hypertension demonstration pharmacology.pptx

cases of hypertension

1. Hypertension Lab 2

2. Definition Hypertension is defined as a sustained systolic blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication. BP=CO*TPR (CO=cardiac output, TPR= total peripheral resistance. Assessing of blood pressure : several recording should be taken over period of weeks or months dr.malak jafari

3. Hypertension may be: 1- primary (essential hypertension) which may develop as a result of environmental or genetic causes, primary hypertension accounts for 90-95% of adult cases 2- secondary, which has multiple etiologies, including renal, vascular, and endocrine causes and accounts for 2-10% of cases. dr.malak jafari

4. Secondary hypertension: ( HBP caused by a pre-existing problem) Factors that may lead to secondary hypertension include: Kidney abnormality, including a tumor on the adrenal gland, which is located on top of the kidneys A structural abnormality of the aorta (the large blood vessel leaving the heart) that has existed since birth Narrowing of certain arteries dr.malak jafari

5. Based on recommendations of the (JNC 7), the classification of BP for adults aged 18 years or older has been as follows   : Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg. Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater dr.malak jafari JNC 7= the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 

6. Risk factors for developing hypertension: Family history advanced age Gender-related risk patterns Lack of physical activity Poor diet. Overweight and obesity Drinking alcohol Possible contributing factors (Psychosocial factor, smoking) dr.malak jafari

7. 1. Family history heart diseases in general have genetic components and contribute to hypertension. hereditary is major unavoidable factor in primary hypertension. 2-advanced age With aging, there is a progressive loss of the visco -elastic properties of vessels These vascular changes lead to a loss of the cushioning function of the vessels and stiffening of the arterial vasculature. leading to an increase in systolic pressure and a fall in diastolic pressure dr.malak jafari

8. 3. Gender-related risk patterns A higher percentage of men than women have HBP until 45 years of age. From ages 45 to 64years of age , the percentages of men and women with HBP are similar. After that, a much higher percentage of women have HBP than men. 4. Drinking alcohol Heavy and regular use of alcohol can increase blood pressure dramatically. It can also cause heart failure, lead to stroke and produce irregular heartbeats dr.malak jafari

9. 5. Lack of physical activity a sedentary lifestyle is associated with increased risk of cardiovascular disease (including hypertension) Moreover, physical activity is associated with reduced risk of CVD mortality, in both men and women, and in middle-aged and older individuals. exercise must be dynamic( isotonic) not isometric, because isometric exercise where muscle activity is associated with lifting weights with arms or legs mostly associated with a considerable increase in mean arterial blood pressure. dr.malak jafari

10. dr.malak jafari dynamic exercise isometric exercise

11. 6. Poor diet. Dietary intakes of fat, cholesterol, fruits and vegetables, fish and sodium are linked to hypertension and cardiovascular risk. A cardioprotective diet should consist of a variety of foods, and should aim to achieve four major goals: a healthy overall diet , a healthy body weight , a desirable lipid profile , and a desirable blood pressure. There is strong observational evidence that reducing intakes of total fat (to less than 30% of calories), saturated fat (to less than 10% of calories), and salt (to less than 5 g per day), and increasing fruits and vegetables (to 400–500 g daily) are likely to be beneficial. dr.malak jafari

12. 7. Overweight and obesity Obesity is strongly related to major cardiovascular risk factors, such as raised blood pressure. there is a good evidence that a net weight reduction of 5.1 kg resulting from restricted energy intake, increased physical activity or both, reduced systolic blood pressure by 4.44 mmHg and diastolic blood pressure by 3.57 mmHg. The long-term benefit of weight reduction on blood pressure control has been confirmed in several studies dr.malak jafari

13. 8. Possible contributing factors Psychosocial factor: some weak evidence suggest that psychosocial factors, such as depression and anxiety, lack of social support, social isolation, may influence the occurrence of hypertension. In the meantime, physicians and health care providers should consider the whole patient. Early detection, treatment and referral of patients with emotional and behavioral problems are, in any case, important for reducing suffering and improving the quality of life. dr.malak jafari

14. Smoking Blood pressure rises slightly when a cigarette is smoked. there is a strong correlation between smoking and atherosclerosis. smoking should be strongly discouraged in hypertensive patients or any patient with CVD. dr.malak jafari

