Beruflich Dokumente
Kultur Dokumente
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion
1
Hypertension and
Cardiovaskular disease
Muhammad Aminuddin MD
Departement Of Cardiology and Vascular
Faculty of Medicine,Airlangga University
Soetomo General Hospital
Surabaya
Natural history of hypertensive disease
16%
23%
19% 42%
Vasoconstriction
Preload Contractility
Fluid volume
Fluid volume
Sympathetic Renin-
nervous angiotensin-
Renal sodium system aldosterone
retention system
Excess Genetic
sodium factors
intake
(Adapted from Kaplan, 1994)
Possible mechanisms leading from hypertension to
atherosclerosis
Hypertension
ATHEROSCLEROSIS
Caused of Hipertension :
Standardized technique:
2.
The cuff must be level with the
1. heart. If the circumference exceeds
The patient should be 33cm, a large cuff must be used.
relaxed and the arm must be Place stethoscope diaphram over 3.
supported. Ensure no tight brachial artery The column of mercury must
clothing constricts the arm be vertical. Inflate to occlude
the pulse. Deflate at 2-3
mm/s. measure systolic (first
sound) and diastolic
(disappearence) to nearest 2
mmHg
1. Urinalysis
2. Complete blood count
3. Blood chemistry (Potassium, Sodium and creatinine)
4. Fasting Glucose
5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low
density lipoprotein cholesterol (LDL), triglycerides
6. Standard 12 leads ECG
1. For those with diabetes or renal disease: 24hour or over night urine protein, as lower goal
blood pressure targets are appropriate.
2. For those with an increased creatinine or renal disease: renal ultrasound to exclude
obstruction.
3. For those with a symptom triad of headache, sweating, palpitations; measure 24 hour urine
catecholamine metabolites to assess for pheochromocytoma.
Berkin K and Ball SG. Essential Hypertension : the heart and
hypertension. Heart 2001; 86 : 467-475
THE CARDIOVASCULAR CONTINUUM
Myocardial Remodelling
ischaemia
Ventricular
CAD dilatation
STROKE
Atherosclerosis Congestive
LVH heart failure
► Modifiable ► Non-modifiable
● Smoking ● Personal history
● Dyslipidaemia of CHD
• raised LDL cholesterol ● Family history
• low HDL cholesterol
of CHD
• raised triglycerides
● Age
● Raised blood pressure
● Gender
● Diabetes mellitus
● Obesity
● Dietary factors
● Thrombogenic factors
● Lack of exercise
● Excess alcohol consumption
HTN Commonly Clusters
with Other Risk Factors
Kaiser Permanente Northwest database;
N=57,573 aged > 35 years with HTN and no CVD
HTN + 2 other
HTN + 3 other risk factors
14
risk factors 3
44 HTN only
39
HTN + 1 other risk factor
Hypertension
Transient ischemic
attack, stroke LVH, CHD, CHF
Peripheral
Retinopathy arterial Chronic kidney disease
disease
250
Ratio (%) of actual to
expected mortality
200
150
100 68-82
83-87
88-92
50
93-97
98-102
0
158-167 148-157 138-147 128-137 98-127
Systolic blood pressure (mmHg)
7
CV Mortality Risk
0
115/75 135/85 155/95 175/105
Structural changes in
Loss of buffering Function compliance arteries Shear stress on Artery
wall
Transmits Compliance
Systolic pressure Wave to Endothelial damage
small arteries
Load on heart
Hypertension
ATHEROSCLEROSIS
Atherosclerosis – Time line
Dr.Sarma@works 27
Overview
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT in Cardiovascular
disease
►Conclusion
28
WHO-ISH* 1999: definition and classification
of BP levels
Adapted from the World Health Organization–International Society of Hypertension, J Hypertens, 1999.
Hypertension
JNC BP Classifications: DBP
130
125 Stage 4
120
Severe Severe Severe
115 Hyper-
Stage 3 Stage 3
100 Consider
Mild Mild Mild
therapy
95 Stage 1 Stage 1 Stage 1
220 Stage 4
210
200 Stage 3
Stage 3
190
180 ISH ISH
SBP 170 Stage 2 Stage 2 Stage 2
(mm Hg) 160
Border- Border-
150 line line Stage 1 Stage 1 Stage 1
140 No recommendations
for SBP in JNC I High- High-
normal normal Prehyper-
130 or JNC II Normal tension
Normal Normal
120
110
Optimal Optimal Normal
Hypertension
Grade 1 140–159 and/or 90–99
Grade 2 160–179 and/or 100–109
Grade 3 180 and/or 110
Isolated Systolic HT 140 and < 90
Overview
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion
34
Benefits of Lowering BP
Lifestyle Modifications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Goals of Therapy
<130/80
Primary Prevention
Diabetes, Chronic Kidney Disease, CAD,
CAD Equivalents, or Framingham Risk Score
≥10%
CAD and Stable Angina
ACS – UA and NSTEMI <130/80
ACS - STEMI
HF of Ischemic Etiology <130/80, but consider <120/70
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion
40
Lifestyle Modifications to
Prevent and Manage Hypertension
► Avoid tobacco
some patients.
