بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم 1

2. HYPERTENSION IN SPECIAL GROUPS M.A. EMAMI cardiologist 1

3. Special Considerations for Hypertensive Diseases in Women 1

4. Oral Contraceptive Use 1

5. Hypertension is mild, but in some it may accelerate rapidly and cause severe renal damage. • When use of the OC is discontinued, BP falls to normal within 3 to 6 months in about 50% of patients. 1

6. Mechanisms • OC use probably causes hypertension by volume expansion because estrogens and some synthetic progestogens used in OC pills cause sodium retention. • ACEIs do not alter BP any more in women with OC-induced hypertension than in women with primary hypertension. • Drospirenone-containing OC pills may cause a reactive rise in serum aldosterone 1

7. Management • The use of estrogen-containing OCs should be restricted in women older than 35 years, particularly if they also smoke or are hypertensive or obese. • Drospirenone-containing OC pills are a better alternative. 1

8. Women given OCs should be monitored as follows • The initial supply should be limited • BP check before an additional supply is provided • If BP has risen, an alternative contraceptive method should be offered. • If OC remains the only acceptable contraceptive method, the elevated BP can be reduced with appropriate therapy. 1

9. Postmenopausal Sex Hormone Therapy • Estrogen therapy does not appear to induce hypertension, but may reduce HTN.Such lower BPs may reflect a number of effects(improved endothelium-dependent vasodilationand reduced muscle sympathetic nerve activity) 1

10. Hypertension During Pregnancy • 12% of first pregnancies in previously normotensive women, hypertension appears after 20 weeks (gestational hypertension) • In about half of cases, this hypertension will progress to preeclampsia when it is complicated by proteinuria, edema, or hematologic or hepatic abnormalities • The diagnosis is usually based on a rise in pressure of 30/15 mm Hg or more to a level above 140/90 mm Hg.. 1

11. Chronic hypertension BP CLASSIFICATION OF HYPERTENSION IN PREGNANCY

12. Chronic hypertension BP CLASSIFICATION OF HYPERTENSION IN PREGNANCY

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14. Prevention and Treatment • Delay of pregnancy until after the teenage years • Better prenatal care • only effective strategy to prevent preeclampsia is the use of low doses of aspirin. • The only cure for preeclampsia is delivery • Drug treatment of maternal BP does not improve perinatal outcome and may be associated with fetal growth retardation. • Most authorities recommend antihypertensive drugs only if diastolic pressures remain above 100 mm Hg. • The only drugs contraindicated are ACEIs and ARBs because of their propensity to induce neonatal renal failure. 1

15. Treatment of Acute Severe Hypertension in Pregnancy • SBP > 160 mm Hg and/or DBP > 105 mm Hg • Parenteral hydralazine is most commonly used. • Parenteral labetalol is second-line drug (avoid in women with asthma and CHF.) • Oral nifedipine used with caution. (Short-acting nifedipine is not approved by FDA for managing hypertension.) • Sodium nitroprusside may be used in rare cases.

16. Chronic Hypertension • If pregnancy begins while a woman is receiving antihypertensive drug therapy, medications including diuretics but excluding ACEIs and ARBs are usually continued 1

17. Chronic hypertension BP MANAGEMENT OF CHRONIC HYPERTENSION IN PREGNANCY DURING PREGNANCY

18. ORAL TREATMENT OF HYPERTENSION IN PREGNANCY

19. HTN IN ELDERLY • Either diastolic (>90 mm Hg) or systolic (>140 mm Hg) hypertension occurs in one half to two thirds of people older than 65 years and in 75% of people older than 80 years.The prevalence varies by race (or genetics) and is slightly higher in African Americans and Hispanics compared with non-Hispanic whites 1

20. HTN IN ELDERLY • The profile of hypertension is altered by aging, with systolic hypertension becoming more prevalent than diastolic hypertension. Systolic blood pressure rises with aging in both men and women but rises more steeply in women 1

