys.
2) There are five types of cardiorenal syndrome classified based on the inciting cardiac or renal event and the affected secondary organs. Type 1 is acute cardiorenal syndrome due to acute worsening of cardiac function leading to kidney injury.
3) Loop diuretics are the mainstay of treatment for congestion in heart failure but aggressive diuresis may worsen kidney function. Other therapies discussed include inotropic agents, vasopressin antagonists
This document discusses the diagnosis and investigation of secondary hypertension. It describes various reversible and irreversible causes of secondary hypertension including renal, endocrine, vascular, and drug-related factors. It provides guidance on screening investigations including plasma and urine tests. It also outlines specialized tests that may be used to investigate particular causes such as renal artery stenosis, Conn's syndrome, phaeochromocytoma, and renal artery stenosis. These involve tests such as renal artery duplex ultrasound, CT/MRI scans, renal vein sampling, and MIBG scans.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
Guideline for the management of heart failureIqbal Dar
This document provides guidelines for the management of heart failure. It defines heart failure and outlines the stages from A to D. It recommends obtaining a thorough history and physical exam, diagnostic tests including biomarkers, and noninvasive cardiac imaging for initial and serial evaluation of heart failure patients. Invasive hemodynamic monitoring is recommended for selected patients with acute heart failure and impaired perfusion. Invasive coronary angiography is reasonable when ischemia may be contributing to heart failure.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document summarizes guidelines for treating hypertensive emergencies and urgencies. It defines hypertensive crisis as a severe elevation in blood pressure (>180/120 mmHg) and differentiates between emergencies and urgencies based on whether there is evidence of impending or progressive target organ dysfunction. The goal in treating hypertensive urgencies is to reduce mean arterial pressure by 10-15% within hours using oral medications. Hypertensive emergencies require more rapid blood pressure reduction, typically using intravenous medications, to prevent or limit end-organ damage. Lifestyle modifications and initial drug choices are outlined based on blood pressure levels and patient risk factors.
Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. It has a prevalence of 0.5-24.7% depending on the population. Causes include nonadherence, lifestyle factors like obesity and sleep apnea, secondary causes like primary aldosteronism and renal artery stenosis, and drug interactions. Evaluation involves assessing medication adherence, lifestyle behaviors, screening for secondary causes with tests like the aldosterone-renin ratio, and imaging of the kidneys and arteries. Management consists of optimizing lifestyle modifications, adjusting medications like adding mineralocorticoid receptor antagonists, and treating any identified
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
The document discusses resistant hypertension, defined as blood pressure above goal despite treatment with 3 or more antihypertensive drugs including a diuretic. Resistant hypertension affects up to 20% of hypertensive patients and increases cardiovascular risk. Causes include primary factors like age and secondary factors like primary aldosteronism. Pseudo-resistance can occur if measurements are inaccurate. Diagnosis requires excluding pseudo-resistance and investigating for reversible causes. Treatment involves lifestyle changes, adding additional drugs like spironolactone, or device therapies such as renal denervation or baroreflex activation. Target organ damage is common and includes left ventricular hypertrophy and kidney disease.
This document provides guidance on guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). It discusses initiation and titration of therapies including angiotensin receptor-neprilysin inhibitors, beta-blockers, sacubitril-valsartan, ivabradine, SGLT2 inhibitors, ACE inhibitors, ARBs, loop diuretics, and aldosterone antagonists. Key points include initiating therapies individually based on patient status, up-titrating doses every 2 weeks to maximize benefits, assessing for response using echocardiograms and biomarkers, and continuing GDMT even if ejection fraction improves to prevent heart failure events. Transcat
This document discusses hypertensive emergencies, which are severe cases of high blood pressure that result in acute organ damage. It defines categories of hypertensive states and provides details on etiology, pathophysiology, presentation, workup, and treatment of hypertensive emergencies. Treatment involves identifying the affected organ system and gradually lowering blood pressure over hours to days to prevent further organ injury, using intravenous medications like nitroprusside, labetalol, or nicardipine depending on the situation. Specific guidance is provided for rapidly lowering blood pressure in conditions like hypertensive encephalopathy, intracerebral hemorrhage, and ischemic stroke.
Resistant hypertension is defined as high blood pressure that remains above goal despite treatment with three or more antihypertensive medications, including a diuretic. Patients with resistant hypertension are at high risk for cardiovascular events and are more likely to have a secondary, potentially reversible cause of their hypertension. Treatment involves identifying and treating any underlying causes, optimizing medication regimens, lifestyle modifications, and specialist management. Recommended medication regimens include an ACE inhibitor or ARB, calcium channel blocker, and thiazide diuretic, with the addition of spironolactone or other agents if needed to achieve blood pressure control.
Hypertension, or high blood pressure, is classified as either primary (essential) or secondary. Primary hypertension accounts for 90% of cases and has no identifiable cause, while secondary hypertension is caused by an underlying condition like renal disease. Treatment involves lifestyle modifications and medication, with thiazide diuretics often used as initial therapy. Other common drug classes for treatment include ACE inhibitors, calcium channel blockers, beta blockers, and alpha blockers. Multiple drug therapy is usually required to control hypertension.
