treatment of hypertension by dr sarma课件

1 Dr Sarma works Dr Sarma works 2 Welcome DearFriends Dr Sarma works 3 TheAlmighty PardonsandGrantsmeheavenEvenifIdon tknowasingleletteraboutCrutzFeldJacob sDiseaseTsutsugamushiFeverCrigglerNazzarSyndromeSouthAmericanequineencephalitisandManyandmuchmorerarertopicsBUT Dr Sarma works 4 TheAlmighty WilldragmetohellandwillnotpardonMyignoranceofeventheminutedetailsofHTMyindifferencetoapplythecurrentknowledgeMynegligenceinscreeningforHT TODMydespondencyaboutpreventingTODMyinadequacyinmaintainingmypatientsasnormo tensiveaspossible Thisisapplicabletoallcommondiseases 5 Dr SarmaRVSN M D M Sc Canada ConsultantPhysicianandChestSpecialist 5 Jayanagar Tiruvallur 6020019380521221 044 27660593 TreatmentofHypertensionACLINICALAPPROACH 6 ManagementofHypertension BasedonthelatestrecommendationsofJNCVII ISH ESH WHO TreatmentofHypertensionACLINICALAPPROACH 7 GloballyRenownedHTSocieties JNCVII JointNationalCommitteeonHT USAISH WHOInternationalSocietyonHTAHA AmericanHeartAssociation USAACC AmericanCollegeofCardiologistBHS BritishHypertensionSocietyNIHLB NationalInst HeartLung BloodvesselsEHS EuropeanHypertensionSocietyCHS CanadianHypertensionSocietyNKF NationalKidneyFoundation USAAKA AmericanKidneyAssociation USA 8 WhatisnewinHypertension 9 10 HYPERTENSION TheTruthis Itisonlyamarkerofthebiggerproblem Hypertensionisamulti organsystemicdisease WhatwerecordasB P TheProblemis Hypertensionisasymptomaticin85 ofcases 11 HowtobewiseinHT TheTruthis ToconsiderHypertensionasanisolateddisease Hypertension DM Dyslipidemia ObesityoftencoexistTheyarethe4pallbearerstothegraveofCHD CVD Forallofthem PrimaryandsecondarypreventionbyTLCistheanswerAfflictedwithone mustbescreenedforallotherthieves Itiswrong 12 TreatmentGoal TheTruthis KeepB P 140 90mmHgineachpatientThismayberevisedto120 80maybe 110 70MRFIT scutoffvaluesare115 75mmHg ItisessentialtokeeptheB PatorbelowthegoalBut ItalsomattershowthegoalB P isachieved GoalBP 13 Definitions AsperJNCVIIandISH WHO 2004WhatisnormalB P Whatisprehypertension AsperJNCVIIandISH WHO 2004NormalSBP 120andDBP 80PreHTSBP120to139mmHgDBP80to99mmHg 14 Definitions Whatisstage1HT Whatisstage2HT Stage1SBP140to159DBP90to99Stage2SBP160andmoreDBP100andmore 15 JNCVIIClassification 16 Definitions ArethevaluessameforDiabetics CKD No forDM IHDandCKDthecriteriaaremorestringentThecutoffvaluesare10mmlowerStage1SBP130to149DBP80to89Stage2SBP150andmoreDBP90andmore 17 HypertensionOptimalTreatment HOT Study Lancet1998 351 1755 62 p 0 005 DM ReductioninCVevents 18 RuleofHalves WhatisthisruleofhalvesinHT Forevery800adultsinthecommunity400areHT either SBPor DBPorboth Ofthemonly200arediagnosedHTOfthemonly100arestartedontreatmentOfthemonly50areoncorrectdrugOftheminonly25thegoalB P isattainedMeans25 400 6 onlyhavegoalBP 19 DiagnosedHT Undertreatment 50 UndiagnosedHT HowmanyarereallyDx andRx ed 37 63 UnRx HT AstudyfromEuropeon23 339patients Dr Sarma works 20 GlobalHypertensionControl 21 IsolatedSystolicHypertension WhatisISH Whatpercentageof65 agedhaveISH