15. It is difficult to decide when a patient is hypertensive for this reasons: mild to moderate hypertension is symptomless. BP reading can be misleadingly high due to mental and physical state of the patient at the time of the recording. This is referred as “white coat hypertension”. dr.malak jafari

16. What are the Symptoms of High Blood Pressure? a common misconception that hypertensive people, will experience symptoms such as nervousness, sweating, difficulty sleeping. The truth is that HBP is largely a symptomless condition only when blood pressure readings reaches a dangerously high levels (systolic of ≥180 OR diastolic of ≥110 ) may obvious symptoms occur. dr.malak jafari

17. What are the symptoms of Hypertensive Crisis? Blood pressure (systolic of ≥180 OR diastolic of ≥110 ) is known as hypertensive crisis, and emergency medical treatment is needed. In addition to extreme readings, a person in hypertensive crisis may experience: 1-Severe headaches 2-Severe anxiety 3-Shortness of breath 4-Nosebleeds dr.malak jafari

18. Complications : Failure to diagnose or uncontrolled hypertension can lead to an increase in mortality and morbidity due to serious of complication associated with organs. dr.malak jafari

19. Types of Complications: 1. Complications associated with the brain: e.g: cerebral Infarction and Cerebral Hemorrhage. 2. Complication associated with the eyes: e.g: Hypertensive Retinopathy (due to hypertensive). 3. Complications associated with the Heart: e.g : Angina Pectoris and Myocardial Infarction 4. Complication associated with the Kidneys: e.g: Renal Vascular Disease (due to Atherosclerotic). 5. Complication associated with the Peripheral arteries: E.g. Gangrene (due to Atherosclerotic). dr.malak jafari

20. Management of hypertension dr.malak jafari

21. The physician must establish with certainty that hypertension is persistent and requires treatment and must exclude secondary causes of hypertension. Persistence of hypertension, should be established by finding an elevated blood pressure on at least three different office visits. Once the presence of hypertension is established, the question of whether to treat and which drugs to use must be considered. The level of blood pressure, the age of the patient, the severity of organ damage (if any) due to high blood pressure, and the presence of cardiovascular risk factors all must be considered dr.malak jafari

22. Assessment of renal function and the presence of proteinuria are useful in antihypertensive drug selection. Selection of drugs is dictated by the level of blood pressure , the presence and severity of end organ damage and the presence of other diseases. Most patients with essential hypertension, however, have had elevated blood pressure for months or years, and therapy is best initiated in a gradual fashion Obesity should be treated and drugs that increase blood pressure (sympathomimetic decongestants, nonsteroidal anti-inflammatory drugs, oral contraceptives, and some herbal medications) should be eliminated if possible. dr.malak jafari

23. Follow-up visits should be frequent enough to convince the patient that the physician thinks the illness is serious . Other factors that may improve compliance are simplifying dosing regimens and having the patient monitor blood pressure at home dr.malak jafari

24. OUTPATIENT THERAPY OF HYPERTENSION 1. The initial step in treating hypertension may be nonpharmacological. A. sodium restriction may be effective treatment for many patients with mild hypertension. B. Eating a diet rich in fruits , vegetables , and low-fat dairy products with a reduced content of saturated and total fat . C. moderation of alcohol intake (no more than two drinks per day) also lower blood pressure. D. Weight reduction even without sodium restriction has been shown to normalize blood pressure in up to 75% of overweight patients with mild to moderate hypertension. E. Regular exercise has been shown in some but not all studies to lower blood pressure in hypertensive patients. dr.malak jafari

25. For pharmacologic management 2. In mild hypertension, blood pressure can be normalized in many patients with a single drug. 3. However, most patients with hypertension require two or more antihypertensive medications. 4. Thiazide diuretics, β blockers, ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers have all been shown to reduce complications of hypertension and may be used for initial drug therapy dr.malak jafari

26. For example: A. drugs that inhibit the renin-angiotensin system are particularly useful in patients with evidence of chronic kidney disease with proteinuria. B. Beta blockers or calcium channel blockers are useful in patients who also have angina. C. diuretics, ACE inhibitors, angiotensin receptor blockers, β blockers or hydralazine combined with nitrates in patients who also have heart failure. D. α 1 blockers in men who have benign prostatic hyperplasia. dr.malak jafari 5. The presence of concomitant disease should influence selection of antihypertensive drugs because two diseases may benefit from a single drug