Resistant hypertension is defined as blood pressure that remains above goal despite treatment with three antihypertensive agents of different classes, one being a diuretic. Refractory hypertension is when blood pressure cannot be controlled despite four or more drugs at maximal doses. Pseudoresistant hypertension occurs when poor control is due to non-adherence or suboptimal treatment rather than true treatment resistance. Evaluation of patients with resistant hypertension includes screening for secondary causes like primary aldosteronism or renal artery stenosis through tests of electrolytes, renal function, and imaging studies. Treatment involves optimizing the current three-drug regimen before adding supplementary drugs like beta blockers or aldosterone antagonists.
Keycards Diuretics in Heart Failure.pdfElizaFattima1
1) Diuretics are commonly used to treat heart failure by reducing fluid overload through different mechanisms of action including inhibiting carbonic anhydrase, blocking sodium reabsorption in loops of Henle (loop diuretics), and inhibiting sodium reabsorption in distal convoluted tubule (thiazide diuretics).
2) Several clinical trials have evaluated strategies for optimizing diuretic use and dosing in acute heart failure, but most have not shown benefit of novel approaches over standard care.
3) Ongoing research continues to evaluate new diuretic agents and strategies to more effectively treat fluid overload in heart failure.
This document provides an overview of recent advances in heart failure. It discusses definitions and types of heart failure, etiology, pathogenesis, biomarkers, life's simple 7 guidelines by ADA, acute decompensated heart failure, factors triggering acute heart failure, parameters associated with worse outcomes, criteria for ICU/CCU hospitalization, general management principles, cardiopulmonary resuscitation, identifying and treating precipitants, phenotypic presentations of acute decompensation, recommendations for oxygen therapy and ventilation, principles of volume management, vascular therapy, inotropic therapy, thrombo-embolism prophylaxis, mechanical assist devices, algorithm for confirming suspected heart failure, management of heart failure with preserved ejection fraction, and the drug LCZ
This study evaluated the safety and efficacy of adding the SGLT2 inhibitor dapagliflozin to furosemide for treating decompensated heart failure in patients with type 2 diabetes and reduced ejection fraction. 100 patients were randomized to receive either dapagliflozin plus furosemide or placebo plus furosemide. The addition of dapagliflozin improved diuresis parameters, reduced body weight and dyspnea scores to a greater extent than furosemide alone, with minimal effects on renal function or electrolyte levels. The results indicate that dapagliflozin enhances the diuretic effect of furosemide and may improve outcomes for patients with heart failure
Angiotensin neprilysin inhibition in acute decompensated heart failureShadab Ahmad
Sacubitril–valsartan is an angiotensin receptor– neprilysin inhibitor that is indicated for the treatment of patients with symptomatic heart failure with reduced ejection fraction
This document discusses guidelines for the treatment of hypertension. It recommends treating patients with a blood pressure consistently above 140/90 mmHg or 130/80 mmHg for those with risk factors. Lifestyle modifications like the DASH diet are encouraged first before drug treatment. The main drug classes for initial monotherapy are thiazide diuretics, calcium channel blockers, and ACE inhibitors/ARBs, with thiazides like chlorthalidone preferred. The goal is to lower blood pressure, not necessarily the specific drug, though combination treatment may provide additional benefits over monotherapy alone. Ongoing monitoring is important to detect side effects like hypokalemia.
UF vs diuretics in treatment of ADHF, Cardiorenal syndrome Mohamed E. Elrggal
1. Fluid overload and congestion are major characteristics of heart failure (HF) that are important treatment targets. Diuretics have limitations like resistance and worsening renal function.
2. Ultrafiltration (UF) theoretically has advantages over diuretics for acute decompensated heart failure (ADHF) by allowing faster fluid removal without electrolyte issues.
3. However, clinical trials have had conflicting results. The UNLOAD trial found greater benefits with UF, while the CARESS-HF trial found increased renal dysfunction and adverse events with UF.
4. Further research is needed to determine optimal patient selection, monitoring of plasma refill rate during UF, and long-term outcomes comparison
Nuove Prospective nel trattamento dello scompenso acutodrucsamal
This document summarizes recent perspectives on the treatment of acute heart failure syndrome. It discusses various therapeutic targets including fluids, renal function, contractility, diastole, vasomotion. It reviews drugs that can help achieve these targets, such as loop diuretics, inotropes, vasodilators, novel agents like istaroxime, urocortins, nesiritide, and chimeric natriuretic peptides. Large trials on rolofylline and nesiritide are also summarized that investigated effects on renal function and other outcomes in acute heart failure patients.
Chlorthalidone for poorly controlled hypertension in chronic kidney diseasesShadab Ahmad
Given the central role of volume excess in the pathogenesis of hypertension in CKD, and the low cost of thiazide diuretics, there is a need to study the use of these drugs to lower BP among patients with uncontrolled hypertension and moderately advanced CKD.
1) Resistant hypertension is defined as blood pressure remaining above goal despite use of 3 antihypertensive agents including a diuretic. 2) Maximizing diuretic therapy is a primary treatment recommendation, through drugs like chlorthalidone and loop diuretics. 3) Adding an aldosterone antagonist like spironolactone is also effective, though it requires monitoring of potassium levels.
For each patient with AF, the two principal goals of therapy are symptom control and the prevention of thromboembolism.
