Treatment of Hypertension by Dr Sarma

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Welcome, Dear Friends
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The Almighty

• Pardons and Grants me heaven
• Even if I don't know a single letter about
• Crutz Feld Jacobs Disease
• Tsutsugamushi Fever
• Criggler Nazzar Syndrome
• South American equine encephalitis and
• Many and much more rarer topics
• BUT .

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The Almighty

• Will drag me to hell and will not pardon
• My ignorance of even the minute details of HT
• My indifference to apply the current knowledge
• My negligence in screening for HT, TOD
• My despondency about preventing TOD
• My inadequacy in maintaining my patients
• as normo-tensive as possible
• (This is applicable to all common diseases)

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Treatment of Hypertension A CLINICAL APPROACH
Dr.Sarma RVSN, M.D., M.Sc (Canada) Consultant
Physician and Chest Specialist, 5, Jayanagar,
Tiruvallur 602 001 93805 21221, (044)
27660593
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Management of Hypertension
Treatment of Hypertension A CLINICAL APPROACH

• Based on the latest recommendations of
• JNC VII, ISH, ESH, WHO

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Globally Renowned HT Societies

1. JNC VII Joint National Committee on HT, USA
2. ISH WHO International Society on HT
3. AHA American Heart Association, USA
4. ACC American College of Cardiologist
5. BHS British Hypertension Society
6. NIHLB National Inst. Heart Lung Blood vessels
7. EHS European Hypertension Society
8. CHS Canadian Hypertension Society
9. NKF National Kidney Foundation, USA
10. AKA American Kidney Association, USA

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What is new in Hypertension?
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HYPERTENSION
What we record as B.P.
It is only a marker of the bigger problem

• The Truth is

Hypertension is a multi-organ systemic disease
The Problem is
Hypertension is asymptomatic in 85 of cases
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How to be wise in HT?
It is wrong
To consider Hypertension as an isolated disease

• The Truth is

Hypertension, DM, Dyslipidemia, Obesity often
coexist They are the 4 pallbearers to the grave
of CHD, CVD
For all of them
Primary and secondary prevention by TLC is the
answer Afflicted with one, must be screened for
all other thieves
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Treatment Goal
Goal BP
Keep B.P. lt 140/90 mm Hg in each patient This may
be revised to 120/80 may be ? 110/70 MRFITs
cut off values are 115/75 mm Hg

• The Truth is

It is essential to keep the B.P at or below the
goal But, It also matters how the goal B.P. is
achieved !
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Definitions

• As per JNC VII and ISH (WHO) 2004
• What is normal B.P ?
• What is pre hypertension ?

As per JNC VII and ISH (WHO) 2004 Normal SBP lt
120 and DBP lt 80 Pre HT SBP 120 to 139 mm Hg
DBP 80 to 99 mm Hg
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Definitions

1. What is stage 1 HT ?
2. What is stage 2 HT ?

Stage 1 SBP 140 to 159 DBP 90 to
99 Stage 2 SBP 160 and more DBP 100 and more
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JNC VII Classification
Category SBP (mm Hg) DBP (mm Hg)
Normal lt 120 lt 80
Pre hypertension 120-139 80-90
Hypertension Hypertension Hypertension
Stage 1 140 159 90 99
Stage 2 160 and above 100 and above
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Definitions

• Are the values same for Diabetics , CKD?

No, for DM, IHD and CKD the criteria are more
stringent The cut off values are 10 mm lower
Stage 1 SBP 130 to 149 DBP 80 to
89 Stage 2 SBP 150 and more DBP 90 and more
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Hypertension Optimal Treatment (HOT) Study
Reduction in CV events
p0.005 (DM)
Lancet 1998 351 175562
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Rule of Halves

• What is this rule of halves in HT ?

• For every 800 adults in the community
• 400 are HT (either ? SBP or ? DBP or both)
• Of them only 200 are diagnosed HT
• Of them only 100 are started on treatment
• Of them only 50 are on correct drug
• Of them in only 25 the goal B.P. is attained
• Means 25 400 6 only have goal BP

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How many are really Dx. and Rx.ed ??
Diagnosed HT
Under treatment (50)
Un Rx. HT
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Undiagnosed HT
A study from Europe on 23,339 patients
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Global Hypertension Control
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Isolated Systolic Hypertension

1. What is ISH ?
2. What percentage of 65 aged have ISH ?
3. Which is more harmful ? SBP or DBP ?
4. Why is ISH important ?

