1 www drsarma in Dr Sarmaworks Welcome Dear

1 www. drsarma. in Dr. Sarma@works

Welcome, Dear Friends www. drsarma. in Dr. Sarma@works 2

The Almighty Pardons and Grants me heaven Even if I don't know a single letter about Crutz Feld Jacob’s Disease Tsutsugamushi Fever Criggler Nazzar Syndrome South American equine encephalitis and Many and much more rarer topics www. drsarma. in Dr. Sarma@works BUT ……. 3

The Almighty Will drag me to hell and will not pardon My ignorance of even the minute details of HT My indifference to apply the current knowledge My negligence in screening for HT, TOD My despondency about preventing TOD My inadequacy in maintaining my patients www. drsarma. in Dr. Sarma@works as normo-tensive as possible – 4

Treatment of Hypertension A CLINICAL APPROACH Dr. Sarma RVSN, M. D. , M. Sc (Canada) Consultant Physician and Chest Specialist, # 5, Jayanagar, Tiruvallur – 602 001 93805 21221, (044) 27660593 www. drsarma. in 5

Treatment of Hypertension A CLINICAL APPROACH Management of Hypertension Based on the latest recommendations of JNC VII, ISH, ESH, WHO www. drsarma. in 6

Globally Renowned HT Societies 1. JNC VII – Joint National Committee on HT, USA 2. ISH – WHO International Society on HT 3. AHA – American Heart Association, USA 4. ACC – American College of Cardiologist 5. BHS – British Hypertension Society 6. NIHLB – National Inst. Heart Lung & Blood vessels 7. EHS – European Hypertension Society 8. CHS – Canadian Hypertension Society 9. NKF – National Kidney Foundation, USA www. drsarma. in 10. AKA – American Kidney Association, USA 7

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WHAT IS NEW IN HYPERTENSION? www. drsarma. in 9

HYPERTENSION What we record as B. P. It is only a marker of the bigger problem The Truth is Hypertension is a multi-organ systemic dis The Problem is Hypertension is asymptomatic in 85% of c www. drsarma. in 10

How to be wise in HT? It is wrong To consider Hypertension as an isolated diseas The Truth is Hypertension, DM, Dyslipidemia, Obesity often They are the 4 pallbearers to the grave of CHD, For all of them Primary and secondary prevention by TLC is th Afflicted with one, must be screened for all othe www. drsarma. in 11

Treatment Goal BP Keep B. P. < 140/90 mm Hg in each patient This may be revised to 120/80 may be ? 11 MRFIT’s cut off values are 115/75 mm Hg The Truth is It is essential to keep the B. P at or below th But, It also matters how the goal B. P. is ach www. drsarma. in 12

Definitions As per JNC VII and ISH (WHO) 2004 1. What is normal B. P ? 2. What is pre hypertension ? As per JNC VII and ISH (WHO) 2004 Normal SBP < 120 and DBP < 80 www. drsarma. in Pre HT SBP 120 to 139 mm Hg DBP 80 to 99 mm Hg 13

Definitions 1. What is stage 1 HT ? 2. What is stage 2 HT ? Stage 1 SBP 140 to 159 DBP 90 to 99 Stage 2 SBP 160 and more DBP 100 and more www. drsarma. in 14

JNC VII Classification SBP (mm Hg) DBP (mm Hg) < 120 < 80 120 -139 80 -90 Stage 1 140 – 159 90 – 99 Stage 2 160 and above 100 and above Category Normal Pre – hypertension Hypertension 15

Definitions Are the values same for Diabetics , CKD? No, for DM, IHD and CKD the criteria are more stringent The cut off values are 10 mm lower Stage 1 SBP 130 to 149 DBP 80 to 89 Stage 2 SBP 150 and more www. drsarma. in 16

Hypertension Optimal Treatment (HOT) Study Reduction in CV events 25 p=0. 005 (DM) DM non-DM Events/1000 pt-years 20 15 10 5 0 <90 www. drsarma. in <85 <80 Target diastolic BP Lancet 1998; 351: 1755– 62 17