Rate- and rhythm-control strategies improve symptoms, but neither has been conclusively shown to improve survival compared to the other.
Fusaro - Renal Denervation, current evidence and new technical developmentsSalutaria
1. Renal denervation is a catheter-based procedure that uses radiofrequency energy to ablate renal nerves and lower blood pressure in patients with resistant hypertension.
2. A randomized controlled trial found that renal denervation produced significant reductions in both systolic and diastolic blood pressure compared to a control group at 6 months.
3. Potential benefits of renal denervation beyond blood pressure lowering include reduced left ventricular mass, improved glucose metabolism, and fewer episodes of atrial fibrillation. However, long-term outcomes require further study.
The document provides 11 cognitive aids developed by the Society for Neuroscience in Anesthesia and Critical Care to assist anesthesia teams facing neuroanesthetic emergencies. Each cognitive aid outlines the differential diagnosis, treatment steps to stabilize the patient, and treatment guidance for common neurosurgical emergencies including acute stroke, aneurysm rupture, intraoperative aneurysm rupture, autonomic hyperreflexia, bleeding during spine surgery, and delayed emergence after craniotomy. The cognitive aids are not protocols but are meant to provide resources during emergent situations.
This document summarizes guidelines for managing resistant hypertension in primary care. It defines resistant hypertension as blood pressure that remains above 140/90 mmHg despite treatment with three antihypertensive medications from different classes, including a diuretic. It estimates that about 10% of hypertensive patients have resistant hypertension. The causes are often multifactorial and secondary causes must be ruled out. Initial treatment involves lifestyle changes and a combination of medications targeting different mechanisms, such as an ACE inhibitor, calcium channel blocker, and thiazide diuretic. Chlorthalidone is recommended over hydrochlorothiazide as the diuretic due to its greater potency, especially for resistant hypertension.
Vericiguat is a novel oral soluble guanylate cyclase stimulator being studied for the treatment of heart failure. The VICTORIA trial investigated vericiguat for reducing cardiovascular death or heart failure hospitalization in patients with recent worsening of chronic heart failure. The trial found that vericiguat reduced the primary composite outcome compared to placebo with an absolute risk reduction of 4.2 events per 100 patient-years. Vericiguat was well-tolerated overall but increased risks of hypotension and syncope compared to placebo. The results suggest vericiguat may be an effective additional treatment for reducing heart failure hospitalizations and cardiovascular death in patients with recent heart failure decompensation.
Recent Advancements in the treatment of Hypertension.Akshata Darandale
Uncontrolled blood pressure had become most common cause of death accounting for more than 7 million deaths per year worldwide. Despite the availability of potent lifestyle and pharmacologic approaches, rates of control of blood pressure are unsatisfactory and additional strategies to curb the burden of hypertension are warranted. Several novel pharmacological and device-based approaches have recently been tested and may prove helpful to achieve better blood pressure control rates and thereby improve cardiovascular outcomes in patients with hypertension.
Hypertension, or high blood pressure, is defined based on average readings from multiple visits. It is classified by the WHO into normal, prehypertension, and stages 1 and 2 hypertension. Primary hypertension has no identifiable cause while secondary hypertension has identifiable underlying causes. Complications arise from damage to blood vessels and target organs like the brain, heart, kidneys, and eyes. Treatment involves lifestyle modifications and medications like diuretics, ACE inhibitors, calcium channel blockers, and beta-blockers. Care must be taken with anesthesia as patients can experience exaggerated blood pressure changes in response to stimuli. Antihypertensive medications should generally be continued during surgery.
This document discusses the treatment of acute decompensated heart failure. It recommends aggressive diuretic therapy for patients presenting with volume overload symptoms. While in the hospital, goals are to continue guideline directed medical therapies when possible and provide mechanical circulatory or respiratory support if needed. Pharmacologic therapies discussed include loop diuretics, vasopressin antagonists, vasodilators, and inotropes. The document also covers evaluating treatment response for both acute decompensated heart failure and chronic heart failure.
mitral regurgitation american guidlines 2014Basem Enany
This document discusses mitral regurgitation (MR), including its etiology, clinical manifestations, physical exam findings, diagnostic testing, and management according to American Heart Association guidelines. The most common cause of primary MR in developed countries is mitral valve prolapse. Secondary MR is usually caused by ischemic heart disease, left ventricular dysfunction, or hypertrophic cardiomyopathy. Diagnosis involves echocardiography to determine the severity and mechanism of MR. Management is generally medical for mild MR but may involve surgery for severe primary MR.
Myocardial infarction clinical picture, investigations European guidlines 2012Basem Enany
This document discusses myocardial infarction (MI), also known as a heart attack. It defines MI as the death of heart muscle cells due to reduced blood flow. The two main types of MI are transmural, affecting the full thickness of the heart wall, and nontransmural, affecting only part of the wall. Symptoms of MI can include chest pain, shortness of breath, nausea, and sweating. Diagnosis involves electrocardiogram (EKG) showing elevated ST segments or new Q waves, and blood tests showing elevated cardiac troponin or CK-MB levels. Early diagnosis and treatment are important to reduce risk of complications and death.
