PRESENATATION BY

DR MISBAHUL FERDOUS MBBS(USTC)

FMD (USTC)

PGT (CARDIOLOGY) NICVD.DHAKA

PUBLICATION- 1 (ORIGINAL ARTICLE) METABOLIC SYNDROME AND ACUTE ST ELEVATION MI IN

HOSPITAL OUTCOME.

PUBLISHED IN B.H.J. JANUARY-2008

MD (CARDIOLOGY), COURSE SHANDONG UNIVERSITY, CHINA.

Hypertension

Rise of blood pressure above the normal level is called hypertension.

Types:1. Primary or essential hypertension. 2. Secondary hypertension.

Korotkoff, 1905

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

Management of Hypertension A.General management.

B.Antihypertensive Drug therapy.

a) General Treatment

(Non Pharmacological treatment)

Life style modification:

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

Investigations of Hypertension Basic test for initial evaluation a) Always included:

1. Urine for: Protein, blood, glucose

2. Haematocrit

3. Serum electrolytes- specially POTASSIUM

4. Blood urea & serum creatinine

5. ECG

6. Plasma cholesterol

Basic test for initial evaluation

b) Usually included depending on cost & other factors:1. Microscopic analysis 2. WBC 3. Blood / plasma glucose

- Fasting Blood glucose level- 2 HPP blood glucose level

4. Serum – Total cholesterol, HDL, LDL, Triglycerides

5. Serum – calcium, phosphate, uric acid 6. X-ray chest P/A view7. ECG

Investigation of SELECTED PATIENT 1. Ambulatory BP recording

2. Renal ultrasonography

3. Renal angiography

4. Renal isotope scan

5. 24 hours urine assay for creatinine meta morphines and catacholamines on plasma catacolamines if phenochromocytoma suspected.

6. Plasma renin activity & aldesterone

Treatment of hypertension

Prehypertension …Prehypertension … Is Is notnot a disease, a disease,

Is Is notnot “hypertension”, “hypertension”,

Is Is notnot an indication for drug treatment of HTN, an indication for drug treatment of HTN,

Does Does notnot have a BP goal, have a BP goal,

DoesDoes predict a higher risk for developing CV events, predict a higher risk for developing CV events,

DoesDoes predict a higher risk for developing HTN, predict a higher risk for developing HTN,

Should be an incentive to improve lifestyle Should be an incentive to improve lifestyle

practices for prevention of HTN and CVD.practices for prevention of HTN and CVD.

Drug use in Hypertension

Class Drugs / Trade name

DIURETICSA. Thiazide diuretics a. Bendro fluazide

b. Cyclopenthiazide c. Hydrochlorothiazide

B. Loop diuretics a. Bumetanide b. Frusemide

C. Potassium-sparing a. Spironolactone b. Amiloride c. Triamterene

Class Drugs / Trade name Drugs / Trade name

Anti-adrenergic agentsA. β-adreno receptor

antagonist (BBs)Cardio selective • Atenolol• Metaprolol• Acebutolol• Betaxolol• Bisoprolol

Non selective • Propranolol• Oxprenolol • Alprenolol• Timolol • Pindolol

B. α- adreno receptor antagonist

a. Prazosin b. Doxazonicc. Indoramin

C. Non selective adrenergic receptor blocker

a. Phantolamineb. Phenoxy benzamine

Central acting a. Methyldopa b. Clonidine

α/β receptor blockera. Lebetolol

Calcium channel blocker Dihydropyridine Phenyl alkylamine

• Nifidipine • Amlodipine • Nicardipine • Isradipine • Felodipine

• Varapamil • Diltiazem

ACE inhibitor • Captopril • Enalopril• Lisinopril

• Ramipril• Benapril• Fosinopril

Angiotensin II receptor blocker• Losartan • Valsartan

Vasodilator (Direct) • Hydralazine • Minoxidil • Diazoxide

• Na-Nitropruside

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

Treatment of hypertension in special situations

1. 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.

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

c) Hypertension with HORMONE REPLACEMENT THERAPY

Presence of hypertension is not contraindicated for post menopausal estrogen replacement therapy.

frequent FOLLOW UP should be advised .

3. Hypertension with co-existing cardiovascular diseases

a) 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.

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

VERAPAMIL or DILTIAZEM may be used in following conditions (i) Non- myocardial infraction (ii) After MI with presented left ventricular

function.

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

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 ]

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.

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.

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.

8. Hypertension with LIVER DISEASE: ALL Antihypertensive drugs can be used

except METHYLDOPA.

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

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's phenomenon.

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

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.

15. Hypertensive crises Hypertensive crises A) Emergency B) Urgency

i) Malignant HTN

ii) Accelerated HTN

Goal of reducing BP 160/100 mm of Hg with in 24 hrsDrugs of Choice:

Oral Drugs are better than I/V

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]

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

Approximately 50 Million Americans Have Hypertension

Uncontrolled72.6%

Controlled27.4%

13.7 million

36 million

Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors

Ezzati et al. Lancet. 2002;360:1347-1360.Ezzati et al. Lancet. 2002;360:1347-1360.Attributable Mortality Attributable Mortality (In thousands; total 55,861,000)(In thousands; total 55,861,000)

High mortality, developing regionHigh mortality, developing region

Lower mortality, developing regionLower mortality, developing region

Developed regionDeveloped region

00 8000800070007000600060005000500040004000300030002000200010001000

High blood pressureHigh blood pressure

TobaccoTobacco

High cholesterolHigh cholesterol

Unsafe sexUnsafe sex

High BMIHigh BMI

Physical inactivityPhysical inactivity

AlcoholAlcohol

Indoor smoke from solid fuelsIndoor smoke from solid fuels

Iron deficiencyIron deficiency

UnderweightUnderweight

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.

Retinopathy Renal failure

Peripheral vascular disease

Complications of Hypertension:

LVH, HF,CHD,

TIA, stroke

Hypertension Hypertension is a risk factoris a risk factor

35%-40%

20%-25%

>50%

Average reduction in events (%)

–60

–50

–40

–30

–20

–10

0Stroke

Myocardialinfarction Heart failure

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events

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.

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).

I M WORKING IN CARDIAC CATH LAB.

The END!Thank You!

Oh, sorry, not the END, just the beginning!

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