Whichismoreharmful SBPorDBP WhyisISHimportant 22 RelativeprevalenceofSBPandDBP Normal ISH DHT S DHT 40 yrs 23 RRforCVD SBPandDBP 24 ISHisuniversalafter65 Personswhoarenormo tensiveatage55havea90 lifetimeriskfordevelopingHTN 25 0 100 200 300 5YearRisk SystolicBloodPressure mmHg HT RRofstrokeandMI Brown M J Lancet2000 355 659 660 20 40 60 80 120 140 160 180 220 240 260 280 Normotensives Hypertensives 26 IsSBPmoredangerousorDBP 27 IsolatedSystolicHypertension WhatisISH SBP140 DBP 90Whatpercentageof65 agedhaveISH Morethan90 Whichismoreharmful SBPorDBP Ofcourse SBPWhyisISHimportant Becauseof CVAandCHDmortality 28 ForadequatecontrolofB P Doyouthinkwecancontrolmostofthepatientsofhypertensionwith OnedrugTwodrugsThreedrugsCan tcontrol InmostofthepatientsofhypertensionTwodrugsarerequiredforadequatecontrolMoresoiftheinitialBPis20 10abovethegoal Today sParadigm GonearethedaysofmonotherapyItistheeraofcombinationtherapyWhyisitso 29 30 WhatarethesocalledCHDriskfactors WhatareknownasCHDriskequivalents WhatisFraminghamriskscore CVDRiskFactors Dr Sarma works 31 GlobalRiskProfileandHT 25 32 HTcombinedwithotherCHDRF Framinghamoffspringstudy subjectsaged17 84 33 WhatarethesocalledCHDriskfactors ListdiscussedinpreviousslideWhatareknownasCHDriskequivalents DM PVD CVA Nephropathy RetinopathyWhatisFramingham10CHDriskestimate 10yearCHDriskestimatebasedonage sex smoking TC HDL SBP Rx forHTseetheprogram CVDRiskFactors 34 WhyisthereTODinHT Whataretheorganstargetedfordamage WhatisthebasisofTOD WhattestsweneedtodotoassessHT TargetOrganDamage 35 DiseasesAttributabletoHypertension Hypertension Heartfailure Stroke Coronaryheartdisease Myocardialinfarction Leftventricularhypertrophy Aorticaneurysm Retinopathy Peripheralvasculardisease Hypertensiveencephalopathy Chronickidneyfailure Cerebralhemorrhage Adaptedfrom ArchInternMed1996 156 1926 1935 AllVascular 36 TargetOrganDamage TOD HeartLeftventricularhypertrophy LVH Anginaorpriormyocardialinfarction CHD PriorCoronaryrevascularizationPTCAorCABGHeartfailure Systolic Diastolicdysfunction BrainCVAStrokeorTransientIschemicAttack TIA Kidney ChronickidneydiseaseandCRFVessels PeripheralarterialdiseasePVDEyes HypertensiveRetinopathy Dr Sarma works 37 Atherosclerosis Timeline 38 EndothelialNOBalance NO 39 TargetOrganDamage Assessment RoutineTestsElectrocardiogram Echocardiography desirable Urinalysisforproteinuria MicroalbuminuriaBloodglucose FandPP andHematocritSerumNaandK CreatinineorGFR CalciumLipidProfilecomplete Eyeexamination ABIOptionaltestsX RayChestPA24hr urinealbuminexcretionorACRMoreextensivetestingisnotgenerallyindicated 40 WhyisthereTODinHT Itisadiseaseofbloodvessels Whataretheorganstargetedfordamage Heart brain kidney eye peripheralvesselWhatisthebasisofTOD ED ArterialstiffnessandAtherosclerosisWhattestsweneedtodotoassessTOD Listdiscussed TargetOrganDamage 41 Itisnotjust B P ParadigmShiftinHTTherapy AlterthemodifiableriskfactorsKeeptheSBP 140andDBP 90PreventorhaltorreduceTOD LVH CHD CHF CVA CRF PVD Retino PreventorcontrolDM asHT