Acute mitral regurgitation is a life-threatening condition requiring urgent medical treatment and usually surgery. It can be caused by flail mitral valve leaflets due to conditions like mitral valve prolapse or infective endocarditis, or ruptured chordae tendineae from trauma, spontaneous rupture, or acute rheumatic fever. Patients present with pulmonary edema, low blood pressure, and signs of shock. Echocardiography is used for diagnosis and assessing severity, showing a flail leaflet or vegetations and quantifying the regurgitation. Medical stabilization involves reducing afterload and increasing cardiac output until urgent surgery, which aims to repair the valve if possible to avoid a prosthetic valve's risks.
This document discusses examination of the jugular venous pulse and provides details on:
- The normal jugular venous waveform including the a, c, x, v, and y waves.
- How to examine the internal or external jugular veins and estimate venous pressure.
- Abnormalities in the jugular venous pulse seen in conditions like cardiac tamponade, constrictive pericarditis, and tricuspid regurgitation.
Infective endocarditis european guidlines 2012Basem Enany
Staphylococci and streptococci account for the majority of infective endocarditis cases. The most common organism causing subacute native valve endocarditis is Streptococcus viridans, while Staphylococcus aureus is most common in intravenous drug users. Blood cultures, echocardiography, and physical exam are important for diagnosis, with echocardiography able to identify valvular vegetations. Transesophageal echocardiography has higher sensitivity than transthoracic echocardiography for detecting vegetations.
This document discusses the etiology, pathophysiology, symptoms, physical exam findings, and electrocardiogram characteristics of mitral stenosis. The main causes are rheumatic heart disease in the majority of cases, and to a lesser extent infective endocarditis, mitral annular calcification, and congenital malformations. Pathophysiologically, mitral stenosis causes elevated left atrial pressure and pulmonary hypertension. Common symptoms include dyspnea, hemoptysis, thromboembolism, and right-sided heart failure. The physical exam may reveal mitral facies, elevated jugular venous pressure, an opening snap, and a decrescendo diastolic murmur.
1. Chronic aortic regurgitation is most commonly caused by rheumatic heart disease in developing countries and aortic root dilation or bicuspid aortic valve in developed countries.
2. It is initially asymptomatic but over time can cause symptoms of heart failure as well as chest pain due to the enlarged left ventricle.
3. Diagnosis is made through echocardiogram demonstrating the regurgitant jet, chest x-ray showing cardiomegaly, and examination findings like widened pulse pressure and diastolic murmur.
This document discusses aortic stenosis, including its etiology, pathogenesis, pathophysiology, clinical manifestations, diagnosis and management. It notes that aortic stenosis can be caused by congenitally abnormal heart valves, rheumatic heart disease or calcific degeneration of the aortic valve. Symptoms include dyspnea, dizziness, syncope and angina. Physical exam may reveal a diminished carotid pulse and ejection murmur. Echocardiography is the primary diagnostic test to assess aortic valve area and function.
This document discusses the management of hypertension in patients undergoing surgery. It notes that hypertension can cause blood pressure and heart rate to rise significantly during anesthesia induction, and these patients are also more likely to experience significant fluctuations in blood pressure intraoperatively and postoperatively. For elective surgery, blood pressure should be controlled below 170/110 mmHg, and surgery should not be delayed if blood pressure is below 110/90 mmHg as long as blood pressure is closely monitored. Most chronic antihypertensive medications should be continued up to and after surgery to prevent rebound effects, though diuretics can cause hypokalemia and beta blockers withdrawal may cause cardiac issues. Parenteral alternatives are recommended for patients unable to take oral
- Treatment of hypertension is the most common reason for physician office visits in the US. The number of hypertensive individuals is increasing due to an aging population and rising obesity rates.
- Up to 5% of hypertension cases are secondary, meaning a specific cause can be identified like renal artery stenosis or pheochromocytoma. However, routine screening for secondary causes is not usually recommended due to low prevalence.
- Complications of uncontrolled hypertension include heart failure, stroke, kidney disease, and heart attacks. Proper treatment and control of blood pressure can significantly reduce risks of these complications.
Heart failure treatment II european guidlines 2012Basem Enany
This document discusses various treatments and considerations for heart failure. It covers topics like ventricular reconstruction surgery, aortic valve replacement, mitral valve repair, heart transplantation challenges, exercise recommendations, mechanical circulatory support issues, managing comorbidities, and treating conditions like anemia, hypertension, cachexia, cancer effects on the heart, COPD, depression, diabetes, kidney dysfunction, gout, obesity, and sleep disorders. Management of heart failure involves addressing the underlying cardiac problem while balancing treatments for comorbidities and potential drug interactions.
Heart failure treatment european guidlines 2012Basem Enany
This document provides guidelines for the treatment of systolic heart failure. It recommends treating patients with angiotensin-converting enzyme inhibitors, beta-blockers, and mineralocorticoid receptor antagonists to relieve symptoms, prevent hospitalization, and improve survival. It discusses the benefits and side effects of these drug classes. The document also addresses other treatments such as digoxin, diuretics, ivabradine, and device therapies. It provides guidance on managing heart failure with preserved ejection fraction as well as heart failure complicated by atrial fibrillation.
