Problem Based Management of HTN 4.pdf

Problem Based Management of HTN

1. Problem based management of HTN
DR. MD. ABDUL MALEQUE
CLINICAL & INTERVENTIONAL CARDIOLOGIS
NICVD, DHAKA

2. Incidence
•About one third of every community is affected by HTN,
among them 36% are unaware of their diagnosis.
•Adequate control is only in 40% cases.
•Adequate control of BP decreases
•The incidence of ACS in 20-25%
•Stroke by 30-35%
•Heart failure by 50%.

3. In Bangladesh
❑54.6% death due to HTN
❑12 million suffers from HTN
❑33.3% of HTN and 29.9% pre HTN
❑1 out of 4(>35 age) and half of them are unaware.
❑25.2% have Knowledge of HTN

4. Hypertension
•DEFINITION OF HYPERTENSION
•Hypertension be diagnosed when a person’s systolic blood pressure
(SBP) in the office or clinic is ≥140 mm Hg and/or diastolic blood
pressure (DBP) is ≥90 mm Hg following repeated examination or
taking antihypertensive medication.
•HBPM: ≥ 135 and/or ≥ 85

5. Definition
Hypertension:
•Systolic blood pressure (SBP) of 140 mmHg or more
OR
•Diastolic blood pressure (DBP) of 90 mmHg or more
OR
•Both SBP & DBP 140/90 mmHg or more
OR
•or taking antihypertensive medication.
(#Based on the average of two or more properly measured BP readings.
#On each of two or more office visits.)

6. Hypertension
Optimal : <120/80 mmHg
Normal : <130/ 85 mmHg
High Normal : 130-139/85-89 mmHg
Hypertension:
Grade 1(mild): 140-159/90-99 mmHg
Grade 2 ( mod): 160-179/100-109 mmHg
Grade 3 ( severe): ≥180/110 mmHg
Isolated Systolic Hypertension:
Grade 1: 140-159/ <90 mmHg
Grade 2: ≥160/< 90 mmHg

7. Hypertension
•Normal BP: <120/<80 mmHg
•Prehypertension: 120-139/80-89 mmHg
•Hypertension stage1 140-159/90-99 mmHg
•Hypertension stage 2 160- 179/100-109 mmHg
•Hypertension stage 3 ≥180/110 mmHg
•Urgency Severe HTN without acute organ damage with or
without symptoms
•Emergency Severe HTN without acute organ damage
•Resistant hypertension Failure of BP control with three
drug regimen including a diuretic
•Isolated systolic HTN >140/<90 hypertension

8. Follow-up visits
•Initial BP Follow-up
<130 & <85 Recheck in 1 year
130-139 & 85-89 Recheck within 3-6 month
140-159 and/or 90-99 Confirm within 2-3 month
160-179 and/or 100-109 Evaluate within 1 month &
treat if confirmed
≥180 and/or ≥ 110 Evaluate & initiate Rx
immediately

9. Treatment strategy

10. Goals of Therapy
▪Reduce Cardiac and renal morbidity and mortality.
▪Treat to BP <140/90 mmHg
▪ BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

11. Non-Pharmacological Treatment
of Hypertension
•Healthy lifestyle choices can prevent or delay the onset of high
BP and can reduce cardiovascular risk.
•Lifestyle modification is also the first line of antihypertensive
treatment.

12. Lifestyle modifications
●Reducing salt intake
●Eating healthy diet & drinks
●Moderate consumption of healthy drinks
●Smoking cessation
●Avoid alcohol consumption
●Reduce weight and avoid obesity.
●Engage in regular moderate intensity aerobic exercise
●Reduce stress and introduce mindfulness.
●Be careful with complementary, alternative or traditional medicines – little/no
evidence

13. Antihypertensive Therapy
(1) To assess lifestyle and identify other cardiovascular risk factors or
concomitant disorders that may affect prognosis and guide treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of target organ damage

14. Antihypertensive Therapy
Monotherapy: Primary hypertension & BP less than 20/10mmHg above goal.
Sequential therapy:
A patient who is relatively unresponsive to one drug, becoming normotensive on a second drug.
If little or no fall of BP after an adequate dose of drug 1, switching to (rather than adding) drug 2 and, if this is ineffective,
switching to drug 3 may allow as many as 60 to 80 percent of patients with stage 1 hypertension to initially be controlled with
a single agent.
Combination therapy :
blood pressure is more than 20/10 mmHg above goal
Fixed-dose combination preparations are available that may improve patient compliance, blood pressure control