Rule of Halves What is this rule of halves in HT ? • For every 800 adults in the community • 400 are HT (either ↑ SBP or ↑ DBP or both) • Of them only 200 are diagnosed HT • Of them only 100 are started on treatment • Of them only 50 are on correct drug www. drsarma. in • Of them in only 25 the goal B. P. is 18

How many are really Dx. and Rx. ed ? ? Under control (40%) Diagnosed HT 37% Hypertensives (22%) Normotensives (78%) 63% Under Un Rx. treatment HT (50%) (7. 5% of the total hypertensives) Uncontrolled hypertension (60%) Undiagnosed HT A study from Europe on 23, 339 patients www. drsarma. in 19

Global Hypertension Control www. drsarma. in Dr. Sarma@works 20

Isolated Systolic Hypertension 1. What is ISH ? – 2. What percentage of 65+ aged have ISH ? 3. Which is more harmful – ↑ SBP or DBP ? 4. Why is ISH important ? www. drsarma. in 21

Relative prevalence of SBP and DBP 40 + yrs ISH S&DHT Normal www. drsarma. in 22

R R for CVD - SBP and DBP www. drsarma. in 23

ISH is universal after 65+ Persons who are normo-tensive at age 55 have a 90% lifetime risk for developing HTN. www. drsarma. in 24

HT- RR of stroke and MI 20 5 Year Risk (%) Normotensives Hypertensives 15 10 Stroke Myocardial Infarction 5 0 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 Systolic Blood Pressure (mm. Hg) www. drsarma. in Brown, M. J. Lancet 2000; 355: 659 - 660 25

Is SBP more dangerous or DBP ? www. drsarma. in 26

Isolated Systolic Hypertension 1. What is ISH ? – SBP 140+ , DBP < 90 2. What percentage of 65+ aged have ISH ? More than 90% 3. Which is more harmful – ↑ SBP or DBP ? Of course ↑ SBP 4. Why is ISH important ? Because of ↑↑ CVA and CHD mortality www. drsarma. in 27

For adequate control of B. P. Do you think we can control most of the patients of hypertension with – One drug Two drugs Three drugs Can’t control In most of the patients of hypertension Two drugs are required for adequate control www. drsarma. in More so if the initial BP is 20/10 above the 28

TODAY’S PARADIGM Gone are the days of monotherapy It is the era of combination therapy Why is it so? www. drsarma. in 29

CVD Risk Factors What are the so called CHD risk factors ? What are known as CHD risk equivalents ? What is Framingham risk score ? www. drsarma. in 30

Global Risk Profile and HT 25) www. drsarma. in Dr. Sarma@works 31

HT combined with other CHD RF Framingham offspring study, subjects aged 17 – 84 www. drsarma. in 32

CVD Risk Factors What are the so called CHD risk factors ? List discussed in previous slide What are known as CHD risk equivalents ? DM, PVD, CVA, Nephropathy, Retinopathy What is Framingham 10 CHD risk estimate ? www. drsarma. in 33

Target Organ Damage Why is there TOD in HT ? What are the organs targeted for damage ? What is the basis of TOD ? What tests we need to do to assess HT ? www. drsarma. in 34

Diseases Attributable to Hypertension Coronary heart disease Stroke Heart failure Cerebral hemorrhage Myocardial infarction Left ventricular hypertrophy Hypertension Aortic aneurysm Retinopathy Peripheral vascular disease www. drsarma. in Adapted from: Arch Intern Med 1996; 156: 1926 -1935. Chronic kidney failure Hypertensive encephalopathy All Vascular 35

Target Organ Damage (TOD) • Heart Left ventricular hypertrophy (LVH) Angina or prior myocardial infarction (CHD) Prior Coronary revascularization PTCA or CABG Heart failure (Systolic / Diastolic dysfunction) • Brain CVA Stroke or Transient Ischemic Attack (TIA) www. drsarma. in • Kidney : Chronic kidney disease and CRF 36