This document summarizes the pathophysiology of heart failure (HF). It discusses how HF results from abnormalities in cardiac structure/function that limit oxygen delivery to tissues, despite normal filling pressures. The progression of HF is driven by neurohumoral activation of the sympathetic nervous system and renin-angiotensin-aldosterone system, which initially help compensate but eventually exacerbate cardiac remodeling and dysfunction. The document outlines the effects of various neurohormones involved in HF, including their normal and maladaptive roles in the progression of disease. Management of HF focuses on interrupting the harmful effects of long-term neurohumoral activation.
Heart failure diagnosis: european guidlines 2012Basem Enany
This document provides information on diagnosing and classifying heart failure. It discusses:
- The ACC/AHA stages of heart failure from A to D based on risk and symptoms.
- Causes of systolic and diastolic dysfunction like coronary heart disease, cardiomyopathy, hypertension.
- Evaluating a patient's history, physical exam findings, and using diagnostic tests like echocardiography, cardiac MRI, and natriuretic peptide levels to diagnose and assess heart failure.
This document presents guidelines for cardiac pacing and cardiac resynchronization therapy (CRT) from the European Society of Cardiology (ESC). It was developed by an international Task Force and covers recommendations for using pacemakers to treat various arrhythmias and heart failure. The guidelines provide evidence-based recommendations for indications and modes of pacing in conditions like sinus node disease, atrioventricular block, and heart failure. It also reviews the clinical effects of CRT as supported by randomized controlled trials. The task force developed the first ESC guidelines on appropriate use of pacemaker devices in Europe.
The document discusses examination of various pulses and abnormalities that may be present. It examines pulses at different locations that should be checked and differences that may indicate issues. Specific abnormalities are then defined and causes explained, including pulsus alternans indicating left ventricular failure, pulsus paradoxus seen in cardiac tamponade, and characteristics of pulses in aortic stenosis like an anacrotic pulse and delayed upstroke.
Cardiovascular diseases during pregnancy, european guidlines 2011Basem Enany
This document discusses cardiac signs, symptoms, and management during pregnancy. Some normal signs include palpitations, edema, and dizziness due to increased blood volume and heart rate. Abnormal signs like anasarca and syncope require evaluation. Testing like echocardiograms are generally safe in pregnancy but radiation exposure should be minimized. Conditions like pulmonary hypertension carry high risks, while repaired defects usually pose little risk. Medical management of valvular issues and heart failure aims to support volume and avoid hypotension.
1. Acute coronary syndrome can present with substernal chest pressure, pain radiating to the shoulders, or pain with exertion. ECG may show ST elevations or new left bundle branch block indicating AMI. Troponin and CK-MB elevations are needed to diagnose AMI.
2. Aortic dissection often presents with sudden, severe chest pain and may be suggested on ECG by discrepancies in blood pressure between arms or signs of ischemia. Chest X-ray may show a widened mediastinum.
3. Pulmonary embolism presentations can vary widely but often include dyspnea. ECG may show signs of right heart strain. Most chest X-rays are normal but some show
1. Acute aortic regurgitation is a medical emergency that can result from conditions like infective endocarditis, aortic dissection, or trauma.
2. It leads to a sudden rise in left ventricular diastolic pressure and fall in cardiac output, often causing profound hypotension and cardiogenic shock.
3. Emergency aortic valve replacement or repair is usually required for severe acute aortic regurgitation, while temporary stabilization measures may be used if surgery faces delay.
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The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the 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 lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
share - Lions, tigers, AI and health misinformation, oh my!.pptx
Resistant hypertension
1. D . B A S E M E L S A I D E N A N Y
L E C T U R E R O F C A R D I O L O G Y
A I N S H A M S U N I V E R S I T Y
Resistant Hypertension:
Treatment
2. Resistant hypertension
--Definition:
2008 American Heart Association guideline blood
pressure that remains above goal in spite of concurrent
use of three antihypertensive agents of different
classes, one of which should be a diuretic. Patients
whose blood pressure is controlled with four or more
medications are considered to have resistant
hypertension (20-30%).
3. Treatment of resistant hypertension
1-Identify and treat secondary hypertension.
2-Stop medications that raise the blood pressure (next
slide).
3-Out-of-office BP monitoring:
Apparently resistant patients should be evaluated by out-of
office blood pressure measurements, either by self
measurement of blood pressure at home or by ambulatory
monitoring. Both home and ambulatory blood pressure
measurements help to identify white coat hypertension.
4-NONPHARMACOLOGIC THERAPY
5-PHARMACOLOGIC THERAPY
5. Diuretics
--Persistent volume expansion (typically not sufficient to produce
edema) contributes to resistant hypertension, even among patients
who have been on conventional doses of thiazide diuretics. Serum
brain-type natriuretic peptide and atrial natriuretic peptide levels are
significantly higher, suggesting volume expansion.
--Diuretics should be titrated until the blood pressure goal or the
maximum recommended dose has been reached or the patient has
signs suggestive of overdiuresis such as fatigue, orthostatic
hypotension, or decreased tissue perfusion as evidenced by an
otherwise unexplained elevation in the serum creatinine
concentration.
--In those with little renal impairment, chlorthalidone is preferred to
hydrochlorothiazide for the treatment of resistant hypertension.