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Relative prevalence of SBP and DBP
40 yrs
ISH
SDHT
DHT
Normal
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R R for CVD - SBP and DBP
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ISH is universal after 65
Persons who are normo-tensive at age 55 have a
90 lifetime risk for developing HTN.
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HT- RR of stroke and MI
Normotensives
Hypertensives
5 Year Risk ()
20
40
60
80
220
240
260
280
0
100
200
300
120
140
160
180
Systolic Blood Pressure (mmHg)

Brown, M.J. Lancet 2000 355 659 - 660
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Is SBP more dangerous or DBP ?
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Isolated Systolic Hypertension

• What is ISH ?
• SBP 140 , DBP lt 90
• What percentage of 65 aged have ISH ?
• More than 90
• Which is more harmful ? SBP or DBP ?
• Of course ? SBP
• Why is ISH important ?
• Because of ?? CVA and CHD mortality

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For adequate control of B.P.

• Do you think we can control most of the
• patients of hypertension with
• One drug
• Two drugs
• Three drugs
• Cant control

In most of the patients of hypertension Two
drugs are required for adequate control More so
if the initial BP is 20/10 above the goal
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Todays Paradigm

• Gone are the days of monotherapy
• It is the era of combination therapy
• Why is it so?

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CVD Risk Factors

• What are the so called CHD risk factors ?
• What are known as CHD risk equivalents ?
• What is Framingham risk score ?

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Global Risk Profile and HT
25)
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HT combined with other CHD RF
Framingham offspring study, subjects aged 17 84
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CVD Risk Factors

• What are the so called CHD risk factors ?
• List discussed in previous slide
• What are known as CHD risk equivalents ?
• DM, PVD, CVA, Nephropathy, Retinopathy
• What is Framingham 10 CHD risk estimate ?
• 10 year CHD risk estimate based on age, sex,
  smoking, TC, HDL, SBP, Rx. for HT
• see the program

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Target Organ Damage

• Why is there TOD in HT ?
• What are the organs targeted for damage ?
• What is the basis of TOD ?
• What tests we need to do to assess HT ?

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Diseases Attributable to Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Hypertension
Left ventricular hypertrophy
Chronic kidney failure
Aortic aneurysm
Hypertensive encephalopathy
Retinopathy
All Vascular
Peripheral vascular disease
Adapted from Arch Intern Med 1996 1561926-1935.
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Target Organ Damage (TOD)

• Heart
• Left ventricular hypertrophy (LVH)
• Angina or prior myocardial infarction (CHD)
• Prior Coronary revascularization PTCA or CABG
• Heart failure (Systolic / Diastolic
  dysfunction)
• Brain
• CVA Stroke or Transient Ischemic Attack (TIA)
• Kidney Chronic kidney disease and CRF
• Vessels Peripheral arterial disease PVD
• Eyes Hypertensive Retinopathy

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Atherosclerosis Time line
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Endothelial NO Balance
NO
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Target Organ Damage - Assessment

• Routine Tests
• Electrocardiogram, Echocardiography (desirable)
• Urinalysis for proteinuria, Microalbuminuria
• Blood glucose (F and PP), and Hematocrit
• Serum Na and K, Creatinine or GFR, Calcium
• Lipid Profile complete, Eye examination, ABI
• Optional tests
• X-Ray Chest PA
• 24 hr. urine albumin excretion or ACR
• More extensive testing is not generally indicated

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Target Organ Damage

• Why is there TOD in HT ?
• It is a disease of blood vessels.
• What are the organs targeted for damage ?
• Heart, brain, kidney, eye, peripheral vessel
• What is the basis of TOD ?
• ED, Arterial stiffness and Atherosclerosis
• What tests we need to do to assess TOD ?
• List discussed

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Paradigm Shift in HT Therapy
It is not just ?B.P.
TODAY we must strive to

• Alter the modifiable risk factors
• Keep the SBP lt 140 and DBP lt 90
• Prevent or halt or reduce TOD
• LVH, CHD, CHF, CVA, CRF, PVD Retino.
• Prevent or control DM (as HT DM is hazardous)
• Prevent or control Dyslipidemia (Endothelial
  Dysf.)
• Reduce morbidity and mortality
• Improve QUALY Quality Adjusted Life Years

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Target Organ Damage

• What is single most imp. predictor of CHD, HF,
  Death ?
• What time course of HT to LVH to LVF to death ?
• Can LVH be regressed at all ?
• Will drugs help to regress LVH and ?TOD ?
• How important is Micro-albuminuria ?