Atherosclerosis – Time line www. drsarma. in Dr. Sarma@works 37

Endothelial NO Balance NO www. drsarma. in 38

Target Organ Damage - Assessment Routine Tests • Electrocardiogram, Echocardiography (desirable) • Urinalysis for proteinuria, Microalbuminuria • Blood glucose (F and PP), and Hematocrit • Serum Na and K, Creatinine or GFR, Calcium • Lipid Profile complete, Eye examination, ABI www. drsarma. in Optional tests 39

Target Organ Damage Why is there TOD in HT ? It is a disease of blood vessels. What are the organs targeted for damage ? Heart, brain, kidney, eye, peripheral vessel What is the basis of TOD ? ED, Arterial stiffness and Atherosclerosis www. drsarma. in 40

Paradigm Shift in HT Therapy It is not just ↓B. P. TODAY we must strive to 1. Alter the modifiable risk factors 2. Keep the SBP < 140 and DBP < 90 3. Prevent or halt or reduce TOD – • LVH, CHD, CHF, CVA, CRF, PVD & Retino. 4. Prevent or control DM (as HT + DM is hazardous) 5. Prevent or control Dyslipidemia (Endothelial Dysf. ) 6. Reduce morbidity and mortality www. drsarma. in 41

Target Organ Damage What is single most imp. predictor of CHD, HF, Death ? What time course of HT to LVH to LVF to death ? Can LVH be regressed at all ? Will drugs help to regress LVH and ↓TOD ? How important is Micro-albuminuria ? www. drsarma. in 42

Normal weight 350 to 450 g www. drsarma. in 43

Transverse Section of HEART - LVH 10 mm www. drsarma. in Dr. Sarma@works 25 mm 44

Echocardiography of Heart - LVH www. drsarma. in Dr. Sarma@works 45

ECG and Left Ventricular Hypertrophy www. drsarma. in 46

Chest PA view of Heart - LVH C/T ratio > 50% www. drsarma. in 47

Progression of HT to LVH to HF www. drsarma. in 48

Survival Rate HT + LVH v/s NT + LVH Source : Am Hear J, 2000; 140 (6) : 848856. 1. 00 Portion Surviving 0. 99 Nomotensive-No LVH 0. 98 0. 97 Hypertensive-No LVH 0. 96 Normotensive-LVH 0. 95 Hypertensive-LVH 0. 94 0. 93 0 www. drsarma. in 2 4 6 8 10 12 Survival Time (Years) 14 16 18 49

Can LVH be reduced at all ? ? LVH is the Single Most important predictor www. drsarma. in 50

Will Treatment Help ? ? Combined results of 17 RCTs ( n = 48, 000) www. drsarma. in Hebert 1993, Moser 1996 51

MAU as a Predictor of Morbidity and Mortality Retinopathy LVH All-cause mortality Diabetes + MAU Nephropathy Non-fatal cardiovascular disease Peripheral/autonom ic neuropathy www. drsarma. in Parving HH. J Hypertens 1996; 14 Suppl 2: S 89 -S 94. 53

Definitions of abnormalities in albuminuria Category 24 hour collection (mg/24 h) Timed collection ( g/min) Spot collection ( g/mg Cr) Normal < 30 < 20 < 30 Microalbuminu 30 -299 ria 20 -199 30 -299 Clinical (macro) albuminuria 200 300 Because of variability in urinary albumin excretion, 2 of 3 specimens over 3 -6 mon should be abnormal before considering diagnostic threshold positive www. drsarma. in False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria. 54

Relative Importance of MAU 10. 02 10 8 6. 52 6 CHD Odds Ratio 4 3. 20 2. 32 2 0 Microalbuminu Smoking ria Hypertension Cholesterol Eastman RC, Keen H. Lancet 1997; 350 Suppl 1: 29 -32. www. drsarma. in 55

