Transcript Case specific approach

‫إعداد ‪:‬‬
‫د‪ 0‬عمر عبدهللا الق اسم‬
Endothelial NO Balance
NO
3
It is not just ↓B.P.
TODAY we must strive to
Alter the modifiable risk factors
Keep the SBP < 140 and DBP < 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
4
Life style modification is the sheet anchor in
the management Hypertension.
This surely reduces the number of drugs
used and their dosage in controlling HT.
Any drug treatment has value only when
coupled with Life style modification.
Modification
Weight reduction
Approximate BP reduction
(range)
5–20 mm/10 kg wt loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Abstinence from alcohol
2–4 mmHg
All put together reduce BP by 20 to 55 mmHg
10
Goal BP
Keep B.P. < 140/90 mm Hg in each patient
This may be revised to 120/80 may be ? 110/70
MRFIT’s 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 !
11
Hypertension
12
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
Don’t use me in
Gout, Hypokalaemia
Dyslipedemia, Uncontrolled
13
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
Don’t use me in
Pregnancy, Creatinine is > 3 mg%, ↑ K 5.0 meq
Bilateral Renal Artery Stenosis, Angio-edema
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
Don’t use me in
Bradycardia, Conduction defects, Caution in CHF
Prinzmetal Angina, MSD, PVD, BA, COPD, Dys lipid
Pheochromocytoma, Chronic smokers
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.
Don’t use me in
Tachycardia, arrhythmias, CHF,
Uncontrolled DM, Volume overload
ABCD Compare & Contrast
Parameter
Diuretic
ACEi, ARB
βblocker
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
17
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 or 3 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
19
Case 6
HT + CHD
Risk F
ACEi
(Perindo)
BB
Case 7
HT + IHD
(No MI)
BB + ACEi
B+A+
D
Case 8
HT + MI
BB (Car) +
ACEi,
ARB
Aldacton
e
Diltiaze
m
Case 9
HT + PZM
Angina
CCB, α
bloc
Not BB
Case 10
HT + Diast.
ARB
Losartan
ACE
Ramipril
BB
Case 11
HT + Sys .
ACEi + D
A+D+
B
20
Case 12
HT + CHF
Diu - Fru. Sp. +
ARB / ACEi
Case 13
HT + DM
ARB, ACEi
Not D, C
Case 14
HT (ISH)
Indap, Amlo, ACEi
Not BB
Case 15
HT + Dys lipidem.
ACEi, CCB
Not BB, D
Case 16
HT + BA / COPD
ACEi / ARB
+/-BB
Case 17
HT + PVD / smoker
CCB, ACEi, HZ
Not BB
Not CCB,
α bloc
21
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
22
In adults with HTN:
Does initiating antihypertensive pharmacologic
therapy at specific BP thresholds improve
health outcomes?
Does treatment with antihypertensive
pharmacologic therapy to a specified goal
lead to improvements in health outcomes?
Do various antihypertensive drugs or drug
classes differ in comparative benefits and
harms on specific health outcomes?
In patients >60 years of age, start medications at
blood pressure of >150/90mm Hg and treat to
goal of <150/90mm Hg
In patients >60 years of age, treatment does not
need to be adjusted if achieved blood pressure is
lower than goal and well-tolerated
Thank You all