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Normal weight 350 to 450 g
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Transverse Section of HEART - LVH
10 mm
25 mm
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Echocardiography of Heart - LVH
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ECG and Left Ventricular Hypertrophy
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Chest PA view of Heart - LVH
C/T ratio gt 50
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Progression of HT to LVH to HF
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Survival Rate HT LVH v/s NT LVH
Source Am Hear J, 2000 140 (6) 848-856.
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LVH is the Single Most important predictor
Can LVH be reduced at all ??
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Will Treatment Help ??
Combined results of 17 RCTs ( n 48,000) Hebert
1993, Moser 1996
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MAU as a Predictor of Morbidity and Mortality
Parving HH. J Hypertens 199614 Suppl 2S89-S94.
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Definitions of abnormalities in albuminuria
Category 24 hour collection (mg/24h) Timed collection (?g/min) Spot collection (?g/mg Cr)
Normal lt 30 lt 20 lt 30
Microalbuminuria 30-299 20-199 30-299
Clinical (macro) albuminuria ? 300 ? 200 ? 300
Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 mon should be abnormal before considering diagnostic threshold positive Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 mon should be abnormal before considering diagnostic threshold positive Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 mon should be abnormal before considering diagnostic threshold positive Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 mon should be abnormal before considering diagnostic threshold positive
False positive exercise lt 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria. False positive exercise lt 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria. False positive exercise lt 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria. False positive exercise lt 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria.
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Relative Importance of MAU


10.02
10 8 6 4 2 0
6.52
CHD Odds Ratio
3.20
2.32
Cholesterol
Microalbuminuria
Smoking
Hypertension
Eastman RC, Keen H. Lancet 1997350 Suppl 129-32.
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Target Organ Damage

• What is single most imp. predictor of CHD, HF,
  Death ?
• LVH LV mass index
• What is the time course of HT to LVH to LVF to
  death ?
• The chart is explained
• Can LVH be regressed at all ?
• Very much Yes. Diuretics and ACEi are the best
• Will drugs help to regress ?TOD ?
• Yes. All TOD regresses LVF and CVA most
• How important is Micro-albuminuria ?
• The most important prognostic indicator of TOD

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Clinical Signs of LV Dysfunction

• Hypotension
• Pulsus alternans
• Trigeminy, Bigeminy
• Reduced volume of carotid
• LV apical
• Enlargement/displacement
• Sustained heave of apex
• Change in heart sounds

• Soft S1
• Paradoxically split S2
• S3 gallop
• S4 impaired LV compliance)
• Mitral regurgitation
• Pulmonary congestion rales

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Ankle-Brachial Index

• Resting and post exercise SBP in ankle and arm.
• Normal ABI gt 1 (Ankle BP more than the arm BP)
• ABI lt 0.9 has 95 sensitivity for angiographic
  PVD
• ABI of 0.5- 0.84 correlates with claudication
• ABI lt 0.5 indicates advanced ischemia

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Dippers Non Dippers

• What is this pattern in HT Dippers and
  Non-dippers ?
• What is its significance and clinical relevance ?

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Dippers Non Dippers
Yonsei, Med J, Vol 43, No 3 2002
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Dippers Non Dippers
Yonsei, Med J, Vol 43, No 3 2002
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Dippers Non Dippers

1. Less than 10 circadian variation in SBP and DBP
2. Essential hypertension patients are usually
   Dippers
3. Non dippers are Dx. by ABPM They are usually
4. Secondary HT cases
5. More end organ damage
6. More LVH
7. More responsive to salt restriction
8. Diabetics are non dippers
9. Diuretics convert a non dipper to dipper

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Ambulatory Blood Pressure Monitoring - ABPM

1. 24 hour B.P monitoring (every 15 minutes)
2. Today - 24 hour B.P. control is essential
3. Identifies dippers and non-dippers
4. Excludes white coat hypertension

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Pulse wave velocity Arterial Stiffness
PulseTrace PCA
Sphygmocor
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What is MOST essential ??