Target Organ Damage What is single most imp. predictor of CHD, HF, Death ? LVH – LV mass index What is the time course of HT to LVH to LVF to death ? The chart is explained Can LVH be regressed at all ? Very much Yes. Diuretics and ACEi are the best Will drugs help to regress ↓TOD ? www. drsarma. in Yes. All TOD regresses; LVF and CVA 56

Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Trigeminy, Bigeminy Reduced volume of carotid LV apical Enlargement/displaceme nt Sustained heave of apex – www. drsarma. in Change in heart sounds Soft S 1 Paradoxically split S 2 S 3 gallop S 4 impaired LV compliance) Mitral regurgitation Pulmonary congestion rales 57

Ankle-Brachial Index Resting and post exercise SBP in ankle and arm. 1. Normal ABI > 1 (Ankle BP more than the arm BP) 2. ABI < 0. 9 has 95% sensitivity for angiographic PVD 3. ABI of 0. 5 - 0. 84 correlates with claudication 4. ABI < 0. 5 indicates advanced ischemia www. drsarma. in 58

Dippers & Non Dippers What is this pattern in HT – Dippers and Nondippers ? What is its significance and clinical relevance ? www. drsarma. in 59

Dippers & Non Dippers Systolic Blood Pressure (mm Hg) 160 150 140 Non - dippers 130 Dippers 120 110 6 8 10 12 14 16 18 20 22 24 2 4 24 hours clock time www. drsarma. in Yonsei, Med J, Vol 43, No 3: 2002 60

Dippers & Non Dippers Diastolic Blood Pressure (mm Hg) Diastolic Blood Pressure 100 90 Non - dippers 80 Dippers 70 6 8 10 12 14 16 18 20 22 24 2 4 24 hours clock time www. drsarma. in Yonsei, Med J, Vol 43, No 3: 2002 61

Dippers & Non Dippers 1. Less than 10% circadian variation in SBP and DBP 2. Essential hypertension patients are – usually ‘Dippers’ 3. Non dippers are Dx. by ABPM – They are usually 1. Secondary HT cases 2. More end organ damage 3. More LVH 4. More responsive to salt restriction www. drsarma. in 5. Diabetics are non dippers 62

Ambulatory Blood Pressure Monitoring - ABPM 1. 24 hour B. P monitoring (every 15 minutes) 2. Today - 24 hour B. P. control is essential 3. Identifies dippers and non-dippers 4. Excludes white coat hypertension 63

Pulse wave velocity – Arterial Stiffness Systole Diastole Pulse. Trace PCA Sphygmoc or www. drsarma. in 64

What is MOST essential ? ? v Not that ‘my drug is superior to yours’ v Not that ‘this trial is better than that’ v Nor ‘this combination is better than that’ v But to get AS MANY PEOPLE as we can to goal SBP < 140 & DBP < 90 www. drsarma. in v And prevent or halt TOD. 65

Morbidity and Mortality in HT Most of the morbidity and mortality of HT is due to v LVH – LV diastolic and systolic dysfunction v Increased risk of Coronary Artery Disease v Increased risk of Cerebral Vascular Disease v Hypertensive heart failure www. drsarma. in 66

The correct Approach to HT • Are all patients screened for hypertension? Step 1 • Are all hypertensives correctly identified? • Are they evaluated for co-morbidities/TOD? Step • Are they assessed for CHD risk factors? 2 • Are the correct drug combinations prescribed? Step • What is the compliance for medicines & f/u? 3 • Is the goal B. P. achieved and maintained? Step • Are there any complications/ side effects? 4 www. drsarma. in 67

So, What is new in Hypertension ? 1. High B. P recorded is only a clinical marker disease 2. HT is a multi-organ disease, often asymptomatic 3. Not to consider in isolation- Must look for ‘Co. Thieves’ 4. Today’s goal BP is 140/90 – It will sure be less tomorrow www. drsarma. in 68

