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Hypertension Update MSD 2016
Hypertension Update MSD 2016
&
Update Management
Presented by:
DR. ..
Hypertension
most important preventable contributors to disease and
death.
Nearly 1 in 3 adults has high blood pressure, which
increases the risks of-
Regional Burden:
One in every 10 deaths in South-East Asia region.
It kills 1.5 Million people in this region each year.
Approximately one third of the adult population in the South-East
Asia region has hypertension.
Bangladesh Situation:
32.9% of adult population never measured BP
(44.5/22.8= Male/Female).
54.7% Measured not diagnosed (44.7/63.3 = M/F).
12.5% Measured and diagnosed (10.9/13.9 = M/F).
Among Them:
30.3% had normal Blood pressure with healthy life style.
17.6% had normal BP with anti hypertensive medication.
30.7% on medication but still hypertension.
21.4% was hypertensive but not taking medicine.
Classification of hypertension:
Classification of hypertension:
Systolic Bp mm Hg
Diastolic BP mm Hg
Normal
<120
<80
Pre-hypertension
120-139
80-89
Stage- 1
hypertension
140-159
90-99
Stage- 2
hypertension
160
100
Investigation:
For all Patients:
X-ray chest (PAV) Cardiomegaly, Heart failure sign
ECG LVH, Ischaemia
Echo Concentric hypertrophy, Aorata dilated, LV dilated, Diastolic
dysfunction.
Urine for routine test : proteinuria
Serum Creatinine, Blood Urea.
Lipid Profile
Serum Electrolytes
RBS
Amlodipine
Cilnidipine
Ca-Channel
Blockade
Only L-type
Ankle edema
Up to 64%
No or Less chance
Reflex Tachycardia
Frequently
happens
Suppress
tachycardia
Protective Effect
No
Cardioprotective,
Neuroprotective,
Renoprotective,
Insulin Sensitivity
No
Has
End Organ
Has no protective
role
SBP mm. Hg
DBP mm Hg
Life style
Modification
Drug Therapy
Normal
120
80
Encourage
No
Pre-Hypertension
120-139
80-89
Yes
No
Stage 1
Hypertension
140-159
90-99
Yes
Yes
Stage 2
Hypertension
160 or
100
Yes
Yes
With Complication
Drugs: Diuretics, ACEI, ARB, BB, CCB As
needed.
With Complication
Drugs: Diuretics, ACEI, ARB, BB, CCB As
needed.
Diuretics
BB
ACEI
ARB
CCB
Aldosterone
Antagonist
Heart Failure
Myocardial infraction
Diabetics
JNC 8
2014 Evidence-Based Guidelines for the
Management of High Blood Pressure in
Adults
JAMA. 2014;311(5):507-520
December 18, 2013
Populatin
Goal BP mm Hg
Initial Drug
Treatment Options
General 60 y
< 150/90
General < 60 y
<140/90
Black: thizide-type
diuretic or CCB
Diabetes
<140/90
Thiazide-type
diuretic, ACEI, ARB
or CCB
CKD no proteinuria
<140/90
ACEI or ARB
CKD + Proteinuria
<130/90
ACEI or ARB
HTN Goal
16
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages 18-39
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade E
Comparison of Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
>140/90 <80 yr
>150/90 >80 yr
>140/90
Threshold
for Drug Rx
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
w/ 2 drugs
>160/100
"Markedly
elevated BP"
>160/100
>160/100
Goal BP
Group
General
CKD**
JNC 8:
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
< 140/90
< 140/90
Weight Reduction
02
Dietary approaches to
stop HTN
03
04
Physical Activity
05
Stop Smoking
Avoid Tabacco
06
Moderation of Alocohol
Consumption
07
08
09
Regular taking
hypertension drug.
10
Complications:
Hypertension is the most important risk factor for death.
Brain:
Hypertensive Emergency:
Require immediate blood pressure reduction within minute to
an hour up to 140/90 mm Hg. Not necessary to normal.
i) Hypertension Encephalopathy,
ii) Acute aortic dissection.
iii) Acute Mi, Unstable Angina.
iv) Acute LVF, Pulmonary oedema.
v) Post coronary artery bypass with hypertension.
vi) Strokes
vii) Eclampsia
Treatment: Drug used short acting Nifedipine, Captopril by
mouth or sublingually, I/V Nitroglycerin, Sodium Nitroprusside.
Hypertensive Urgencies
Required Blood Pressure reduction with 12-24 hr to up to
140/90 mm Hg. Not necessary to normal level.
i) Severe systolic hypertension >200 mm Hg. Or severe
Diastolic hypertension >120 mm Hg. Without complication.
ii) Malignant hypertension without complication.
iii) Pre-operative hypertension.
Hypertensive Encephalopathy:
Severe hypertension systolic BP 210 or Diastolic 120
mm Hg. Associated with Headache, Drowsiness, Vision
disorder, Nausea & Vomiting. Symptoms are collectively
referred to as hypertensive encephalopathy.
Fixed-dose combinations
Single-pill combinations of two antihypertensive
drugs, known as fixed-dose combinations, are now
widely available, often combining an ACEI or an
ARB as agents that target the reninangiotensin
system (RAS) with either a thiazide diuretic or a
CCB.
At low doses, fixed-dose combinations may have
greater efficacy and better tolerability than the
respective high-dose monotherapies
28
Combination therapy
The rationale behind combination therapy,
using two or more drugs with different and
complementary mechanisms of action, is the
potential to improve BP control by the
combined effects and, by allowing lower
doses of the drugs, to reduce unwanted
side-effects.
29
Olmesartan/amlodipine combination
therapy
ARB Olmesartan is of interest since it has been
shown in pharmacodynamic studies to produce a
strong level
of
AT1 receptorproduces
blockade in robust
relation to
dose
Olmesartan
antihypertensive
efficacy over 24 hours, the daytime, night-time,
and end-of dosing interval periods relative to
losartan, candesartan or valsartan monotherapy,
and was at least as efficacious as irbesartan.
Clinical data suggest that olmesartan may
protect against end-organ damage and, in this
regard, renoprotective and anti-atherosclerotic
effects have been reported in clinical and
experimental
Am J Hypertens. 2007;20(8):907916
studies.
Clin Pharmacol Ther. 2005;78(5):501507
J Hypertens. 2010;28(3): 520526
Conclusion
For all persons with hypertension, the potential
benefits of a healthy diet, weight control, and
regular exercise cannot
be overemphasized. These lifestyle treatments have
the potential to improve BP control and even reduce
medication needs.
Although the authors of this hypertension guideline
did not conduct an evidence review of lifestyle
treatments in patients taking and not taking
antihypertensive
medication,
wesupport
the
recommendations of the 2013 Lifestyle Work Group.
Conclusion
35
Acknowledgements
Courtesy by:
Calnor
Amlodipine+Olmesartan
Cildip
Cilnidipine
Olsart
Olmesartan