• Not that my drug is superior to yours
• Not that this trial is better than that
• Nor this combination is better than that
• But to get AS MANY PEOPLE as we
• can to goal SBP lt 140 DBP lt 90
• And prevent or halt TOD.
• Of course, tailor the treatment as per
• individual patients co-morbidities.

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Morbidity and Mortality in HT

• Most of the morbidity and mortality of HT is due
  to
• LVH LV diastolic and systolic dysfunction
• Increased risk of Coronary Artery Disease
• Increased risk of Cerebral Vascular Disease
• Hypertensive heart failure
• Chronic Renal Disease of hypertension
• Hypertensive vascular damage

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The correct Approach to HT
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So, What is new in Hypertension ?

1. High B.P recorded is only a clinical marker
   disease
2. HT is a multi-organ disease, often asymptomatic
3. Not to consider in isolation- Must look for
   Co-Thieves
4. Todays goal BP is 140/90 It will sure be less
   tomorrow
5. It matters to attain goal matters more how it is
   attained
6. In DM, CKD, IHD the cut off values are 10 mm less
7. Remember rule of ½ in HT Adequate control only
   in 7

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What is new in Hypertension - continued

• 8. ? SBP is more important than ? DBP Often
  ignored it is !
• 9. Wide pulse pressure (SBP-DBP) signifies
  arterial damage
• 10. Days of monotherapy have gone Combined Rx
  replaces
• 11. All HT must be screened for CHD risk factors
  addressed
• 12. Target organ damage (TOD) must be
  investigated and Rx.
• 13. LVH is the single most predictor of mortality
  and morbidity
• 14. ABI, MAU, ABPM, PWV etc., identify high risk
  cases early

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Lifestyle Modification

1. Life style modification is the sheet anchor in
   the management Hypertension.
2. This surely reduces the number of drugs used and
   their dosage in controlling HT.
3. Any drug treatment has value only when coupled
   with Life style modification.

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Lifestyle Modification
Modification Approximate BP reduction(range)
Weight reduction 520 mm/10 kg wt loss

Adopt DASH eating plan 814 mmHg
Dietary sodium reduction 28 mmHg
Physical activity 49 mmHg
Abstinence from alcohol 24 mmHg
All put together reduce BP by 20 to 55 mmHg
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What to choose from the ocean

• 16 different classes of drugs
• 117 approved molecules as on date
• Innumerable drug combinations
• Over 1800 clinical trials of repute
• Five international societies on HT
• Seven JNC guidelines so far
• Multiple target organs damage
• Many co-morbidities
• Varied outcomes of interest
• Cost constraints

No significant change in the proportion of HT
under control
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Many avoidable HT deaths !
On April 12, 1945, US President Franklin D.
Roosevelt died of cerebral hemorrhage, a
consequence of HT. It was a devastating illness
for him. By current standards, President
Roosevelts death was unnecessary. President
Roosevelt was never treated with
Anti-hypertensive drugs. Modern treatment would
have controlled his BP and prolonged his life.
Arch Int Med,
Sept, 23,1996
. . . so also of many others!
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The Many Faces of HT Therapy Today
CCBs
Enalapril Lisinopril Ramipril Quinapril Perindopri
l
Centrally acting agents
ARBs
Diuretics
ACE inhibitors
Beta blockers
Hypertension
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Which drug should we prescribe ?

