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How to Manage a Patient Whose Blood Pressure is Uncontrolled Despite Triple Drug Therapy?

How to Manage a Patient Whose Blood Pressure is Uncontrolled Despite Triple Drug Therapy?. Dr. Satyavan Sharma, MD, DM, FACC, FAMS, FESC, FSCAI Consultant Cardiologist, Bombay Hospital & Medical Research Center Mumbai, INDIA.

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How to Manage a Patient Whose Blood Pressure is Uncontrolled Despite Triple Drug Therapy?

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  1. How to Manage a Patient Whose Blood Pressure is Uncontrolled Despite Triple Drug Therapy? Dr. Satyavan Sharma, MD, DM, FACC, FAMS, FESC, FSCAI Consultant Cardiologist, Bombay Hospital & Medical Research Center Mumbai, INDIA NOTE: The following slides are to be used for medical education purposes only. Copyright belongs to Prous Science and Prous Science is not responsible for any modification or change made by the users to these slides. For Contact: Phone: 91-22-22054532, 91-9820122010 Fax: 91-22-22054532 E-mail: drsharma@bom3.vsnl.net, drsatyavan@vsnl.net

  2. Index of Presentation 1. Title, 2. Index, 3. Key words, 4. Definition, 5. What is target BP (JNC-7), 6. Prevalence of uncontrolled HT, 7. Causes for uncontrolled HT, 8. Causes : Check list 1, 9. 24 hrs ambulatory BP monitoring, 10. Causes Check List 2, 11. What to do?,12. Searching for secondary HT : Check List 3, 13. HT : Physical Examination, 14. Fundus Examination showing, 15. Investigations in a patient with uncontrolled HT, 16. Evaluation (imaging techniques ) for secondary hypertension, 17. Investigations for renal artery stenosis, 18. Causes of RAS, 19. CT angiography in patient with secondary HT, 20. Aortoarteritis causing hypertension refractory to drugs, 21. Coarctation of aorta diagnosed on angiography, 22. Pheochromocytoma diagnosed on MIBG scan, 23. Clues to renal parenchymal HT, 24. What drugs to avoid ?, 25. How to treat uncontrolled HT?, 26. Fibro muscular dysplasia treated by renal angioplasty, 27. Stenting for atherosclerotic RAS, 28. Genuine drug refractoriness, 29. Summary, 30. References.

  3. Key Words • Uncontrolled hypertension (HT) • Resistant hypertension (HT) • Refractory hypertension (HT) • Secondary hypertension • Renovascular hypertension • Renal artery stenosis (RAS)

  4. Definition of Refractory (Resistant) / Uncontrolled BP • When BP cannot be reduced to target level (JNC 7 ) • even when using an optimal 3-drug regime including • a diuretic in a compliant patient+ • In isolated systolic HT: target level of • systolic BP should be < 140 mmHg +Reference 1

  5. What is Target Blood Pressure (BP)? Classification of HT (JNC – 7)+ +Reference 2

  6. Prevalence of Uncontrolled Hypertension Prevalence difficult to estimate General population: Low Specialized HT clinics: High *Clinical trials +: 30-50% *(ALLHAT, CONVINCE, LIFE, INSIGHT: BP not reduced to target levels of >140/90 in 30-50%) + Reference 3

  7. Causes for Uncontrolled BP • Potentially correctable factors (check list 1) • Assess change in clinical phase, renal function, • concomitant conditions (check list 2) • Search for secondary hypertension (check list 3) • True refractory hypertension

  8. Causes : Check List 1 • Patient related: compliance, salt intake, unhealthy life style (alcohol, obesity), other drugs • Doctor related: suboptimal dosage, irrational regimens, drug interactions • Office related: improper cuff size, white coat hypertension (Ambulatory, Home Recordings) • Volume overload: excess salt, drug induced, inadequate diuretics, worsening renal function

  9. 24 h Ambulatory BP Monitoring to Exclude White Coat Hypertension

  10. Causes: Check List 2 • Malignant, accelerated phase • Renal insufficiency • Subsequent occurrence of renal artery stenosis (RAS) in essential hypertension • Progression of insignificant RAS or fibromuscular dysplasia (FMD) • Sleep apnea syndrome

  11. What to do? • Interview patient • Check prescription • Exclude white coat HT (24-h ambulatory monitoring) • Search for true resistance, secondary causes

  12. Searching for Secondary HT: Check List 3 • Renal, renovascular + • Coarct, aortoarteritis • Pheochromocytoma • Primary aldosteronism • Hypo- and hyperthyroidism • Others + Reference 4, 5, 6

  13. Hypertension: Physical Examination • BP measurement (contralateral, all arms) • Weight, waist circumference • Peripheral pulses, bruits, thyroid • Cardiovascular system examination • Abdomen: masses, bruit, aortic pulsation • Fundus examination