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition:
42
http://www.accesspharmacy.com/
Dietary
Approaches to
Stop
Hypertension
► Lowers systolic BP
● in normotensive
patients by an
average of 3.5 mm Hg
● In hypertensive
patients by 11.4 mm
Hg
► Copies available from
NHLBI website
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Overview
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion
45
Ideal Hypertension Agent :
S Once Daily
S Smooth anti HT effect
S Well tolerated, minimal SE
S Beneficial CV effect independent of BP lowering
• Monitor: S Cr, K
• Compelling indications: HF, post-MI,
High CAD risk, Diabetes, CKD, Stroke
ARB’s
• Monitor: S Cr, K
• Compelling indications: HF, post-MI,
High CAD risk, Diabetes, CKD, Stroke
Choice of Treatment
NO YES
Standardized Individualized
treatment treatment
Associated risk factors? or
Target organ damage / complications? or
Concomitant diseases / conditions?
NO YES
algorithm
and/or
and/or
Concomitant
diseases/conditions
Normal Encourage
<120/80 mm Hg
A B C
SBP 130-139 or SBP 140-179 or SBP 180 or
DBP 85-89 mm Hg DBP 90-109 mm Hg DBP 110 mm Hg
High normal BP Grades 1 and 2 hypertension Grade 3 hypertension
Assess risk factors, TOD, ACC Assess risk factors, TOD, ACC Begin drug Tx
Initiate lifestyle measures Initiate lifestyle measures Assess risk factors, TOD, ACC
and risk factor correction and risk factor correction
Initiate lifestyle measures
Stratify absolute risk Stratify absolute risk and risk factor correction
Very high Very high
SBP 140 or
Begin drug Tx Begin drug Tx
DBP 90 mm Hg
High High Begin drug Tx
Begin drug Tx Begin drug Tx
SBP 140-159
Moderate Moderate or DBP 90-99 mm Hg
Monitor BP Monitor & reassess after 3 mo Consider drug Tx
Low Low
No BP intervention Monitor & reassess 3-12 mo
TOD = target organ damage; ACC = associated clinical conditions.
Adapted from Guidelines Committee. J Hypertens. 2003;21:1011-1053.
Pharmacological Treatment
1. Treatment of Systolic/Diastolic
hypertension without other compelling
indications
CONSIDER
• Nonadherence Dual Combination
• Secondary HTN
• Interfering drugs or
*Not indicated as first
lifestyle Triple or Quadruple line therapy over 60 y
• White coat effect Therapy
Lifestyle modification
therapy
Thiazide Long-acting
ARB
diuretic DHP CCB
Diuretics
AT1-receptor
-blockers
blockers
Calcium
-blockers antagonists
ACE inhibitors
Compelling
Indications Diuretic ßB ACEI ARB CCB AA
Heart failure
Post-MI
High CAD risk
Diabetes
Chronic kidney
disease
Recurrent
stroke
prevention
AA, aldosterone antagonist; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II-receptor blocker; βB, ß-blocker; CCB,
calcium channel blocker; MI, myocardial infarction;
CAD, coronary artery disease.
Chobanian AV, et al. JAMA. 2003;289(19):2560-2572.
Overview
►Introduction
►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion
65
Treatment of Hypertension
with Diabetes
with Alternate:
Nephropathy
ACE-I ARB
without
Nephropathy ACE-I
Beta-blocker
Target BP < 130/80 mm Hg
Treatment of Hypertension
with Non Diabetic Renal Disease
Additive therapy:
Bilateral renal artery
Diuretic stenosis
This add-on is
Standard HTN treatment. recommended in patients
If thiazide, add taking a beta-2
potassium-sparing diuretic agonist. e.g.: salbutamol,
which lowers potassium
Airway disease*
Avoid diuretics.
Note: asymptomatic
hyperuricemia is not a
Gout Thiazides contraindication of
treatment
with diuretics
Add on allopurinol
if a diuretic is
essential
Treatment of Hypertension
with Peripheral Vascular Diseases
Vasodilators:
Raynaud’s Alpha-blockers, CCB,
May have
syndrome beneficial effects
ACE-I, ARB
Beta-blocker
Post Myocardial Infarction
1. Beta-blocker
Stable angina
2. Long-acting CCB
Short-acting
nifedipine
Beta-blocker and
Recent ACEI or ARB (if
myocardial
infarction ACEI not
tolerated)
If beta-blocker
contraindicated or
not effective
Long-acting CCB
- ACEI
- ARB,
Left ventricular
- CCB
hypertrophy - Thiazide Diuretic
- BB (if age below 60)*
Vasodilators:
Hydralazine, Minoxidil can increase LVH
QuickTime™ and a
Sorenson Video 3 decompressor
are needed to see this picture.
Heart Failure
Treatment of Hypertension
with Arrhythmia*
* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs
ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker;
DBP: diastolic blood pressure; SBP: systolic blood pressure 79
80
80
Key messages
• Lifestyle recommendations
• Treat to target
• Work on adherence/compliance
?
Hypertension