What is new in Hypertension - continued 8. ↑ SBP is more important than ↑ DBP; Often ignored it is ! 9. Wide pulse pressure (SBP-DBP) signifies arterial damage 10. Day’s of monotherapy have gone; Combined Rx replaces 11. All HT must be screened for CHD risk factors & addressed www. drsarma. in 69

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Lifestyle Modification 1. Life style modification is the sheet anchor in the management Hypertension. 2. This surely reduces the number of drugs used and their dosage in controlling HT. 3. Any drug treatment has value only when coupled with Life style www. drsarma. in modification. 71

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Lifestyle Modification Weight reduction Approximate BP reduction (range) 5– 20 mm/10 kg wt loss Adopt DASH eating plan 8– 14 mm. Hg Dietary sodium reduction 2– 8 mm. Hg Physical activity 4– 9 mm. Hg Abstinence from alcohol 2– 4 mm. Hg www. drsarma. in All put together reduce BP by 20 to 55 mm. Hg 73

What to choose from the ocean v 16 different classes of drugs v 117 approved molecules as on date v Innumerable drug No significant change in the combinations proportion of HT under control v Over 1800 clinical trials of repute v Five international societies on HT v Seven JNC guidelines so far www. drsarma. in v Multiple target organs damage 74

Many avoidable HT deaths ! On April 12, 1945, US President Franklin D. Roosevelt died of cerebral hemorrhage, a consequence of HT. It was a devastating illness for him. By current standards, President Roosevelt’s death was unnecessary. President Roosevelt was never treated with Anti-hypertensive drugs. Modern treatment would have controlled his BP and prolonged his life. . so also of many others! www. drsarma. in Arch Int Med, Sept, 75

The Many Faces of HT Therapy Today CCBs Centrally acting agents tics e r Diu rs e ck o l b a t Be ARBs ACE – inhibit ors Enalapril Lisinopril Ramipril Quinapril Perindopril Hypertension www. drsarma. in 76

Which drug should we prescribe ? v Choice must be tailored to individual patient v Should be rational and as per approved guidelines v Only class 1 evidence based medications to be used v Suitable to patients’ purse v Can never be arbitrary www. drsarma. in 77

Physicians’ Bias in HT v Isolated SHT is often dubbed as ‘aging factor’ v To consider HT is only in the ‘ARM’ and not in the body v No concept of ‘pulse pressure’ – Not seeing the whole v Worry about side effects – Need to watch, not to worry v OK, some control is achieved – why attain goal BP ? v Not insisting on compliance with drugs and assessments v Pressure from patients – B. P. How much ? v Concentrating on the pill and not on the ill – TLC forgotten www. drsarma. in 78

Anti Hypertensive drug classes The A, B, C, D approach www. drsarma. in 79

Anti Hypertensive drug classes v ACEi – Angiotensin converting enzyme inhibitors – Enalapril- let us call them ‘A’ v ARB – Angiotensin Receptor Blockers – Losartan - Let us call them also as ‘A’ v BB – Beta Receptor Blockers – Metoprolol, Carveidilol, Atenelol - let us call them ‘B’ v CCB – Calcium channel blockers – Amlodepine Verapamil, Diltiazem - let us call them ‘C’ v Diuretics – Hydrochlor Thiaz. - Furosemide, Spiranolactone - let us call them ‘ D ’ www. drsarma. in 80

AB/CD Rule – HT Treatment Beta-blocker. Ca++-blocker, Diuretic) = (AB/CDACEi, AGE Younger (< 55) High Renin HT BB I ACE i Renin Older (> 55) Low Renin HT CC B A + B + D + C + II D + B DIV: Add / substitute alpha blocker A C Resistant HT / Intolerance www. drsarma. in III Diureti I c II V: Re-consider 20 causes trial of spironolactone Dickerson et al. Lancet 353: 2008 -11; 1999 81

