Slide 1

Slide 2

Treatment Of Hypertension

Slide 3

BY PROF.DR. KAMAL MAHMOUD AHMAD

Slide 4

HEAD OF THE CARDIOLGY UNIT MEDICAL RESEARCH INSTITUTE ALEX. UNIVERSITY

Slide 5

Easy to diagnose OFTEN remains undetected Simple to treat OFTEN remains untreated Despite availability of potent drugs, treatment is too OFTEN ineffective Hypertension even today is a triple paradox which is:

Slide 6

European Society of Hypertension European Society of Cardiology JNC 7 Canadian Guidelines Egyptian Guidelines

Slide 7

Slide 8

ComorbidityRelationship to Hypertension Coronary artery disease 50% of patients with coronary artery disease have hypertension Left ventricular hypertrophy 15% to 20% of hypertensive adults have an increased left ventricular mass Ischemic stroke 77% of patients who have a first stroke have a blood pressure >140/90 mm Hg Chronic kidney disease 8% to 15% of hypertensive adults have decreased renal function Diabetes 75% of added cardiovascular risk in diabetic patients is attributable to hypertension Peripheral artery disease 74% of patients with peripheral artery disease have hypertension Rosamond W, et al. Circulation. 2007;115:69-171 ;

Slide 9

Hypertension is a major health problem in Egypt with a prevalence rate of 26.3% among the adult population (> 25 years). Its prevalence increases with aging, pproximately 50% of Egyptians above the age of 60 years suffer from hypertension..

Slide 10

1940 patients Egyptian HTN Physician & Patient Survey * *M. Mohsen Ibrahim -

Slide 11

Poor understanding of the magnitude of the risk. Poor communication (doctor-patient) Patient forgetfulness. Lack of motivation. Logistic barrier..Cost. Side effects. Complex regimen. Poor follow up.

Slide 12

Normal100 BP ClassificationSBP mmHgDBP mmHg

Slide 13

BHS classification of blood pressure levels

Slide 14

o Allow the patients to relax for several minutes o Take at least two measurements spaced by 1-2 min and additional measurements if the first two are quite different [use phase I and V (disappearance) Korotkoff sounds to identify SBP and DBP] o Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and children o Have the cuff at the heart level o Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one o Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients and in other conditions in which postural hypotension may be frequent or suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)

Slide 15

Slide 16

Self-measurement of BP at home should be encouraged Response to antihypertensive therapy Improving adherence with therapy Evaluating white-coat HTN On the contrary, Self-measurement of BP should be discouraged when: it causes anxiety to the patient it induces self-modification of the treatment regimen

Slide 17

ABPM is warranted for evaluation of white-coat HTN in the absence of target organ injury. Ambulatory BP values are usually lower than clinic readings. Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg. BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.

Slide 18

24-Hour Blood Pressure (n = 19)

Slide 19

Slide 20

Signs suggesting secondary hypertension Features of Cushing syndrome Skin stigmata of neurofibromatosis (phaeochromocytoma) Palpation of enlarged kidneys (polycystic kidneys) Auscultation of abdominal murmurs (renovascular hypertension) Auscultation of precordial or chest murmurs; Diminished and delayed femoral pulses femoral BP (aortic coarctation or aortic disease)

Slide 21

Slide 22

Routine Tests Electrocardiogram Urinalysis Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Slide 23

Slide 24

Slide 25

Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmHg Isolated systolic hypertension

Slide 26

Slide 27

To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 2300 mg / day Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating. Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7/week in addition to routine activities of daily living Maintenance of ideal body weight (BMI 18.5-24.9 kg/m 2 ) Waist Circumference Men Women - Europid, Sub-Saharan African, Middle Eastern

Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Dual Combination Triple or Quadruple Therapy Lifestyle modification Thiazide diuretic ACE-I Long-acting CCB Beta- blocker* TARGET 20 mmHg systolic or > 10 mmHg diastolic above target

Slide 47

Slide 48

Thiazide diuretics ACE inhibitors -blockers Angiotensin receptor antagonists Calcium antagonists - blockers The preferred combinations in the general hypertensive population are represented as thick lines.

Slide 49

New components and functions of the (RAS) system Since then, an expanded view of RAS has gradually emerged. Local tissue RAS systems have been identified in most organs. Evidence for an intracellular RAS has been reported. The new expanded view of RAS therefore covers both endocrine, paracrine and intracrine functions.

Slide 50

Slide 51

Slide 52

Slide 53

ISCHEMIC HEART DISEASE

Slide 54

ANTI- Hypertensive V.D., Vascular Media (Hypertrophy) sympathetic activity ANTI - Ischemic NO, oxidation of LDL-C ANTI - Thrombotic TF., PAI, Platelet Aggregation ANTI Inflammatory IL6, Hs CRP, ICAM, VCAM ANTI- Proliferative SMC Prol., MMP, Collagen, Medial HTN ANTI - LVH Myocytic Hypertrophy Reno Protective MicroAlbumninurea, Glomerular pressure Progress to ESRD Improved Insulin Sensitivity LA Size, LVH, Collagen in LA New Onset Diabetes Mellitus Recurrence of Atrial Fibrillation

Slide 55

Slide 56

Improvement of insulin sensitivity Decreased hepatic insulin clearance Antiinflammatory effect Improved blood flow to pancreas Effect on abdominal fat Increase skeletal muscle blood flow

Slide 57

BP lowering itself may cause reduction of perfusion of genital organs. B blockers, diuretics, and centrally acting drugs have been associated with ED. While ACEIs, ARBs, and CCBs have not been observed to increase its incidence.

Slide 58

If ED appears after institution of antihypertensive drug therapy, the offending agent should be discontinued and treatment restarted with another agent.

Slide 59

SILDENAFIL OR other phosphodiesterase-5 inhibitors may be prescribed without a significant likelihood of adverse reactions in those with concomitant antihypertensive therapy so long as nitrates are avoided. ERECTIL DYSFUNCTION

Slide 60

ANTIHYPERTENSIVE DRUGS AND PREGNANCY Methyldopa. Preferred based on long-term followup studies supporting safety BBs. Reports of intrauterine growth retardation (atenolol) Generally safe Labetalol. Increasingly preferred to methyldopa due to reduced side effects

Slide 61

No short-term adverse effects have been reported from exposure to methyldopa or hydralazine. Propanolol and labetalol are preferred if a BB is indicated. Diuretics may reduce milk volume and thereby suppress lactation. ACEIs and ARBs should be avoided,

Slide 62

Calcium antagonists. Limited data. No increase in major teratogenicity with exposure Diuretics. Not first-line agents. Probably safe ACEIs, angiotensin II receptor antagonists Contraindicated . Reported fetal toxicity and death

Slide 63

Slide 64

Assess and manage hypertensive patients for smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia and diabetes

Slide 65

Vascular Protection for Hypertensive Patients: ASA Consider low dose ASA Caution should be exercised if BP is not controlled.

Slide 66

In addition to current Canadian recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria: Male Age 55 or older Smoking Total-C/HDL-C ratio of 6 mmol/L or higher Family History of Premature CV disease LVH ECG abnormalities Microalbuminuria or Proteinuria ASCOT-LLA Lancet 2003;361:1149-58

Slide 67