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PRESENATATION BY DR MISBAHUL FERDOUS MBBS(BANGLADESH)

PRESENATATION BY DR MISBAHUL FERDOUS MBBS(BANGLADESH) FMD (USTC) PGT (CARDIOLOGY) NICVD MD (CARDIOLOGY), COURSE SHANDONG UNIVERSITY CHINA. Hypertension.

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PRESENATATION BY DR MISBAHUL FERDOUS MBBS(BANGLADESH)

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  1. PRESENATATION BY DR MISBAHUL FERDOUS MBBS(BANGLADESH) FMD (USTC) PGT (CARDIOLOGY)NICVD MD (CARDIOLOGY), COURSE SHANDONG UNIVERSITY CHINA

  2. Hypertension Rise of blood pressure above the normal level is called hypertension. • Types: • Primary or essential hypertension. 2. Secondary hypertension.

  3. Korotkoff, 1905

  4. Ref: Davidson’s Principles & Practice of Medicine 20th P-609

  5. Management of Hypertension A.General management. B.Antihypertensive Drug therapy. • General Treatment (Non Pharmacological treatment) Life style modification:

  6. REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 26

  7. Investigations of Hypertension • Basic test for initial evaluation • Always included: • Urine for: Protein, blood, glucose • Haematocrit • Serum electrolytes- specially POTASSIUM • Blood urea & serum creatinine • ECG • Plasma cholesterol

  8. Basic test for initial evaluation b) Usually included depending on cost & other factors: • Microscopic analysis • WBC • Blood / plasma glucose • Fasting Blood glucose level • 2 HPP blood glucose level • Serum – Total cholesterol, HDL, LDL, Triglycerides • Serum – calcium, phosphate, uric acid • X-ray chest P/A view • ECG

  9. Investigation of SELECTED PATIENT • Ambulatory BP recording • Renal ultrasonography • Renal angiography • Renal isotope scan • 24 hours urine assay for creatinine meta morphines and catacholamines on plasma catacolamines if phenochromocytoma suspected. • Plasma renin activity & aldesterone

  10. Treatment of hypertension

  11. Prehypertension … • Is not a disease, • Is not “hypertension”, • Is not an indication for drug treatment of HTN, • Does not have a BP goal, • Does predict a higher risk for developing CV events, • Does predict a higher risk for developing HTN, • Should be an incentive to improve lifestyle practices for prevention of HTN and CVD.

  12. Drug use in Hypertension

  13. REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 27, 28,29

  14. Treatment of hypertension in special situations • Hypertension in children and adolescent • Life style modification,. if fail pharmacological therapy should be started • Dosage of antihypertensive medication should be smaller and adjusted very carefully for children. • ACE inhibitor & A-II receptor blocker should not be used In pregnant mother • Use of anabolic steroid for body building & smocking strictly prohibited.

  15. b) Hypertension in PREGNANCY • In the 2nd & 3rd trimester, antihypertensive agents often are not indicated unless the Diastolic BP exceeds 100 mm Hg. • If drugs will be methyldopa, Beta-blocker, CCB in order of preference. • Hydralazine (Parenteral) & prazosin may be used. • Should not be used: ACEi, A-II Receptor blocker, Diuretics, Nitroprusside

  16. c) Hypertension with HORMONE REPLACEMENT THERAPY • Presence of hypertension is not contraindicated for post menopausal estrogen replacement therapy. • frequent FOLLOW UP should be advised .

  17. 3. Hypertension with co-existing cardiovascular diseases • Hypertension with CCF • Diuretics & ACEi are preferable drugs. • Contraindications: Ca++ channel blockers & β-blockers. • ACEi used alone or in conjugation with DIGOXIN or DIURETICS. • When ACEi is contraindicated, the vesodilators combination of HYDRALAZINE and ISOSORBIDE DINITRATE is also effective in this patient. • In one trial A-II receptor blocker (LOSARTAN POTASSIUM) was superior to CAPTROPIL in decrease mortality.

  18. b) Hypertension with coronary artery disease: • Goal BP < 140/ 90 mm Hg • β-blocker & Ca++ channel blocker may be specially useful in patient with HTN & angina pectoris. • ACEi also useful in MI. • If β-Blockers are ineffective on contraindicated VERAPAMILorDILTIAZEMmay be used in following conditions • (i) Non- myocardial infraction • (ii) After MI with presented left ventricular function.