--Begin chlorthalidone at 12.5 mg daily, which requires splitting of the
25 mg pill, with subsequent titration up to 25 mg daily
or, rarely, higher. {serum K}
6. --Among patients with an estimated glomerular
filtration rate of less than 30 mL/min per m2, thiazide
diuretics are less effective and loop diuretics, such as
furosemide, torsemide, or bumetanide, may be
necessary for effective volume control. Furosemide is
relatively short acting and usually requires at least
twice daily dosing. A loop diuretic with a longer
duration of action and more consistent
absorption, such as torsemide, may be more effective
7. Aldosterone antagonists
--Spironolactone, eplerenone, and amiloride provide
significant antihypertensive benefit when added to
existing multiple drug regimens in patients with
resistant hypertension .{significantly higher plasma
aldosterone levels in patients with resistant
hypertension compared with individuals who have
normal blood pressure or controlled hypertension }
--Spironolactone may be more likely to cause
hyperkalemia in patients with chronic kidney disease .
8. CHOICE OF REGIMEN
--The triple combination of an ACE inhibitor or ARB, a long-
acting dihydropyridine calcium channel blocker (usually
amlodipine), and a long-acting thiazide diuretic (preferably
chlorthalidone) is often effective and generally well tolerated.
--Uncontrolled with such a three drug regimen at maximum
recommended and tolerated doses spironolactone: 12.5
mg/day (which requires splitting of a 25 mg tablet) before
titrating to 25 and, if necessary, 50 mg/day.
The risk of adverse effects such as gynecomastia, breast
tenderness, and erectile dysfunction increases with higher
doses.
[eplerenone, is now generic and does not induce the side effects
seen with spironolactone]
9. --Some patients with resistant hypertension are being treated with a three
drug regimen different:
If the patient is on hydrochlorothiazide, switch to chlorthalidone.
If the current regimen includes a drug not from the three recommended drug
classes, add the missing preferred drug and assess the response. Do not
discontinue any drugs, as long as they are well tolerated, before achieving
blood pressure control.
--If the patient is still hypertensive, additional medications are added
sequentially. Possible agents that may be used include vasodilating beta
blockers (labetalol, carvedilol, or nebivolol), centrally acting agents (clonidine
or guanfacine)[may be effective, but adverse effects are common], and direct
vasodilators (hydralazine or minoxidil) [Fluid retention and tachycardia are
common side effects. Minoxidil also causes hirsutism, which may be a
particular problem in women that may require switching to
hydralazine(lupus
like=withdrawal, nausea, vomiting, flushing,tachycardia), and pericarditis].
10. Catheter-based radiofrequency ablation of renal
sympathetic nerves
The mechanism by which renal sympathetic
denervation improves management of BP is complex
and involves the following factors:
-Decreasing efferent sympathetic signaling to kidneys
-Reducing norepinephrine spillover
-Natriuresis
-Increasing renal blood flow
-Lowering plasma rennin activity
-Decreasing renal afferent signalling and central
sympathetic activation
11.
12. Indications
--Refractory hypertension with office SBP >160 mmHg
despite treatment with the least 3 antihypertensive
medications including diuretic in optimal doses.
--Exclusion of secondary forms of hypertension.
--Exclusion of “white coat” hypertension using
ambulatory blood pressure monitoring.
13.
14. SYMPLICITY HTN-3: Renal Denervation Fails to
Reduce BP in Resistant-Hypertension Patients
Led by Dr Deepak Bhatt (Brigham and Women's
Hospital, Boston, MA) and Dr George Bakris (University
of Chicago, IL), SYMPLICITY HTN-3 is a
randomized, sham-controlled renal-denervation study in
535 patients with severe resistant hypertension. After six
months, the mean change in systolic blood pressure was a
reduction of 14.13 mm Hg in the renal-denervation arm
and 11.74 mm Hg in the sham-controlled arm, a difference
of 2.39 mm Hg that was not statistically significant.
Regarding the change in the 24-hour ambulatory systolic
blood pressure, the reduction at six months was 6.75 mm
Hg in the renal-denervation arm and 4.79 mm Hg in the
control arm, a difference of 1.96 mm Hg that was also not
statistically
15. For anyone who participates in clinical trials, the oversight of a clinical
trial is such that the patients are very rigorously followed, and there is
pill-counting and recommendations for strict compliance, all of which
is very different from what happens with "optimal medical therapy" in
real-world practice.
Furthermore, this was a renal denervation strategy with a particular
device, so it could be that this particular device isn't the best device for
renal denervation.
A third practical question, which is unanswered, is whether we really
achieved renal denervation. The animal and preclinical trials looked at
how much energy was needed to create an injury that went from the
renal artery lumen down to the renal nerves. Perhaps in this middle-
aged group of patients with hypertension on a western diet, there is
greater thickening of the renal vessel, which could actually cause
problems in delivering the energy required to achieve effective renal
denervation.
16.
17. Contraindications
--Increased bleeding risk (bleeding
diathesis, thrombocytopenia, severe anemia)
--Chronic renal disease
--eGFR < 45 mL/min/1.73m2
--Type 1 diabetes
--Previous renal artery intervention (angioplasty, stent
implantation)
--Anatomic abnormalities and variants of renal artery
including aneurysms, severe stenosis, reference diameter
<4 mm, excessive tortuosity, aortic aneurysm
--Age < 18 years
--Pregnancy
18. Technique
--Vascular access is similar to renal angiography and angioplasty.