27. 6. If a single drug does not control BP, drugs with different sites of action can be combined to effectively lower BP and minimizing toxicity. 7. If a diuretic is not used initially, it is often selected as the second drug. If three drugs are required, combining a diuretic, a sympathoplegic agent or an ACE inhibitor, and a direct vasodilator is often effective. 8. The large Hypertension Optimal Treatment study suggests that the optimal blood pressure end point is 138/83 mm Hg . Lowering blood pressure below this level produces no further benefit. 9. Non compliance with medication, causes of failure to respond to drug therapy dr.malak jafari

28. Case study: Case 1 Mr. Alton is 49 years old has recurrent cough and upper respiratory tract infection, he has no other signs, no other past medical condition, taking no medication and has no known allergies. He is a regular smoker since he was a teen and drink sometimes on the weekends Mr. Alton observations: body temperature 37C, BP (148\94mmHg), repeated BP (144/92)

29. a- dose he has hypertension? Mr. Alton may have hypertension because his BP is abnormal but the diagnosis of hypertension based on multiple BP measurements. b- Dose Mr. Alton need blood pressure lowering agents? a. Before giving any medication diagnosis must be confirmed b. If hypertension confirmed, history should be recorded (check for any cardiovascular diseases or any organ damage) c-risk factors needs to be assessed (life modification is needed regardless the risk factors). what should be the first line treatment? a.Calcium channel blockers or ARBs can be used b. Beta blockers should be avoided because he is a smoker since very long period of time and COPD is most likely to occur.

30. Case 2 ( discussion) Mr. kin is a fit 61 years old semi-retired market gardener, he is moderate smoker, with minimal alcohol intake, with no other cardiovascular risk factors, his average blood pressure from several readings over the last 4 months is 190/102 mmHg (despite life modification to do more exercise and decrease salt intake) He has normal serum lipids, glucose, uric acid and electrolytes level with no history of asthma. a- why Mr.kin at high risk? b- What is the best management protocol for Mr.kin ?

31. Case 3 (discussion) Mary is 36 years old white female, recently returned to work after 10 weeks after the birth of her first child, she has a family history of DM and no history of smoking, normal ECG, normal electrolytes, BP= 138/89mmHg. a- what your recommendation for Mary? b- one week later she start exercising and her blood pressure returned to 138\88 mmHg , is she hypertensive? c- what is the best treatment for her case?

32. Home work (group 1 & 2) Ali is a 52-year-old teacher visited his doctor for a recurrent upper respiratory tract infections. taking a treatment only for prostatic hyperplasia, has no known allergies but he is a regular smoker In the next visit to doctor Ali BP was 149/95mmHg repeated to found 148/94 mmHg A- Does Ali have hypertension? B-Does Ali need BP-lowering medicine? C-What should be the first choice hypertension drug treatment for Ali? dr.malak jafari

33. Home work (group 5 & 6) Sami is a 28-year-old computer engineer visited his doctor for his annual check up, he does not smoke nor consume any alcohol but his BMI is high (he is obese) his BP was 134/89 mmHg, with normal lipid profile and blood sugar @Does Sami have hypertension? @Does he need BP-lowering medicine? @how this case could be managed? dr.malak jafari

34. Home work (group 3& 4) Amanda is 29 years old woman, she is 22 weeks pregnant, she has a family history of DM and hypertension, and she stopped smoking before her pregnancy, normal ECG, normal electrolytes, her average BP is 139/91mmHg. a- is she hypertensive? b- what is her risk factors to devalope hypertension? c- what is the best treatment for her case? dr.malak jafari

35. Home work (group 7&8) Mr. Tomas is a 68-year-old man visited his doctor for his monthly check up, he does not smoke nor consume any alcohol, but he has DM and chronic kidney problems his average BP was 150/90 mmHg, with normal lipid profile. a- Does he have hypertension? b- Does he need BP-lowering medicine? c- what is the best treatment for his case? dr.malak jafari

36. References: Prevention of cardiovascular disease : guidelines for assessment and management of total cardiovascular risk (WHO ).2003 American heart association The American Society of Hypertension Basic and Clinical Pharmacology 12th Edition.by Katzung & Trevor's dr.malak jafari