DMishazardous PreventorcontrolDyslipidemia EndothelialDysf ReducemorbidityandmortalityImproveQUALY QualityAdjustedLifeYears TODAYwemuststriveto 42 Whatissinglemostimp predictorofCHD HF Death WhattimecourseofHTtoLVHtoLVFtodeath CanLVHberegressedatall WilldrugshelptoregressLVHand TOD HowimportantisMicro albuminuria TargetOrganDamage 43 Normalweight350to450g Dr Sarma works 44 TransverseSectionofHEART LVH 10mm 25mm Dr Sarma works 45 EchocardiographyofHeart LVH 46 ECGandLeftVentricularHypertrophy 47 ChestPAviewofHeart LVH C Tratio 50 48 ProgressionofHTtoLVHtoHF 49 SurvivalRateHT LVHv sNT LVH Source AmHearJ 2000 140 6 848 856 50 LVHistheSingleMostimportantpredictor CanLVHbereducedatall 51 Combinedresultsof17RCTs n 48 000 Hebert1993 Moser1996 WillTreatmentHelp 53 MAUasaPredictorofMorbidityandMortality ParvingHH JHypertens1996 14Suppl2 S89 S94 54 Definitionsofabnormalitiesinalbuminuria 55 EastmanRC KeenH Lancet1997 350Suppl1 29 32 Microalbuminuria 1086420 10 02 Smoking Hypertension CHDOddsRatio 6 52 Cholesterol 2 32 3 20 RelativeImportanceofMAU 56 Whatissinglemostimp predictorofCHD HF Death LVH LVmassindexWhatisthetimecourseofHTtoLVHtoLVFtodeath ThechartisexplainedCanLVHberegressedatall VerymuchYes DiureticsandACEiarethebestWilldrugshelptoregress TOD Yes AllTODregresses LVFandCVAmostHowimportantisMicro albuminuria ThemostimportantprognosticindicatorofTOD TargetOrganDamage 57 ClinicalSignsofLVDysfunction HypotensionPulsusalternansTrigeminy BigeminyReducedvolumeofcarotidLVapicalEnlargement displacementSustainedheaveofapex Changeinheartsounds SoftS1ParadoxicallysplitS2S3gallopS4impairedLVcompliance MitralregurgitationPulmonarycongestionrales 58 Ankle BrachialIndex RestingandpostexerciseSBPinankleandarm NormalABI 1 AnkleBPmorethanthearmBP ABI 0 9has95 sensitivityforangiographicPVDABIof0 5 0 84correlateswithclaudicationABI 0 5indicatesadvancedischemia 59 WhatisthispatterninHT DippersandNon dippers Whatisitssignificanceandclinicalrelevance Dippers NonDippers 60 Yonsei MedJ Vol43 No3 2002 Dippers NonDippers 61 Yonsei MedJ Vol43 No3 2002 Dippers NonDippers 62 Lessthan10 circadianvariationinSBPandDBPEssentialhypertensionpatientsare usually Dippers NondippersareDx byABPM TheyareusuallySecondaryHTcasesMoreendorgandamageMoreLVHMoreresponsivetosaltrestrictionDiabeticsarenondippersDiureticsconvertanondippertodipper Dippers NonDippers AmbulatoryBloodPressureMonitoring ABPM 63 24hourB Pmonitoring every15minutes Today 24hourB P controlisessentialIdentifiesdippersandnon dippersExcludeswhitecoathypertension 64 www drsarma in Pulsewavevelocity ArterialStiffness Sphygmocor PulseTracePCA 65 WhatisMOSTessential Notthat mydrugissuperiortoyours Notthat thistrialisbetterthanthat Nor thiscombinationisbetterthanthat ButtogetASMANYPEOPLEaswecantogoalSBP 140 DBP 90AndpreventorhaltTOD Ofcourse tailorthetreatmentasperindividualpatient sco morbidities 66 MorbidityandMortalityinHT MostofthemorbidityandmortalityofHTisduetoLVH