--Current 5F system uses 6F guide catheters. After engaging the renal
artery, and angiography to evaluate the anatomy of the renal
arteries, the ablation catheter is placed under fluoroscopic guidance in
the distal segment of the renal artery.
--Each RF application is followed by retraction by at least 5 mm and
rotation by 90 degrees of the catheter tip, from the first distal main
renal artery bifurcation to the ostium.
--To achieve complete denervation, multiple (4-6) RF applications are
used depending on the length of the trunk of both renal arteries. This
approach provides circumferential disruption of sympathetic nerves.
--The procedure is performed under analgetic or conscious sedation to
lessen the pain
20. **Procedure-related complications are:
-Access site complication
(hematoma, pseudoaneurysm, dissection)
-Renal artery dissection
-Progression of a pre-existing renal artery stenosis
-Regeneration of efferent nerves leading to relapse of
resistant hypertension
-Bradycardia
21. --Was tested in the Symplicity-HTN-2 trial of 106 patients with
resistant hypertension despite treatment with an average of five
antihypertensive medications including a diuretic.
--The patients were randomly assigned to renal sympathetic
denervation or maintenance of previous medical therapy.
--At six months, radiofrequency ablation significantly decreased the
office blood pressure from 178/97 to 143/85 mmHg compared with no
decrease in blood pressure in patients maintained on baseline
antihypertensive therapy.
--In addition, a systolic pressure of less than 140 mmHg was attained
significantly more often with radiofrequency ablation (39 versus 6 %).
--There was no significant difference between the groups in kidney
function. Complications related to radiofrequency ablation included
one femoral artery pseudoaneurysm.
--Long-term data regarding efficacy and safety of radiofrequency
ablation remain limited.
22. Possible indications
1-Sleep apnea:
The mechanism of such effect of renal denervation of sleep
apnea is unknown, however the influence on sodium retention
and volemic status is likely to be involved.
2-Insulin Resistance/type 2 diabetes mellitus:
The beneficial effects on glucose metabolism may be explained
by several effects of renal denervation: inhibition of central
sympathetic tone, reduced release of norepinephrine, better
perfusion of skeletal muscles mediated via a decrease of alpha-
adrenergic tone leading to increased glucose uptake.
3-Congestive Heart Failure:
Increased sympathetic activity is present in patients with heart
failure and it is correlated with functional class.
23. Electrical stimulation of carotid sinus
baroreceptors
--Electrical stimulation of the carotid sinus baroreflex
system, or baroreflex activation therapy (BAT), may
decrease blood pressure in patients with resistant
hypertension.
--Three feasibility studies have shown reductions in
blood pressure after implantation of a device designed
to stimulate the carotid baroreflex system .
24. *In the Rheos Pivotal Trial, 265 patients with resistant hypertension underwent
surgical implantation of a device designed to stimulate the carotid baroreceptors.
One month after surgery, patients were randomly assigned to have BAT turned on
immediately or to have BAT turned on six months later. The patients were followed for
at least 12 months:
--At six months, patients receiving BAT had a nonsignificantly larger decrease in
systolic pressure (16 versus 9 mmHg) and a nonsignificantly greater likelihood of
having a 10 mmHg or larger decrease in systolic pressure (54 versus 46 %). In
addition, patients receiving BAT were significantly more likely to achieve a goal systolic
pressure of 140 mmHg or lower (42 versus 24 %).
--At twelve months, the mean reduction in systolic pressure in the BAT group was 25
mmHg; more than 80 % of these patients had at least a 10 mmHg decrease in systolic
pressure.
--Within one month of surgery, 35 % of patients had a serious procedure-related
adverse event, including nerve injury. In most patients, procedure-related adverse
events resolved spontaneously. Seven patients died (3 %), but none were
attributable to the device.
25. *Malignant hypertension:
--Refers to marked hypertension with retinal
hemorrhages, exudates, or papilledema. These findings may be
associated with hypertensive encephalopathy{cerebral oedema}.
--Usually associated with BP>180/120 mmHg. However, it can occur
at diastolic pressures as low as 100 mmHg in previously normotensive
patients with acute hypertension due to preeclampsia or acute
glomerulonephritis.
*Hypertensive urgency:
--Severe hypertension (as defined by a diastolic blood pressure above
120 mmHg) in asymptomatic patients.
--There is no proven benefit from rapid reduction in BP in
asymptomatic patients who have no evidence of acute end-organ
damage and are at little short-term risk.
26. Hypertensive urgencies
*BP>180/120mmHg, no symptoms apart from headache.
*A relatively rapid reduction in blood pressure (BP) was
recommended in the past. However, in the absence of
symptoms a more gradual reduction in pressure is
suggested.
*While a variety of oral therapeutic modalities have been
used, including clonidine, sublingual nifedipine, and oral
or sublingual captopril, sublingual nifedipine is now
contraindicated in this setting {blood pressure falls below
the range at which tissue perfusion can be maintained by
autoregulation}.
27. *All patients should be provided a quiet room to rest; this can lead to a fall in
BP of 10 to 20 mmHg or more.
*Previously treated hypertension:
--Increase the dose of existing antihypertensive medications, or add another
agent.
--Reinstitution of medications in non-adherent patients.
--Addition of a diuretic, and reinforcement of dietary sodium restriction, in
patients who have worsening hypertension due to high sodium intake.