15. Antihypertensive Therapy
◼Diuretics
◼Agents affecting adrenergic function
◼Vasodilators
◼Agents affecting Renin Angiotensin System (RAS)

16. Treatment strategy
Step 1 :
AGE < 55 years- ACEI/Angiotensin receptor blocker (A)
Age> 55 years –Calcium channel Blocker (C) /Thiazide Diuretics (D)
Step 2 :
If not control then combined
A+C orA+D
Step 3 :
If not controlled then use combination of 3 drugs
A+C+D
Step 4 :
If not control called resistant HTN
Add another drugs with A+C+D
Diuretic (spironolactone) /alpha blocker /beta Blocker/vasodilator .

17. Calcium channel blockers
Non- Dihydropyridines : verapamil, diltiazem

Dihydropyridines: nifedipine, nicardapine, amlodipine
Adverse effects: headache, flushing, ankle edema, dizziness, reflex
tachycardia (no reflex tachycardia with verapamil and diltiazem)
Use: Hypertension, angina.
Useful as an antiarrhythmic drug (Verapamil & diltiazem).

18. Diuretics
Thiazide diuretics: use as antihypertensive
Spironolactone: Volume overload ,in resistant HTN
High efficacy (ceiling) diuretics
•Indicated in following conditions with or without HTN when
complicated by
✓Chronic renal failure
✓Coexisting CHF
✓Severe edema due to use of potent vasodilators

19. Diuretics
Thiazides should be avoided in patients with concommitant:
•Diabetes mellitus
•Gout
•Hyperlipidaemia
•Renal insufficiency

20. Diuretics
•Adverse Effects:
•Hypokalaemia
•Hyperglycemia: Inhibition of insulin release due to K+ depletion (proinsulin to insulin)
– precipitation of diabetes
•Hyperlipidemia: rise in total LDL level – risk of stroke
•Hyperurecaemia:
•Sudden cardiac death – tosades de pointes (hypokalaemia)
•All the above metabolic side effects – higher doses (50 – 100 mg per day)
•But, its observed that these adverse effects are minimal with low doses (12.5 to 25
mg) - Average fall in BP is 10 mm of Hg

21. RAAS blockers
Indications
•Hypertension
•Congestive Heart Failure
•Myocardial Infarction
•Prophylaxis of high CVS risk subjects
•Diabetic Nephropathy
•Schleroderma crisis
Contraindications: Pregnancy, bilateral renal artery stenosis, hypersensitivity
and hyperkalaemia

22. RAAS blockers
•Cough – persistent brassy cough in 20% cases – inhibition of bradykinin and
substanceP breakdown in lungs
•Hyperkalemia
•Hypotension – 1
st
dose
•Acute renal failure: CHF and bilateral renal artery stenosis
•Angioedema: swelling of lips, mouth, nose etc.
•Rashes, urticaria etc
•Dysgeusia: loss or alteration of taste
•Foetopathic: hypoplasia of organs, growth retardation etc
•Contraindications: Pregnancy, bilateral renal artery stenosis,
hypersensitivity and hyperkalaemia

23. Beta blockers
❤️❤️1st line drug –
Post MI &Tachyrrythmia – Metoprolol, Bisoprolol
Chronic HF/ CCF- Carvedilol, ( not used in Acute LVF-stage iii & iv
Pregnancy (Labetalol).
❤️❤️ Maximum Antihypertensive effect: Nebivolol & Carvedilol, Bisoprolol।But inCarvedilol need high dose & bd.
❤️❤️IV : Acute Tachyrrythmia (IV Sotalol),
Acute aortic dissection & Thyroid storm (IV Esmolol ),
IV Propranolol best in thyroid storm
All hypertensive emergency (labetalol)
❤️❤️ Nebivolol : Most selective beta blocker.Drug of choice- Asthma /COPD. Young patients ( no erectile dysfunction)
❤️❤️ Propranolol:non selective lipid soluble, cross blood brain barrier
Anxiety/panic attack, prophylaxis of migraine, thyrotoxicosis/subacute thyroiditis, essential tremor control .