  14. Fundus Examination Showing Hypertensive Changes

  15. Investigations in a Patient With Uncontrolled BP • Assess renal function, thyroid function, K+, diabetes status • Evaluate for target organ damage (microalbuminuria, fundus, cardiac assessment by ECG, 2DE) • Investigations for secondary causes • Renal ultrasound, Doppler • CT, MRA, aortography (renal angio) • Tests for phaeochromocytoma or other conditions as needed

  16. Evaluation (Imaging Techniques) for Secondary Hypertension+ +Reference 2, 6

  17. Screening Ultrasound, Doppler Renogram / scintigraphy Peripheral PRA Definitive CT angio, MRA, DSA Conventional angio Renal vein renin ratio Investigations for Renal Artery Stenosis (RAS)+ Abbreviations: PRA=plasma renin activity, CT= computed tomography, MRA= magnetic resonance imaging, DSA= digital subtraction angiography + Reference 4, 6

  18. Causes of RAS • Atherosclerosis • Aortoarteritis • Fibromuscular dysplasias (intimal, medial, perimedial, adventitial) • Aneurysms / dissection • Thromboembolism • Others

  19. CT Angiography in a Patient with Secondary HT RT RENAL Bilateral Atherosclerotic RAS with Functioning Lt. Kidney

  20. Aortoarteritis Causing Refractory Hypertension MRA (left), digital subtraction (middle), showing aortic narrowing and CT angio (right), showing renal artery stenosis in different patients

  21. Coarctation of Aorta Diagnosed on Angiography

  22. Pheochromocytoma Diagnosed on MIBG Scan

  23. Clues to Renal HT: Parenchymal/Obstructive) • H/O flank pain, UTI, hematuria, trauma • Palpable kidney, fundus changes • Urine, urine culture, intravenous pyelography • Ultrasound , renogram, computed tomography, magnetic resonance imaging • Digital subtraction angiography

  24. What Drugs to Avoid? • Combining antihypertensive drugs with • similar class of action • Using drugs or supplements that antagonize • antihypertensive drugs or increase BP • (e.g., steroids, nonsteroidal antiinflamatory • agents, herbal drugs, contraceptives) • Excess of alcohol, smoking, tobacco, nasal • decongestants, cocaine

  25. How to Treat Uncontrolled BP Consult hypertension specialist Treat correctable cause, if any (renal angioplasty, Stenting+, surgery for phaeochromocytoma) Aggressive drug therapy: - Optimize existing drugs - Add frusemide, aldosterone antagonist - Hydralazine or minoxidil with betablocker and a diuretic - Clonidine (oral or transdermal) - Combine ACE-I and ARB - Renin inhibitors (aliskiren) Intensify lifestyle modifications +Reference 7

  26. Fibromuscular DysplasiaTreated by Renal Angioplasty

  27. Stenting for Atherosclerotic Renal Artery Stenosis

  28. Genuine Drug Refractoriness • Consult hypertension specialist • Hospitalize: intravenous (i.v.) drugs • Dialysis in renal failure patients • Nonpharmacological – “biofeed back”

  29. Summary • Uncontrolled BO on optimal drug therapy not uncommon in clinical practice • A thorough search for potential reasons, mechanisms and secondary causes is warranted • Renovascular hypertension secondary to RAS can be treated by catheter interventions • Aggressive drug therapy (optimizing existing drugs, adding frusemide, aldactone, direct vasodilators) controls BP in majority

  30. References • 1. Chobanian, A.V. , Bakris , G. L., Black, H. R., et al. The seventh report of the of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure : The JNC 7 report. JAMA 2003; 289: 2560-72.2. Ram, C.V.S. Refractory hypertension: Clinical management in Hypertension. An International monograph (ed. Anand, M.P., Nadkar, M.Y.), IJCP group of publications, India, 2007, PP 376-72.3. Japanese Society of Hypertension guidelines for management of hypertension (JSH 2004). Hypertension Res 2006; 29: S 59-60.4. Garovis, V.D., Textor, S.C. Renovascular hypertension and ischemic nephropathy. Circulation 2005; 112 : 1362-74.5. Fraaco, V., Oparil, S., Carretero, O.A. Hypertension therapy: part 2 Circulation 2004; 109: 3081-88.6. Balk, E., Raman G., Chung, M, et al. Comparative effective management strategies for renal artery stenosis: A systematic review. Ann Intern Med 2006; 145 : 901-12.7. Rocha-Singh, K. Jaff, M.R., Rosenfield, K. et al. for the ASPIRE2 trial investigators. JACC 2005; 46: 776-83.

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