• Choice must be tailored to individual patient
• Should be rational and as per approved guidelines
• Only class1 evidence based medications to be used
• Suitable to patients purse
• Can never be arbitrary

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Physicians Bias in HT

• Isolated SHT is often dubbed as aging factor
• To consider HT is only in the ARM and not in
  the body
• No concept of pulse pressure Not seeing the
  whole
• Worry about side effects Need to watch, not to
  worry
• OK, some control is achieved why attain goal BP
  ?
• Not insisting on compliance with drugs and
  assessments
• Pressure from patients B.P. How much ? How much
  ?
• Concentrating on the pill and not on the ill
  TLC forgotten

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Anti Hypertensive drug classes
The A, B, C, D approach
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Anti Hypertensive drug classes

• ACEi Angiotensin converting enzyme
• inhibitors Enalapril- let us call them A
• ARB Angiotensin Receptor Blockers
• Losartan - Let us call them also as A
• BB Beta Receptor Blockers Metoprolol,
• Carveidilol, Atenelol - let us call them
  B
• CCB Calcium channel blockers Amlodepine
• Verapamil, Diltiazem - let us call them C
• Diuretics Hydrochlor Thiaz.- Furosemide,
• Spiranolactone - let us call them D

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AB/CD Rule HT Treatment
ACEi, Beta-blocker
Ca-blocker, Diuretic)
(AB/CD

AGE
Younger (lt 55) High Renin HT
Older (gt 55) Low Renin HT
ACEi
BB
Diuretic
CCB
I
I
III
III
A B
A B D
D C A
D C
II
II
Dickerson et al. Lancet 3532008-111999
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The A B C D classes
D Diuretics
A ACEI, ARB
Ca channelBlockers Fourth Choice, Useful Can
be combined with D, A
DIURETICS First and Best Choice Can be combined
with A, B, C
ACEI and ARB Second Best Choice Can be combined
with D, B, C
ßBlockers Good third Choice Can be combined
with A, D
D A B C
B ß-Blockers
C Ca-Blockers
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A B C D some brand names

• Thiazide diuretics
• Hydrochlorothiazide - Aquazide, Hydride, Xenia
• Chlorthalidone Hythalton, Loop diuretic
  Frusemide
• Potassium sparing
• Triamterene, Amiloride, Spironalactone (Aldo
  anta)
• Beta blockers
• Selective Metoprolol, Metoprolol XL, Atenelol
• Combined alpha and beta blockers Carveidilol,
  Labetolol
• ACEI Enalapril, Ramipril, Lisinopril,
  Quinapril, Perindopril
• ARB Losartan, Valsratan, Candesartan,
  Irbesartan
• CCB Nefedipine, Amlodipine, Varapamil,
  Diltiazem
• Alpha Blokers Prazocin, Doxizocin, Terazocin,
  Tamsulocin

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Hypertension Why Combinations ?

• If goal BP is not achieved by a single drug in
  full dose
• Then adding another agent will help achieve the
  goal BP
• Two agents sometimes nullify each others side
  effects
• Fixed dose combinations will reduce the no. of
  tablets
• Once daily formulations are good for compliance
• Sustained release or LA formulations for 24 h BP
  control
• If three drugs cant achieve goal BP Resistant
  HT

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Drug Combinations
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Hypertension Rational Drug Combinations
ACEI and ARB A Beta Blockers B Calcium
Channel (CCB) C Diuretics Drugs D
Diuretics D Rank 1 ACEI and ARB A Rank
2 Beta Blockers B Rank 3 CCB C Rank 4
D and A combination is excellent - Ramace H,
Losar H, Enace D D and B combination next
- Betaloc H, Atecard D, Tenoric D and C
combination sixth - Amlogaurd H, Stamlo D A and
B combination Third - Losar A, Cardif Beta A and
C combination fourth - Amlopres L, Hipril A, Amlo
LS B and C combination fifth - Amlo AT,
Amlobet, Beta Nicardia
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Some Irrational Combinations
Beta blockers Beta1 stimulants - Rebound HT,
Paradoxical BP ? Beta blockers Vepapamil
- Extreme bradycardia, HB, CHF Thiazide
Furesemide - Potential volume ? and K ? CCB
Thiazide - No RCTs to support the
additive Prazocin Beta blocker - They nullify
the effects of each other Verapamil / Dilzem
Nefidepine - No rationale (cardiac actions
contridic) Beta blocker ACEI Not for HT alone,
Good for CHF, MI, IHD Sub clinical doses of two
drugs Try one drug in good dosage, then add Two
drugs of same class - No rationale (like
Enalapril Ramipril) (Atenelol Metoprolol,
Nefidepine Amlo)
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KNOW ME WELL
I am D for DIURETIC
DIURETIC

