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Selection of Antihypertensive Drug

Selection of Antihypertensive Drug. Hypertension classification. Risk Stratification. Clinical trial and guideline basis for compelling indications for individual drug classes. Low risk - 3 months Medium risk - 2 – 3 months High & very high risk - immediate Diuretics

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Selection of Antihypertensive Drug

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  1. Selection ofAntihypertensive Drug

  2. Hypertension classification

  3. Risk Stratification

  4. Clinical trial and guideline basis for compelling indications for individual drug classes

  5. Low risk - 3 months • Medium risk - 2 – 3 months • High & very high risk - immediate • Diuretics • e.g.:- Hydrochlorothiazide 12.5 – 50 mg od

  6.  - blockers • eg:- Atenolol 25 – 100 mg od • propranolol long acting 60 – 180 mg od

  7. Calcium channel blockers: Amlodipine 2.5 – 10 mg od Diltiazem XR – 180 – 420 mg od Verapamil long acting 120 – 480 mg od –bd

  8. ACE Inhibitors: Enalapril 5 -40 mg od – bd Ramipril 2.5 – 20mg od

  9. ARBs: Losartan – 25 – 100 mg od – bd

  10. When to add 2nd drug? • Single drug fails to active BP goal (BP is 20 / 10 mm Hg above goal) • Most stage 2 hypertension • Thiazide – type diuretic + ACE, ARB, BB, CCB • Enalapril 5 mg + Hydrochlorothiazide 12.5 mg. • Losartan 50mg + Hydrochlorothiazide 12.5 mg. • Propranolol LA + Hydrochlorothiazide 40 / 25 mg. • Amlodipine + Hydrochlorothiazide 5/12.5 mg.

  11. When to add 3rd drug? What to add? ACE + CCB + Diuretic Enalapril 5 + Amlodipine 5 + Hydrochlorothiazide 12.5 mg BB + CCB + Diuretic Atenolol 50 + Amlodipine 5+ Hydrochlorothiazide12.5mg

  12. Resistant : Add either  - blocker prazosin 2 – 20mg bd –tds or Doxazosin 1 – 16 mg od Spironolactone – 25 mg Other diuretic – Metolazone 2.5 mg – indapamide 1.25 – 2.5 mg

  13. - Acute myocardial ischemia • Nitroglycerin –5 to 10 µg / min as IV infusion •  - blockers –ESMOLOL 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes • ACEI (if available) – ENALAPRILAT 1.25 to 5 mg q6 hour IV • CHF with pulmonary edema • Nitroglycerin –5 to10 µg / min as IV infusion • Frusemide • Morphine

  14. - Acute aortic dissection • Nitroprusside IV plus  - blockers esmolol 1. Dose is 5 to 10 µg / min as IV infusion 2. Dose is 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes. • Alternative – Trimethaphan plus  - blocker • Cerebral vascular accident: • Nitroprusside -5 to10 µg / min as IV infusion • Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion • Nimodipine

  15. - Pheocheromocytoma • Phentolamine 5-15 mg IV • Nitroprusside –5 to 10µg / min as IV infusion • Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion - Hypertensive encephalopathy • Nitroprusside –5 to 10µg / min as IV infusion • Trimethaphan •  - blockers - 250 to 500µg / kg / min for I minute, then 50 to 100µg / kg for 4 maintained

  16. Hypertensive encephalopathy • Hydralazine- 10-50 mg IV / IM • Labetalol – 20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion • Magnesium IV

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