21. HTN IN ELDERLY • After the age of 65 years, average systolic blood pressures are higher in women than in men. In contrast, diastolic blood pressure is relatively constant from 50 to 80 years of age, with average diastolic pressures higher in men than in women from the age of 50 to 80 years. 1

22. HTN IN ELDERLY • “Isolated” systolic hypertension, without elevation of diastolic blood pressure, is present in about 8% of sexagenarians and more than 25% of the population older than 80 years. 1

23. HTN IN ELDERLY • A large number of older people are unaware that they have hypertension. Even when it is recognized, hypertension is not controlled in many older patients, and older age is considered one of the strongest risk factors for resistant hypertension 1

24. Treatment • Relative risks for cardiovascular events associated with increasing blood pressure do not decline with older age, and absolute risk increases markedly in older patients, emphasizing the need for treatment of hypertension in the elderly 1

25. Treatment • Most of these studies used thiazide diuretics, beta blockers, or calcium channel blockers as first-line therapy with addition of secondary agents. ARBs were used in one study that showed only stroke benefits, and ACE inhibitors and ARBs have been used in comparative trials of newer drugs to older drugs that show stroke and cardiovascular benefits 1

26. Treatment • A recent trial enrolling the very old has demonstrated the safety and efficacy of carefully monitored treatment of systolic hypertension to a target of 150/80 mm Hg using indapamide with or without an ACE inhibitor in patients older than 80 years 1

27. Treatment • In addition to reduced stroke, heart failure, and deaths from cardiovascular causes, overall mortality was also reduced 1

28. Treatment • Morbidity and mortality benefits of treatment of hypertension in the elderly have been seen with the five major antihypertensive classes—diuretics, beta blockers, calcium antagonists, ACE inhibitors, and angiotensin receptor antagonists. 1

29. Treatment • Arthritis is second in prevalence to cardiovascular disease in the elderly, and NSAIDs are among the most frequently consumed drugs (prescription and over-the-counter) in older people. 1

30. Treatment • In addition to the potential for cardiovascular ischemic events, adverse renal effects or hyperkalemia may occur when NSAIDs are given in combination with ACE inhibitors, ARBs, aldosterone, or renin antagonists. 1

31. Treatment • Loss of blood pressure control and heart failure have been precipitated by administration of nonselective NSAIDs as well as COX-2–selective NSAIDs. Age-related bone loss accelerates in older men and women and is the major contributing cause of osteoporosis. 1

32. Treatment • Osteoporosis in turn is a major risk factor for fractures in older people; the lifetime risk of osteoporotic fracture in Americans is estimated at 40% for women and 13% for men. Thiazides have been shown to preserve bone mineral density 1

33. Treatment • Older patients for whom thiazide diuretics may not be a good choice include patients with urinary frequency problems (stress incontinence, urinary frequency with or without incontinence due to prostatic hypertrophy, overactive bladders, and patients needing assistance with toileting) because drugs that do not increase urinary frequency may have higher adherence. 1

34. Treatment • Postural hypotension of >20 mm Hg or 20% of systolic pressure is a risk factor for falls and fractures that carry significant morbidity and mortality. Antihypertensive medications add to the risk of postural hypotension, as do many antiparkinson agents, antipsychotic agents, and tricyclic antidepressant drugs 1

35. Treatment • Postprandial declines in both systolic and diastolic blood pressure occur in hospitalized, institutionalized, and community-dwelling elderly. The greatest decline occurs about 1 hour after eating, with blood pressure returning to fasting levels at 3 to 4 hours after eating. Vasoactive medications with rapid absorption and peaks should not be administered with meals. 1

36. Treatment • Systolic as well as diastolic hypertension should be treated; current recommendations are based on brachial artery measurements:    • Diastolic target is <90 mm Hg • Systolic target is <140 mm Hg for most (<150 mm Hg for patients older than 80 years). 1

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