• My Good aspects
• Fluid depletion, Na washout, Low cost
• Improve CHF, Systolic function, Ca saving
• Reduce LVH, Morbidity Mortality
• My Bad aspects
• Potassium washout, ? in Uric acid, ? Ca
• Adverse on Lipids, Glucose control
• Dont use me in
• Gout, Hypokalaemia
• Dyslipedemia, Uncontrolled DM

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KNOW ME WELL
I am A for ACEI and ARB
ACEI, ARB

• My Good aspects
• Improve Diastolic function, Systolic function
• Control Proteinuria, Very favourable in DM
• Improve Coronary Ischemia, Good on Lipids
• Reduce LVH, Morbidity Mortality
• My Bad aspects
• Bradykinin accumulation, Angio-edema
• ? Serum K , ? GFR
• Dont use me in
• Pregnancy, Creatinine is gt 3 mg, ? K 5.0 meq
• Bilateral Renal Artery Stenosis, Angio-edema

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I am B for ßBlocker
ß Blocker
KNOW ME WELL

• My Good aspects
• ?Heart rate, ?Forceof contraction,
  ?Conduction
• ?Myocardial O2 demand, Improve
  Ischemia
• Improve QUALY in CHD, Useful in CHF, Migraine
• My Bad aspects
• Constrict peripheral vessels, Bradycardia
• Unfavourable on Lipids, Glucose
• Dont use me in
• Bradycardia, Conduction defects, Caution in CHF
• Prinzmetal Angina, MSD, PVD, BA, COPD, Dys lipid
• Pheochromocytoma, Chronic smokers

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KNOW ME WELL
I am C for Ca channel Blocker
Ca Blockers

• My Good aspects
• Vasodilatory, Suitable in elderly, Low cost
• Anti arrhythmic (Verapamil), ?Coronary BF
  (Diltz)
• Neutral on lipidemia, Vasospastic Angina
• My Bad aspects
• Fluid retention, Impair failing heart
• Adverse on Glucose control , Pedal edema ? Rx.
• Dont use me in
• Tachycardia, arrhythmias, CHF,
• Uncontrolled DM, Volume overload

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ABCD Compare Contrast
Parameter Diuretic ACEi, ARB ßblocker Ca Blocker
Ischemia No effect Improves Improves Negative
LVH, LVF Improves Improves Improves Negative
CV Mortality Improves Improves Improves Increases
Heart rate No effect No effect Bradycardia Tachycardia
Use in DM Negative Excellent Negative Negative
Lipid effects Negative Excellent Negative Neutral
Fluid Na Enhances No effect Vasoconstr. Vasodilatory
K ex / bronchi Enhances No effect Bronchospa No effect
UA / Conduct. ? Uric acid No effect ?conduction No effect
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Which drug in each class
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Persistence with hypertensive therapy
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Hypertension Case specific approachsome
selected case scenarios
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Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
97
Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
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Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
99
Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
100
Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
101
Case specific approach
Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D A
Case 3 Stage 2 HT Two Drugs D A, D B
Case 4 HT Tachycardia Beta blockers Not CCB
Case 5 HT Bradycardia Heart Blocks BBB CCB, ACEi Not BB
102
Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
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Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
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Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
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Case specific approach
Case 6 HT CHD Risk f ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
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Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
107
Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
108
Case specific approach
Case 6 HT CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT IHD (No MI) BB ACEi B A D
Case 8 HT MI or (RVP) BB (Car) ACEi, ARB Aldactone Diltiazem
Case 9 HT PZM Angina CCB, a bloc Not BB
Case 10 HT Diast. Dys ARB Losartan ACE Ramipril BB - Meto
Case 11 HT Sys Dys ACEi D A D B
109
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
110
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
111
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
112
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
113
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
114
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
115
Case specific approach
Case 12 HT CHF Diu - Fru. Sp. ARB / ACEi Not CCB, a bloc
Case 13 HT DM (No DK) ARB, ACEi Not D, C
Case 14 HT DM DKD MD, HYZ, D Not CCB, ACEi, ARB
Case 15 HT Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT BA / COPD ACEi / ARB Not BB
Case 17 HT PVD / smoker CCB, ACEi, HZ Not BB
116
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
117
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
118
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
119
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
120
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH - SBP gt 140 Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
121
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
122
Case specific approach
Case 18 HT BPH a bloc, Tamsu Not BB
Case 19 HT ED a bloc, HZ, ACEi /CCB Not BB
Case 20 HT Pregnancy MD, HYZ, CCB Not ACEi, or ARB
Case 21 HT Gout, ? UA ACEi, CCB Not D
Case 22 ISH Indap, Amlo, Enalapril Not BB
Case 23 HT Cough ACEi cough Cough remedy
123
Case 24 Hypertension and cough