The A B C D classes D A Diuretics ACEI, ARB Ca channel. Blockers ACEI and ARB DIURETICS βBlockers D A Fourth Choice, Useful Second Best Choice First and Best Choice Good third Choice B C Can be combined with D, A Can be combined with D, B, C Can be combined with A, D B C β-Blockers Ca-Blockers www. drsarma. in 82

A B C D – some brand names v Thiazide diuretics – Hydrochlorothiazide - Aquazide, Hydride, Xenia Chlorthalidone – Hythalton, Loop diuretic – Frusemide v Potassium sparing Triamterene, Amiloride, Spironalactone (Aldo anta) v Beta blockers Selective – Metoprolol, Metoprolol XL, Atenelol Combined alpha and beta blockers – Carveidilol, Labetolol v ACEI – Enalapril, Ramipril, Lisinopril, Quinapril, Perindopril v ARB – Losartan, Valsratan, Candesartan, Irbesartan v CCB – Nefedipine, Amlodipine, Varapamil, Diltiazem v Alpha Blokers – Prazocin, Doxizocin, Terazocin, Tamsulocin www. drsarma. in 83

Hypertension – Why Combinations ? v If goal BP is not achieved by a single drug in full dose v Then adding another agent will help achieve the goal BP v Two agents sometimes nullify each others side effects v Fixed dose combinations will reduce the no. of tablets v Once daily formulations are good for compliance v Sustained release or LA formulations for 24 h BP control v If three drugs can’t achieve goal BP – Resistant HT www. drsarma. in 84

Drug Combinations Dr. Sarma@works 85

Hypertension – Rational Drug Combinations ACEI and ARB = A Diuretics = D – Rank 1 Beta Blockers = B ACEI and ARB = A – Rank 2 Calcium Channel (CCB) = C Beta Blockers = B – Rank 3 Diuretics Drugs= D CCB = C – Rank 4 D and A combination is excellent - Ramace H, Losar H, Enace D D and B combination next - Betaloc H, Atecard D, Tenoric D and C combination sixth - Amlogaurd H, Stamlo D A and B combination Third - Losar A, Cardif Beta A and C combination fourth - Amlopres L, Hipril A, Amlo LS B and C combination fifth - Amlo AT, Amlobet, Beta Nicardia www. drsarma. in 86

Some Irrational Combinations Beta blockers + Beta 1 stimulants - Rebound HT, Paradoxical BP ↑ Beta blockers + Vepapamil - Extreme bradycardia, HB, CHF Thiazide + Furesemide Potential volume ↓ and K ↓ - CCB + Thiazide - No RCTs to support the additive Prazocin + Beta blocker - They nullify the effects of each other Verapamil / Dilzem + Nefidepine - No rationale (cardiac actions contridic) Beta blocker + ACEI Not for HT alone, Good for CHF, MI, IHD Sub clinical doses of two drugs Try one drug in good dosage, then add Two drugs of same class - No rationale (like Enalapril + Ramipril) (Atenelol + Metoprolol, Nefidepine + Amlo) www. drsarma. in 87

DIURETIC www. drsarma. in I am. KNOW ‘D’ for MEDIURETIC WELL v My Good aspects Fluid depletion, Na washout, Low cost Improve CHF, Systolic function, Ca saving Reduce LVH, Morbidity & Mortality v My Bad aspects Potassium washout, ↑ in Uric acid, ↑ Ca Adverse on Lipids, Glucose control v Don’t use me in Gout, Hypokalaemia 88

ACEI, ARB www. drsarma. in I am ‘A’ KNOW for ME ACEI WELL and ARB v My Good aspects Improve Diastolic function, Systolic function Control Proteinuria, Very favourable in DM Improve Coronary Ischemia, Good on Lipids Reduce LVH, Morbidity & Mortality v My Bad aspects Bradykinin accumulation, Angio-edema ↑ Serum K , ↓ GFR v Don’t use me in Pregnancy, Creatinine is > 3 mg%, ↑ K 89