  19. c)Hypertension with LVF: • All antihypertensive drug can be used except direct vasodilatation e.g. HYDRALAZINE • In one study treatment with diuretics & an ACEi are better than other drug. d) Hypertension with BRADYCARDIA: • Nifidipine & ACEi are preferable drugs. • Better to avoid β-BLOKERS, VERAPAMIL, DILTIAGEM

  20. 4. Hypertension in Diabetes: • Goal BP <140 / 80 mm Hg [ref: Davidson’s 20th ] • Goal BP <130 / 80 mm Hg [ref: JNC 7 ] • Life style modification • No antihypertensive are contraindicated in DM • ACEi, A-II receptor, Alpha blocker, CCB, low dose diuretics are preferred choice. • Better avoid β-blocker and high dose diuretics unless special situation. • *ACEi→↓69% protein urea in type-I DM [ref: Davidson’s 20th]

  21. 5. Hypertension in Dyslipidaemia: • Common co-existence & demand aggressive management of both conditions. • High dose THIAZIDES, LOOPS DIURETICS & BETA BLOCKERS may transiently increase total cholesterol, still has significant reduction CV morbidity & sudden death. So should be used without hesitation.

  22. 6. Hypertension with ASTHMA & COPD: • Ca++ channel blocker is the preferable drug. • ACEi are safe in most patients with asthma. • A-II receptor blocker may be used if cough is trouble some problem after using ACEi. • Contraindications: β-blocker, α-blocker should not be used in patient with asthma except in special circumstances.

  23. 7. Hypertension with CVD: • BP is actually raised after stroke. Unless end organ damage in present or malignant HTN is present, elevated BP should not be lowered in acute stage since it will always return towards normal within 24-28 hours. • After 10 days gentle reduction of BP started as a part of secondary prevention strategy of ischemic stroke. • If hemorrhage stroke there is no value in reducing the high BP (except very high) until at least some days after stroke.

  24. 8. Hypertension with LIVER DISEASE: • ALL Antihypertensive drugs can be used except METHYLDOPA.

  25. 9. Hypertension with GOUT • All hypertensive drugs can be used • But all Diuretics can increase serum uric acid level but rarely induced acute gout. So diuretics should be avoided if possible. • Contraindications: NO DIURETICS

  26. 10. Hypertension with PSORIASIS: • β-Blocker and ACEi aggravate psoriasis. So better to avoid them. 11. Hypertension with Scleroedema with Reynaud's phenomenon • NIFIDIPINE and PROSTACYCLINE infusion may occasionally helpful in patient with severe Reynaud'sphenomenon.

  27. 12. Hypertension with peripheral vascular disease • Better to use Ca++ channel blocker & Vasodilators. 13. Hypertension with Renal parenchymal disease • Goal BP 130 / 85 or <125 /75 mm Hg. • Unless contraindicated ACEi + Diuretic should be used. • Loop diuretics should be used & potassium sparing diuretics should be avoided. • Thiazide diuretics are not effective with advanced renal insufficiency. • ACEi used with caution if serum creatinine> 3 mg / dl

  28. 14. Adjuvant drug therapy • Aspirin: Anti Platelet therapy is a powerful means of reducing cardiovascular risk. • Indications:Age 50 or more, who have well controlled BP and either target organ damage, Diabetes, or a 10 year coronary heart disease- Risk of > 15% • Statins: Treating hyperlipidaemia & also produce a reduction of cardiovascular risk. • Indications:Established vascular disease or hypertension with a high risk of developing coronary heart disease.

  29. 15. Hypertensive crises Hypertensive crises • Emergency B) Urgency i) Malignant HTN ii) Accelerated HTN Goal of reducing BP 160/100 mm of Hg with in 24 hrs Drugs of Choice: Oral Drugs are better than I/V

  30. Follow up & Monitoring • serum potassium and creatinine monitored 1-2 times per year. • after BP at goal and stable, follow up visits at 3 to 6 months interval. [ref: JNC 7]

  31. Recommendations for Improving Outcomes Physician Establish treatment goals Maintain adherence Minimize side effects Patient Self-Monitor BP Keep diary of BP therapy Make life-style changes

  32. Approximately 50 Million Americans Have Hypertension 13.7 million Controlled27.4% 36 million Uncontrolled72.6%

  33. High mortality, developing region Lower mortality, developing region Developed region Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency 0 1000 2000 3000 4000 5000 6000 7000 8000 Attributable Mortality (In thousands; total 55,861,000) Ezzati et al. Lancet. 2002;360:1347-1360.

  34. TIA, stroke LVH, HF,CHD, Renal failure Retinopathy Peripheral vascular disease Complications of Hypertension: Hypertension is a risk factor TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; HF = heart failure.Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22.

  35. Long-Term Antihypertensive Therapy Significantly Reduces CV Events Stroke Heart failure Myocardial infarction 0 –10 –20 Average reduction in events (%) 20%-25% –30 –40 35%-40% –50 >50% –60 Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

  36. JNC 7: Appropriate BP Targets • For both CVD and kidney disease, systolic BP is far more important than diastolic BP • Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease) • Only a small fraction of hypertensives are achieving appropriate BP control • Multiple antihypertensive agents are needed for most patients • Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD.

  37. JNC 7: Considerations for olderpersons with hypertension • This population has the lowest rates of BP control and the greatest absolute benefit with effective therapy. • Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. • More than two-thirds of people over 65 have HTN, i.e. ISH (Isolated systolic hypertension).

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