LVdiastolicandsystolicdysfunctionIncreasedriskofCoronaryArteryDiseaseIncreasedriskofCerebralVascularDiseaseHypertensiveheartfailureChronicRenalDiseaseofhypertensionHypertensivevasculardamage ThecorrectApproachtoHT 67 So WhatisnewinHypertension HighB PrecordedisonlyaclinicalmarkerdiseaseHTisamulti organdisease oftenasymptomaticNottoconsiderinisolation Mustlookfor Co Thieves Today sgoalBPis140 90 ItwillsurebelesstomorrowItmatterstoattaingoal mattersmorehowitisattainedInDM CKD IHDthecutoffvaluesare10mmlessRememberruleof inHT Adequatecontrolonlyin7 68 WhatisnewinHypertension continued 8 SBPismoreimportantthan DBP Oftenignoreditis 9 Widepulsepressure SBP DBP signifiesarterialdamage10 Day sofmonotherapyhavegone CombinedRxreplaces11 AllHTmustbescreenedforCHDriskfactors addressed12 Targetorgandamage TOD mustbeinvestigatedandRx 13 LVHisthesinglemostpredictorofmortalityandmorbidity14 ABI MAU ABPM PWVetc identifyhighriskcasesearly 69 70 Dr Sarma works 71 LifestyleModification LifestylemodificationisthesheetanchorinthemanagementHypertension ThissurelyreducesthenumberofdrugsusedandtheirdosageincontrollingHT AnydrugtreatmenthasvalueonlywhencoupledwithLifestylemodification Dr Sarma works 72 73 LifestyleModification AllputtogetherreduceBPby20to55mmHg 74 Whattochoosefromtheocean 16differentclassesofdrugs117approvedmoleculesasondateInnumerabledrugcombinationsOver1800clinicaltrialsofreputeFiveinternationalsocietiesonHTSevenJNCguidelinessofarMultipletargetorgansdamageManyco morbiditiesVariedoutcomesofinterestCostconstraints NosignificantchangeintheproportionofHTundercontrol 75 OnApril12 1945 USPresidentFranklinD Rooseveltdiedofcerebralhemorrhage aconsequenceofHT Itwasadevastatingillnessforhim Bycurrentstandards PresidentRoosevelt sdeathwasunnecessary PresidentRooseveltwasnevertreatedwithAnti hypertensivedrugs ModerntreatmentwouldhavecontrolledhisBPandprolongedhislife ArchIntMed Sept 23 1996 soalsoofmanyothers ManyavoidableHTdeaths 76 TheManyFacesofHTTherapyToday Centrallyactingagents Diuretics Betablockers CCBs ARBs ACE inhibitors EnalaprilLisinoprilRamiprilQuinaprilPerindopril Hypertension 77 Whichdrugshouldweprescribe ChoicemustbetailoredtoindividualpatientShouldberationalandasperapprovedguidelinesOnlyclass1evidencebasedmedicationstobeusedSuitabletopatients purseCanneverbearbitrary 78 Physicians BiasinHT IsolatedSHTisoftendubbedas agingfactor ToconsiderHTisonlyinthe ARM andnotinthebodyNoconceptof pulsepressure NotseeingthewholeWorryaboutsideeffects Needtowatch nottoworryOK somecontrolisachieved whyattaingoalBP NotinsistingoncompliancewithdrugsandassessmentsPressurefrompatients B P Howmuch Howmuch Concentratingonthepillandnotontheill TLCforgotten 79 AntiHypertensivedrugclasses TheA B C Dapproach 80 AntiHypertensivedrugclasses ACEi Angiotensinconvertingenzymeinhibitors Enalapril letuscallthem A ARB AngiotensinReceptorBlockers Losartan Letuscallthemalsoas A BB BetaReceptorBlockers Metoprolol Carveidilol Atenelol letuscallthem B CCB Calciumchannelblockers AmlodepineVerapamil Diltiazem letuscallthem C Diuretics HydrochlorThiaz Furosemide