24. •All -adrenoceptor blockers produce:
•Reduced exercise tolerance
•Mild chronic fatigue
•Sedation
•Increased airway resistance
•Bradycardia
•Sleep disturbances-  melatonin release

25. Class of drug Example Initiating dose Usual maintenance
dose
Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.
-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.
Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.
channel
blockers
-blockers prazosin 2.5 mg o.d 2.5-10mg o.d.
ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.
Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.
receptor blockers

26. Scenario 1
•60 year old male
•Presented to you with BP-155/95 mmHg
•On history & examination: Nothing definite abnormality
•How will you approach to manage HTN in this patients?

27. Stage 1 primary HTN
•Confirm HTN
•Associated co-morbidity, secondary causes
•Treated with CCBs/Thiazide diuretics

28. Scenario 2
•50 year old male
•Presented to you with BP-175/105 mmHg
•On history & examination: Nothing definite abnormality
•How will you approach to manage HTN in this patients?

29. Stage 2 primary HTN
•Confirm HTN
•Associated co-morbidity, secondary causes
•Treated with FDC drugs

30. Scenario 3
•60 year old male
•Presented to you with neck pain, vertigo, weakness & BP-200/115
mmHg
•On history & examination: No features of acute organ damage
•How will you approach to manage HTN in this patients?

31. Stage 3 HTN (Hypertensive urgency)
•Monitoring for 4 to 6 hrs
•F/U care mandatory within 24 to 48 hrs
•Oral antihypertensive
•Preferable drugs: Captopril, Labetalol, Long acting Nifedipine
•25% reduction over 24 hrs but not lower than 160/90 mmHg
•Goal achieved over 1 to 3 months

32. Scenario 4
•55 year hypertensive old male
•Presented to you with AMI anterior

•BP-180/100 mmHg, lung-clear
•How to manage HTN in this patients?

33. HTN in IHD
•RAS blockers
•Beta-blockers
Irrespective of BP levels used as first-line drugs in NSTE-ACS & STEMI.
•Beta-blockers
•Calcium channel blockers (CCBs)
First-line drugs in CCS.

34. Hypertensive Emergency
•IV nitrates
•RAS blocker
•Beta blocker

35. Hypertensive Crisis
Emergency:
•Severely elevated BP associated with acute
hypertension mediated organ damage (HMOD).
•Requires immediate BP lowering, usually with IV
therapy.
Urgency:
•Severely elevated BP without acute HMOD.
•Can be managed with oral antihypertensive agents

36. Hypertensive Emergency
•ACS/Acute Pulmonary oedema/ ALVF- Nitroglycerine (Immediate, <140
mmHg)
•Acute aortic dissection- Esmolol, Nitroglycerine (Immediate, <120 mmHg)

•Acute ischemic/haemorrhagic stroke/Hypertensive encephalopathy
- Labetalol, Nicardipine
•Eclampsia/Severe preeclampsia-Labetalol/Nicardipine & Magnesium
sulphate (Immediate, < 160/105 mmHg)
•ARF- Labetalol, Nicardipine

37. Emergency: if acute, life-threatening manifestations of target organ damage
(hypertensive encephalopathy, subarachnoid or intracerebral hemorrhage, acute ischemic
stroke or MI, pulmonary edema, unstable angina, aortic dissection, acute renal failure
severe preeclampsia/eclampsia, or pheochromocytoma crisis).

Admit to ICU for continuous BP monitoring
parenteral antihypertensive drug therapy
Controlled reduction of BP
> 25% of MAP in 1
st
hour
160/100-110 mmHg over next 2-6 hors
Normal over 24-48 hors
Supportive management
Withdraw of contributing factors
Treatment of complications

38. Scenario 5
•55 year hypertensive old male
•Presented to you with OMI anterior with chronic HF(CCF)
•How to manage HTN in this patients?

39. HTN in HFrEF
• Angiotensin receptor-Neprilysin inhibitor (ARNI; sacubitril-valsartan)/
RAS blockers (ACE inhibitor & ARB)
• Beta-blockers (Carvedilol-most preferable)
• Mineralocorticoid receptor antagonists – Spironolactone and

•Empagliflozin/Dapagliflozin

All effective in improving clinical outcome in patients with established HFrEF.