β Blocker I am KNOW ‘B’ for MEβBlocker WELL v My Good aspects ↓Heart rate, ↓Forceof contraction, ↓Conduction ↓Myocardial O 2 demand, Improve Ischemia Improve QUALY in CHD, Useful in CHF, Migraine v My Bad aspects Constrict peripheral vessels, Bradycardia Unfavourable on Lipids, Glucose v Don’t use me in Bradycardia, Conduction defects, Caution in CHF www. drsarma. in Prinzmetal Angina, MSD, PVD, BA, COPD, 90

Ca+ Blockers I am ‘C’ KNOW for Ca. ME channel WELL Blocker v My Good aspects Vasodilatory, Suitable in elderly, Low cost Anti arrhythmic (Verapamil), ↑Coronary BF (Diltz) Neutral on lipidemia, Vasospastic Angina v My Bad aspects Fluid retention, Impair failing heart Adverse on Glucose control , Pedal edema ? Rx. v Don’t use me in Tachycardia, arrhythmias, CHF, www. drsarma. in Uncontrolled DM, Volume overload 91

ABCD Compare & Contrast βblocker Ca+ Blocker Improves Negative Parameter Diuretic ACEi, ARB Ischemia No effect Improves LVH, LVF Improves* Negative CV Mortality Improves Increases Heart rate No effect Bradycardi Tachycardi a a Use in DM Negative Excellent Negative Lipid effects Negative Excellent Negative Neutral Vasoconstr. Vasodilato ry Fluid & Na www. drsarma. in K ex / Enhances No effect Bronchosp 92

Which drug in each class DIU • • HCZ Chlortha Indapami Furosemi Torsemid Spirono Triamter www. drsarma. in ACEi • • Enalapril Ramipril Lisinopril Perindopr Quinapril Captopril Benazopr CCB BB ARB • • • Losartan Telmisart Valsartan Irbesartan Candesart • • Metoprol Carvedio Atenelol Labetolol Nebivol Bisiprol Pindolol Proprano • • Amlodep Nefidepin Felodepin Nitrendep • Verapami • Diltiazem 93

Persistence with hypertensive therapy www. drsarma. in 94

Hypertension Case specific approach some selected case scenarios www. drsarma. in 95

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 96

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 97

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 98

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 99

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 100

Case specific approach Case 1 Pre Hypertension TLC, No Drug Yearly F/u Case 2 Stage 1 HT Single Drug D or D + A Case 3 Stage 2 HT Two Drugs D + A, D + B Case 4 HT + Tachycardia Beta blockers Not CCB Case 5 HT + Bradycardia Heart Blocks BBB CCB, ACEi Not BB www. drsarma. in 101

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 102

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 103

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 104

Case specific approach Case 6 HT + CHD Risk f ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 105

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 106

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 107

Case specific approach Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto) Case 7 HT + IHD (No MI) BB + ACEi B + A + D Case 8 HT + MI or (RVP) BB (Car) + ACEi, ARB Aldactone Diltiazem Case 9 HT + PZM Angina CCB, α bloc Not BB ARB Losartan ACE Ramipril BB - Meto ACEi + D A + D + B Case 10 HT + Diast. Dys Case 11 HT + Sys Dys www. drsarma. in 108

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 109

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 110

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 111

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 112

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 113

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 114

Case specific approach Case 12 HT + CHF Case 13 HT + DM (No DK) Diu - Fru. Sp. Not CCB, + ARB / ACEi α bloc ARB, ACEi Not D, C Case 14 HT + DM+ DKD MD, HYZ, D Not CCB, ACEi, ARB Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D Case 16 HT + BA / COPD ACEi / ARB Not BB Case 17 HT + PVD / smoker CCB, ACEi, HZ www. drsarma. in Not BB 115

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 116

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 117

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 118

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 119

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Case 22 ISH - SBP > 140 Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 23 HT + Cough www. drsarma. in 120