*Rapidly lowering blood pressure below the autoregulatory range of an organ
system (most importantly the cerebral, renal, or coronary beds) can result in
reduced perfusion, leading to ischemia and infarction. It is usually
appropriate in these situations instead to gradually reduce blood pressure
over 24 to 48 hours.
Most patients with hypertensive urgency can be treated as outpatients.
28. *Untreated hypertension:
--The approach should take into consideration the individual patient's risk with
persistence of severe hypertension, the likely duration of severe hypertension, and of
cerebrovascular or myocardial ischemia with rapid reduction in blood pressure.
--Relatively rapid initial blood pressure reduction (over several hours): oral furosemide
(if the patient is not volume depleted) at a dose of 20 mg (or higher if the renal
function is not normal); a small dose of oral clonidine (0.2 mg); or a small dose of oral
captopril (6.25 or 12.5 mg) observed for a few hours, to ascertain a reduction in
blood pressure of 20 to 30 mmHg longer acting agent is prescribed and the patient is
sent home to follow up within a few days.
--Reduction over one to two days: Depending on the patient, a calcium channel blocker
(but not sublingual nifedipine), beta blocker or angiotensin converting enzyme (ACE)
inhibitor or receptor blocker can be started. Examples in these categories are oral
nifedipine 30 mg once daily (of the long-acting preparation), oral metoprolol XL 50 mg
daily, or ramipril 10 mg once daily. Some experts initiate therapy with two agents or a
combination agent, one of which is a thiazide diuretic. The rationale is that most
patients with blood pressure ≥20/10 mmHg above goal.
--Patients at high risk for cardiovascular events (eg, long-standing diabetes, known
coronary artery disease or prior stroke), should probably be admitted.
29. MECHANISMS OF VASCULAR INJURY
--With mild to moderate elevations in blood pressure, the initial response is
arterial and arteriolar vasoconstriction. This autoregulatory process both
maintains tissue perfusion at a relatively constant level and prevents the
increase in pressure from being transmitted to the smaller, more distal
vessels.
--With increasingly severe hypertension, however, autoregulation eventually
fails damage to the vascular wall. Disruption of the vascular endothelium
then allows plasma constituents (including fibrinoid material) to enter the
vascular wall, thereby narrowing or obliterating the vascular lumen. Within
the brain, the breakthrough vasodilation from failure of autoregulation leads
to the development of cerebral edema and the clinical picture of hypertensive
encephalopathy.
--The level at which fibrinoid necrosis occurs is dependent upon the baseline
BP.
30. CLINICAL MANIFESTATIONS
--Most often occurs in patients with long-standing uncontrolled hypertension, many of
whom have discontinued antihypertensive therapy. Underlying renal artery stenosis is
also commonly present.
--Marked elevation in BP.
--Retinal hemorrhages and exudates (representing both ischemic damage and leakage
of blood and plasma from affected vessels) and papilledema.
--Malignant nephrosclerosis, leading to acute kidney injury, hematuria, and
proteinuria. The renal vascular disease in this setting leads to glomerular ischemia and
activation of the renin-angiotensin system, possibly resulting in exacerbation of the
hypertension.
--Acute myocardial infarction, pulmonary edema, unstable angina, dissecting aortic
aneurysm, or eclampsia
--Neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar
infarcts, or hypertensive encephalopathy {insidious onset of headache, nausea, and
vomiting, followed by nonlocalizing neurologic symptoms such as
restlessness, confusion, and seizures and coma}
**Magnetic resonance imaging may reveal edema of the white matter of the parieto-
occipital regions, a finding termed reversible posterior leukoencephalopathy
syndrome. When the MRI reveals primarily pontine abnormalities, the condition has
been called hypertensive brainstem encephalopathy
31. --Initial goal of reducing mean arterial blood pressure by 10% to
15%, but no more than 25%, in the first hour and then, if stable, to a
goal of 160/100-110 mm Hg within the next 2 to 6 hours gradual
healing of the necrotizing vascular lesions.
--Aortic dissection is a special situation that requires
reduction of the systolic blood pressure to at least 120 mm Hg within
20 minutes.
--More aggressive hypotensive therapy is both unnecessary and may
reduce the blood pressure below the autoregulatory range, possibly
leading to ischemic events (such as stroke or coronary disease) .
--Then: switched to oral therapy, with the diastolic pressure being
gradually reduced to 85 to 90 mmHg over two to three months.
--Even with effective antihypertensive therapy, most patients who
have had malignant hypertension still have moderate to severe chronic
and acute vascular damage and are at continued risk for
coronary, cerebrovascular, and renal disease.
38. -- A slower onset of action and an inability to control the degree
of BP reduction has limited the use of oral antihypertensive
agents in the therapy of hypertensive crises.
--They may, however, be useful when there is no rapid access to
the parenteral medications described above. Both sublingual
nifedipine (10 mg) and sublingual captopril (25 mg) can
substantially lower the BP within 10 to 30 minutes in many
patients.
--The major risk with these drugs is ischemic symptoms
(eg, angina pectoris, myocardial infarction, or stroke) due to an
excessive and uncontrolled hypotensive response. Thus, their
use should generally be avoided in the treatment of hypertensive
crises if more controllable drugs are available.