Beruflich Dokumente
Kultur Dokumente
2004-2005
Case presentation 1
•D.A. 45 years
•Female
•Risk factors:
•Family history: mother - HT
•smoker
•Obesity (BMI = 30)
•Asymptomatic
•BP= 135/85 mmHg, HR= 62 b/min (medicated)
Associated risk factors
Dislipidemia
•HDL = 32 mg/dL
A. What is the risk of a 45 year old woman
with high normal hypertension?
2
Optimal
•The
• The risk for 1o years? 0
0 2 4 6 8 10 12 14
HIGH
HIGH RISK!
RISK!
Time
(years))
10 years cardiovascular events rate in women
with obesity and HT
Vasan RS, Larson MG, Leip EP, et al. N Engl J Med. 2001;345:1291-1297.
Vasan RS, Beiser A, Seshadri S, et al. JAMA. 2002;287:1003-1010.
B. Does BP normally increase with aging?
Diastolic Systolic
95 175
• Cohort study
90 165
BP (mm Hg)
155
BP (mm Hg)
85
4
3 145
80
135
75 2
125
1
70
115
65 105
30-34
40-44
50-54
60-64
70-74
75-79
80-84
30-34
40-44
80-84
50-54
60-64
35-39
65-69
45-49
55-59
75-79
35-39
70-74
45-49
55-59
65-69
Age Age
(years) (years)
1. Lifestyle change:
- diet (low sodium, low cholesterol intake,
hypocaloric)
- daily exercise
4. Dislipidemia - Statin
CASE PRESENTATION 2
• B.P. 50 years
• Male
• Type 2 DM (for 8 years, treated with gliclazid and
metformin)
• HbA1C 8.2% 1 month ago
• no retinopathy or neuropathy
• Obesity (BMI 32)
• BP 140/85 mm Hg, HR 64 b/ min (treated with
dihydropirydine)
Associated risk factors
• TG 200 mg/dL
• Albuminuria
A. Connection between HT and DM
Excessive Inherited
• HT is more frequent in caloric intake genetic
disorders
type 2 diabetes
Obesity Diabetes (NIDDM)
Insulin
resistance
HIGH RISK!
Hyperinsulinemia
Atherosclerosis
Hypertension
HyperTG
Hyper CT
LowHDL
• Dislipidemia
• Insulinresistance
– Lifestyle changes
- diet
- exercise
– control glycemia (HbA1C <7%):
hypoglycemic drugs + diet, insulin
being often necessary
– BP<130/80 mm Hg
– LDL below 100 mg/dL
- statins
C. Comments regarding the assessment
and management
Smoking HT
x 1.6 x 4.5 x3
x 16
x6 x9
x4
Cholesterol
DIAGNOSTIC STEPS IN HT
(1) ASSESS BP
SBP DBP
Hospital 140 90
(3) Investigations
(3) Investigations
(3) Investigations
BP (mmHg)
RF
Normal High normal Grade 1 Grade 2 Grade 3
SBP 120-129 or SBP 130-139 or SBP 140-159 SBP 160-179 SBP ≥ 180 or
DBP80-84 DBP 85-89 or or DBP ≥ 110
DBP 90-99 DBP 100-109
No other RF Average risk Average risk Low added risk Moderate High added risk
added risk
1-2 RF Low added risk Low added risk Moderate Moderate Very high
added risk added risk added risk
3 or more RF or Moderate added High added risk High added risk High added Very high
TOD or diabetes risk risk added risk
ACC High added risk Very high Very high Very high Very high
added risk added risk added risk added risk
ACC – associated clinical conditions; TOD – target organ damage; SBP – systolic blood pressure; DBP –
diastolic blood pressure
“White-coat” HT
(3) Grade 3 HT
• Assess - other RF
- Diabetes mellitus
- Target organ damage
- Associated clinical conditions
b) Recommended BP:
BP < 140/90 mmHg
BP < 130/80 mmHg (diabetics)
DIURETICS
AT1-BLOCKERS
(A) DIHYDROPYRIDINES:
GENERATION I Nifedipin
Nicardipin
GENERATION II Phelodipin Nimodipin
Nifedipin SR
Nisoldipin Nitrendipin
GENERATION III Lercanidipin
Lacidipin Amlodipin
(B) Verapamil SR
(C) Diltiazem
ALFA-1 BLOCKERS
(A) Alpha 1 selective: Prazosin Doxazosin Terazosin
(B) Non-selective: Phenoxybenzamin
Urapidil
DIRECT VASODILATORS
(A) (Di)Hydralazin
(B) Minoxidil
(C) Diazoxid
(D) Sodium nitroprusside
(E) Nitroglycerine
Antihypertensive drugs with long-term action:
Diuretics
BB AT1-receptor
blockers
ACE inhibitors
CHOICE OF ANTIHYPERTENSIVE DRUGS
2. Cost of drugs
Type 1 DM
- without albuminuria : diuretics
beta-blockers
- with albuminuria : ACE inhibitors
2. GESTATIONAL HT
a) without proteinuria
b) with significant proteinuria (> 500 mg/day)
= PRE-ECLAMPSIA
- develops after 20 weeks of gestation
- it resolves within 40 days postpartum
1. MALIGNANT HT
Onset : hypertensive encephalopathy
Convulsive crises
• DBP > 140 mmHg
• Severe hypertensive retinopathy
• Spontaneous evolution : death/ cerebral, cardiac , renal damage
• Assessment: clinic: BP, diuresis
lab: urea, creatinine, ions
• Therapy: loop diuretics
arteriolar vasodilators: Hydralazin/Diazoxid/Na nitoprusside
ACE inhibitors
haemodialysis
2. PAROXISTIC HT
Etiology: - Phaeochromocytoma
- Aortic dissection
- Abrupt cessation of antihypertensive agents
- Brainstem tumors
Therapy:
* Regitin
* Loop diuretic
* Diazoxid or - Na nitroprusside
- Labetalol
- Clonidin
3. HT CRISIS and ACUTE CORONARY SYNDROME
* Na nitroprusside
* ACE inhibitors
* Sympathetic central inhibitors (Guanfacine)
* Nitrates
Antihypertensive agents in HT
emergency - dosis