Spiranolactone letuscallthem D 81 AGE Younger 55 HighReninHT AB CDRule HTTreatment ACEi Beta blocker Ca blocker Diuretic AB CD Dickersonetal Lancet353 2008 11 1999 Older 55 LowReninHT ACEi BB A B A B D Diuretic CCB D C A D C I II III III II I 82 DIURETICSFirstandBestChoiceCanbecombinedwithA B C BlockersGoodthirdChoiceCanbecombinedwithA D CachannelBlockersFourthChoice UsefulCanbecombinedwithD A ACEIandARBSecondBestChoiceCanbecombinedwithD B C DDiuretics AACEI ARB B Blockers CCa Blockers DABC TheABCDclasses 83 ABCD somebrandnames Thiazidediuretics Hydrochlorothiazide Aquazide Hydride XeniaChlorthalidone Hythalton Loopdiuretic FrusemidePotassiumsparingTriamterene Amiloride Spironalactone Aldoanta BetablockersSelective Metoprolol MetoprololXL AtenelolCombinedalphaandbetablockers Carveidilol LabetololACEI Enalapril Ramipril Lisinopril Quinapril PerindoprilARB Losartan Valsratan Candesartan IrbesartanCCB Nefedipine Amlodipine Varapamil DiltiazemAlphaBlokers Prazocin Doxizocin Terazocin Tamsulocin www drsarma in 84 Hypertension WhyCombinations IfgoalBPisnotachievedbyasingledruginfulldoseThenaddinganotheragentwillhelpachievethegoalBPTwoagentssometimesnullifyeachotherssideeffectsFixeddosecombinationswillreducetheno oftabletsOncedailyformulationsaregoodforcomplianceSustainedreleaseorLAformulationsfor24hBPcontrolIfthreedrugscan tachievegoalBP ResistantHT www drsarma in DrugCombinations 85 Dr Sarma works 86 Hypertension RationalDrugCombinations ACEIandARB ABetaBlockers BCalciumChannel CCB CDiureticsDrugs D DandAcombinationisexcellent RamaceH LosarH EnaceDDandBcombinationnext BetalocH AtecardD TenoricDandCcombinationsixth AmlogaurdH StamloDAandBcombinationThird LosarA CardifBetaAandCcombinationfourth AmlopresL HiprilA AmloLSBandCcombinationfifth AmloAT Amlobet BetaNicardia Diuretics D Rank1ACEIandARB A Rank2BetaBlockers B Rank3CCB C Rank4 www drsarma in 87 www drsarma in SomeIrrationalCombinations Betablockers Beta1stimulants ReboundHT ParadoxicalBP Betablockers Vepapamil Extremebradycardia HB CHFThiazide Furesemide Potentialvolume andK CCB Thiazide NoRCTstosupporttheadditivePrazocin Betablocker TheynullifytheeffectsofeachotherVerapamil Dilzem Nefidepine Norationale cardiacactionscontridic Betablocker ACEINotforHTalone GoodforCHF MI IHDSubclinicaldosesoftwodrugsTryonedrugingooddosage thenaddTwodrugsofsameclass Norationale likeEnalapril Ramipril Atenelol Metoprolol Nefidepine Amlo 88 KNOWMEWELL Iam D forDIURETIC MyGoodaspectsFluiddepletion Nawashout LowcostImproveCHF Systolicfunction CasavingReduceLVH Morbidity MortalityMyBadaspectsPotassiumwashout inUricacid CaAdverseonLipids GlucosecontrolDon tusemeinGout HypokalaemiaDyslipedemia UncontrolledDM DIURETIC www drsarma in 89 KNOWMEWELL Iam A forACEIandARB MyGoodaspectsImproveDiastolicfunction SystolicfunctionControlProteinuria VeryfavourableinDMImproveCoronaryIschemia GoodonLipidsReduceLVH Morbidity MortalityMyBadaspectsBradykininaccumulation Angio edema SerumK GFRDon tusemeinPregnancy Creatinineis 3mg K5 0meqBilateralRenalArteryStenosis