40. HTN in HFpEF
•RAS blocker (ACE inhibitor & ARB)- IIa
• Beta-blockers - IIa
• Diuretics to control symptoms of volume overload – I
•CCB or others- if BP not controlled
in patients with established HFpEF/ Diastolic HF.

41. Scenario 6
•55 year hypertensive old male
•Admitted into CCU with acute decompensated HF
•How to manage HTN in this patients?

42. Treatment strategy for this patients
•IV diuretics
•IV nitrates
•ACEI
•Spironolactone
•Add Carvedilol ASAP

43. Scenario
•65 years male
•Presented to ED with sudden onset of unconsciousness, right sided
weakness, planter extensor, his BP 230/120 mmHg,
•How will you manage the patient?

44. Antihypertensive in Ischemic stroke
•RAS blockers
•CCBs and
•Diuretics

45. •Acute ischemic stroke(<72 h from symptom onset):
Routine BP lowering (III)
1. IV thrombolytic therapy:
- carefully decrease & maintain to < 180/105 mmHg
for at least first 24 hour after thrombolysis ( IIa)
2. Not receive fibrinolysis:
- if BP ≤ 220/120- initiating or reinitiating drug (III)
- If ≥ 220/120 –lower BP 15% during first 24 h (IIb)

46. •Acute ICH (<6h from symptom onset):
- SBP < 220 mmHg, ( class III)
- SBP ≥ 220 mmHg, Carefully i.v therapy to < 180 mmHg (IIa)

47. Scenario 5
•60 years old patients
•Presented with HTN & Renal impairment (s. creatinine 2.3 & eGFR
40ml/min/m2)

•How to manage HTN of this patient?

48. Hypertension and Chronic Kidney Disease (CKD)
•RAS-inhibitors are first-line drugs because they reduce albuminuria in addition to
BP control.
•CCBs and
•diuretics (loop-diuretics if eGFR <30 ml/min/1.73m
2
)

49. Hypertension and Chronic Obstructive Pulmonary Disease
(COPD)
•When RAAS inhibitors, ARNI or SGLT2 inhibitors are started, the initial decrease in the glomerular filtrati
The treatment strategy should include
•an angiotensin AT
1-receptor blocker (ARB)
• and CCB and/or
• diuretic
•while beta blockers (ß
1-receptor selective) may be used in selected patients (eg, CAD, HF).
•anges are generally transient but is associated with slower worsening of renal function in the lo

50. Hypertension and Diabetes
•The treatment strategy should include an RAS inhibitor (and a CCB
and/or thiazide-like diuretic).

51. HTN & DYSLIPIDEMIA
•BP should be lowered as done in the general population,
preferentially with RAS-inhibitors (ARB, ACE-I) and CCBs.

52. Hypertension in Pregnancy
•Initiate Drug treatment if BP persistently:
•>150/95 mmHg in all women
•>140/90 mmHg if gestational hypertension or
subclinical HMOD
•First Line Drug Therapy Options
•Methyldopa, beta-blockers (labetalol), and Dihydropyridine-
Calcium Channel Blockers (DHP-CCBs)

53. Hypertension in Pregnancy
•If SBP ≥170mmHg or DBP ≥110mmHg (Emergency):
•Immediately hospitalize
•Initiate IV labetalol (alternative i.v. nicardipine, esmolol,
hydralazine, urapidil), or oral methyldopa or DHP-CCBs)
•Magnesium
•If pulmonary edema, IV nitroglycerin

54. Labetalol in hypertensive emergency
•Initial bolus of 20 mg IV followed by 20 to 80 mg IV bolus every 10
minutes (maximum 300 mg) ( 1 amp=50 mg/10ml)
or
•0.5 to 2 mg/minute as IV loading infusion following an initial 20 mg IV
bolus (maximum 300 mg)
•Onset of action 5 to 10 minutes
•Effect lasts 2 to 4 hours

55. Nitroglycerine in hypertensive emergency
•10 ml + 40 ml 5% DA OR NS (1 amp= 10ml= 50mg)
Through syringe pump:
Starting dose: 0.3 ml/hr
Double the dose every 10 minutes intervally
max: 12 ml/hr

56. Management of HTN
Antihypertensive in different situations