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 121

Case specific approach Case 18 HT + BPH Case 19 HT + ED α bloc, Tamsu Not BB α bloc, HZ, ACEi /CCB Not BB Not ACEi, or ARB Case 20 HT + Pregnancy MD, HYZ, CCB Case 21 HT + Gout, ￪ UA ACEi, CCB Not D Indap, Amlo, Enalapril Not BB ACEi cough Cough remedy Case 22 ISH Case 23 HT + Cough www. drsarma. in 122

Case 24 Hypertension and cough v Hypertensives may present with cough – watch out 1. Consider LVF as the cause of cough 2. Consider ACEI induced dry cough 3. Stop ACEI and give ARB or other agents 4. Check the composition of the cough remedy you give 5. Ephedrine, Pseudephedrine, should be avoided 6. Oral Beta agonists like Orciprenaline, Salbutamol, Terbutaline the less used, the better. 7. Inhaled beta agonists, ICS are safe 8. Decongestants like phenyl propanolamine to be avoided www. drsarma. in 123

Case 25 Secondary Hypertension – various causes v Secondary HT v Treatment Usually Stage 2 - HT Secondary causes will be present May present in young individuals Look for secondary cause and treat Life style interventions must Vigorous efforts required to control HT Often two or even 3 drugs may be required Resistant HT may be encountered Anti HT drugs as per secondary cause v Absolute contra www. drsarma. in ACEI or ARB in bilateral renal artery stenosis 124

Case 26 Secondary Hypertension in Pheochromocytoma v Pheochromocytoma Usually Stage 2 HT, Episodic or Labile Secondary adrenal medullay tumor May present in young individuals v Treatment Surgical Ablation of the chromaffin tissue HT needs to be controlled before surgery Alpha blockers are the drugs of choice Phentolamine, Phenoxybenzamine, Prazocin Vigorous efforts required to control HT Often two or even 3 drugs may be required Resistant HT may be encountered v Surgery First reduce HT, then surgery v Do not use www. drsarma. in Beta blockers 125

Case 27 v Resistant HT v Reasons v Rationale www. drsarma. in Resistant Hypertension Usually Stage 2 HT May present in young individuals May have secondary causes Not taking medication (liers) Improper BP measurement Excessive Na intake, Inadequate diuretic Rx. Full doses of drugs not employed Drug interactions – NSAIDs, SMA, OCP, OTC Herbal remedies, Excessive alcohol use Identify the above and correct Secondary causes to be searched for 126

Case 29 Hypertensive emergencies v HT emergency Marked DBP elevation Acute TOD present v TOD Presentation Encephalopathy, MI, ACS, Pul Edema, Eclampsia, stroke, head trauma, lifethreatening arterial bleeding, or aortic dissection With TOD immediate admission to ICU IV Nitroprusside, Diazoxide, Labetolol Without TOD Combination of 2 or 3 drugs Close monitoring Life style modification not now – no time No sublingual nefedipine, v Treatment v Do not use www. drsarma. in 127

Case 30 Hypertensive with Acute CVA (Stoke) v HT + CVA (Stroke) Marked DBP elevation May be SAH, ICH, Acute Brain Infarction v Rationale In acute setting, no consensus on treatment of elevated BP HT at time of an acute stroke associated with increased risk of cerebral hemorrhage and edema, increased mortality After acute ischemic stroke, cerebral auto regulation affected Active treatment of BP in the first 7 days could worsen symptoms v Treatment Recommendation not to start HT Rx. before 7 to 10 days after ischemic stroke www. drsarma. in 128

Current Indications for Alpha Blockers 1. Hypertension with BPH 2. In Pheochromoytoma before surgery 3. In the treatment of Ergot over dose 4. Raynaud’s syndrome and PVD, TAO 5. Vasospastic (prinzemetal Angina) 6. Diabetic neuropathy 7. Hypertensive smokers 8. Hypertension with Dyslipidemia First dose syncope and Postural Hypotension How to avoid ? www. drsarma. in 129

Learning is a cyclical process Each of these presentations is a valuable learning experience for me Thank You all www. drsarma. in 130