• Hypertensives may present with cough watch out
• 1. Consider LVF as the cause of cough
• 2. Consider ACEI induced dry cough
• 3. Stop ACEI and give ARB or other agents
• 4. Check the composition of the cough remedy you
  give
• 5. Ephedrine, Pseudephedrine, should be avoided
• 6. Oral Beta agonists like Orciprenaline,
  Salbutamol,
• Terbutaline the less used, the better.
• 7. Inhaled beta agonists, ICS are safe
• 8. Decongestants like phenyl propanolamine to be
  avoided

124
Case 25 Secondary Hypertension various
causes

• Secondary HT Usually Stage 2 - HT
• Secondary causes will be present
• May present in young individuals
• Treatment Look for secondary cause and treat
• Life style interventions must
• Vigorous efforts required to control HT
• Often two or even 3 drugs may be required
• Resistant HT may be encountered
• Anti HT drugs as per secondary cause
• Absolute contra ACEI or ARB in bilateral renal
  artery stenosis

125
Case 26 Secondary Hypertension in
Pheochromocytoma

• Pheochromocytoma Usually Stage 2 HT, Episodic
  or Labile
• Secondary adrenal medullay tumor
• May present in young individuals
• Treatment Surgical Ablation of the chromaffin
  tissue
• HT needs to be controlled before surgery
• Alpha blockers are the drugs of choice
• Phentolamine, Phenoxybenzamine, Prazocin
• Vigorous efforts required to control HT
• Often two or even 3 drugs may be required
• Resistant HT may be encountered
• Surgery First reduce HT, then surgery
• Do not use Beta blockers

126
Case 27 Resistant
Hypertension

• Resistant HT Usually Stage 2 HT
• May present in young individuals
• May have secondary causes
• Reasons Not taking medication (liers)
• Improper BP measurement
• Excessive Na intake, Inadequate diuretic Rx.
• Full doses of drugs not employed
• Drug interactions NSAIDs, SMA, OCP, OTC
• Herbal remedies, Excessive alcohol use
• Rationale Identify the above and correct
• Secondary causes to be searched for

127
Case 29 Hypertensive emergencies

• HT emergency Marked DBP elevation
• Acute TOD present
• TOD Presentation Encephalopathy, MI, ACS, Pul
  Edema, Eclampsia, stroke, head trauma,
  life- threatening arterial bleeding, or aortic
  dissection
• Treatment With TOD immediate admission to ICU
• IV Nitroprusside, Diazoxide, Labetolol
• Without TOD Combination of 2 or 3 drugs
• Close monitoring
• Life style modification not now no time
• Do not use No sublingual nefedipine,

128
Case 30 Hypertensive with Acute
CVA (Stoke)

• HT CVA (Stroke) Marked DBP elevation
• May be SAH, ICH, Acute Brain Infarction
• Rationale In acute setting, no consensus on
  treatment of elevated BP
• HT at time of an acute stroke associated
  with increased risk of cerebral hemorrhage
  and edema, increased mortality
• After acute ischemic stroke, cerebral
  auto regulation affected
• Active treatment of BP in the first 7 days
  could worsen symptoms
• Treatment Recommendation not to start HT Rx.
  before 7 to 10 days after ischemic stroke

129
Current Indications for Alpha Blockers

1. Hypertension with BPH
2. In Pheochromoytoma before surgery
3. In the treatment of Ergot over dose
4. Raynauds syndrome and PVD, TAO
5. Vasospastic (prinzemetal Angina)
6. Diabetic neuropathy
7. Hypertensive smokers
8. Hypertension with Dyslipidemia

First dose syncope and Postural Hypotension How
to avoid ?
130
Learning is a cyclical process
Each of these presentations is a valuable
learning experience for me
Thank You all