Angio edema ACEI ARB www drsarma in 90 Iam B for Blocker MyGoodaspects Heartrate Forceofcontraction Conduction MyocardialO2demand ImproveIschemiaImproveQUALYinCHD UsefulinCHF MigraineMyBadaspectsConstrictperipheralvessels BradycardiaUnfavourableonLipids GlucoseDon tusemeinBradycardia Conductiondefects CautioninCHFPrinzmetalAngina MSD PVD BA COPD DyslipidPheochromocytoma Chronicsmokers Blocker KNOWMEWELL www drsarma in 91 KNOWMEWELL Iam C forCachannelBlocker MyGoodaspectsVasodilatory Suitableinelderly LowcostAntiarrhythmic Verapamil CoronaryBF Diltz Neutralonlipidemia VasospasticAnginaMyBadaspectsFluidretention ImpairfailingheartAdverseonGlucosecontrol Pedaledema Rx Don tusemeinTachycardia arrhythmias CHF UncontrolledDM Volumeoverload Ca Blockers www drsarma in 92 ABCDCompare Contrast www drsarma in Whichdrugineachclass 93 www drsarma in Persistencewithhypertensivetherapy 94 www drsarma in 95 HypertensionCasespecificapproachsomeselectedcasescenarios www drsarma in 96 Casespecificapproach www drsarma in 97 Casespecificapproach www drsarma in 98 Casespecificapproach www drsarma in 99 Casespecificapproach www drsarma in 100 Casespecificapproach www drsarma in 101 Casespecificapproach www drsarma in 102 Casespecificapproach www drsarma in 103 Casespecificapproach www drsarma in 104 Casespecificapproach www drsarma in 105 Casespecificapproach www drsarma in 106 Casespecificapproach www drsarma in 107 Casespecificapproach www drsarma in 108 Casespecificapproach www drsarma in 109 Casespecificapproach www drsarma in 110 Casespecificapproach www drsarma in 111 Casespecificapproach www drsarma in 112 Casespecificapproach www drsarma in 113 Casespecificapproach www drsarma in 114 Casespecificapproach www drsarma in 115 Casespecificapproach www drsarma in 116 Casespecificapproach www drsarma in 117 Casespecificapproach www drsarma in 118 Casespecificapproach www drsarma in 119 Casespecificapproach www drsarma in 120 Casespecificapproach www drsarma in 121 Casespecificapproach www drsarma in 122 Casespecificapproach www drsarma in 123 Case24Hypertensionandcough Hypertensivesmaypresentwithcough watchout1 ConsiderLVFasthecauseofcough2 ConsiderACEIinduceddrycough3 StopACEIandgiveARBorotheragents4 Checkthecompositionofthecoughremedyyougive5 Ephedrine Pseudephedrine shouldbeavoided6 OralBetaagonistslikeOrciprenaline Salbutamol Terbutalinethelessused thebetter 7 Inhaledbetaagonists ICSaresafe8 Decongestantslikephenylpropanolaminetobeavoided www drsarma in 124 Case25SecondaryHypertension variouscauses SecondaryHTUsuallyStage2 HTSecondarycauseswillbepresentMaypresentinyoungindividualsTreatmentLookforsecondarycauseandtreatLifestyleinterventionsmustVigorouseffortsrequiredtocontrolHTOftentwooreven3drugsmayberequiredResistantHTmaybeencounteredAntiHTdrugsaspersecondarycauseAbsolutecontraACEIorARBinbilateralrenalarterystenosis www drsarma in 125 Case26SecondaryHypertensioninPheochromocytoma PheochromocytomaUsuallyStage2HT EpisodicorLabileSecondaryadrenalmedullaytum