DEPARTMENT OF GENERAL MEDICINE WELCOMES

Transcription

1 DEPARTMENT OF GENERAL MEDICINE WELCOMES

2 1 Dr.Mohamed Omar Shariff, 2 nd Year Post Graduate, Department of General Medicine. DR.B.R.Ambedkar Medical College & Hospital.

3 2 INTRODUCTION Leading cause of global burden of disease. Major risk factor for stroke and MI. Likely to end up being an epidemic in the near future. 1/3 rd of the world population vulnerable by 2020.

4 3 INDIAN SCENARIO 100 million hypertensive patients. PREVALENCE RURAL (%) URBAN (%) AWARENESS TREATMENT CONTROLLED BP (J Hypertens. Jun 2014; 32(6): )

5 4 High Prevalence rates for hypertension In percentage are projected to 22.9 Indian men and 23.6 for Indian women by Rising Numbers Year after Years Prevalence of hypertension in the last six decade has increased from 2 to 25% among urban residents from 2% to 15 % among the rural residents in India. Urban-Rural Phenomenon Incidence of hypertension is increasing not only in the urban areas but also in rural population as well. CSI TEXTBOOK OF CARDIOLOGY

6 5 Prehypertension % of screen subjects,highlighting the need for screening of individuals begining at age of 30yrs or earlier. Young Hypertensives (18-39 years) 11 to 19.6% in Indian setting Risk Factors Obesity,Inactivity,>Processed food rich in salt,stress,smoking,alcohol consumption

7 6 Hypertension Co-morbidities Diabetes, CKD, CAD,Stroke. Other co-morbidities like obesity, obstructive sleep apnea, chronic obstructive pulmonary disease and chronic infections also need special attention. Disability In India hypertension is the third most common cause of years of life lost due to premature mortality (YLL) and years lived with disbility. Cost of Disease Large expenditure.

8 7 WHY SO MANY GUIDELINES? They are changed when sufficient new evidence suggests the old ones weren t accurate or relevant anymore.

9 8 NEWER CONCEPTS BP Measurement Out-of-office BP measurements: 1. Ambulatory BP 2. Home BP Target BP in elderly patients Emphasizes biological age (fragility, independence & tolerability of treatment.) y:140/90 mmhg 2. >80 y:160/90 mmhg

10 9 SINGLE PILL STRATEGY Advocates single pill two-drug combination therapy for initial treatment of most patients.

11 10 TARGET BP Based on: 1. Age 2. Specific comorbidities

12 11 ESH / ESC (2018) BP Category Systolic BP (mmhg) Diastolic BP (mmhg) Optimal <120 & <80 Normal &/or High Normal &/or Grade 1 HTN &/or Grade 2 HTN &/or Grade 3 HTN 180 &/or 110 Isolated Systolic HTN 140 & <90 Munich, Germany 24 to 29 th August 2018

13 12 ESH/ESC (2018) V/s ACC/AHA (2017) BP Category ESH/ ESC (2018) BP Category ACC/ AHA (2017) Systolic (mmhg) Diastolic (mmhg) Systolic (mmhg) Diastolic (mmhg) Optimal <120 & <80 Normal <120 & <80 Normal &/or Elevated & <80 High Normal &/or Stage & Grade 1 HTN &/or Stage 2 >140 or >90 Grade 2 HTN &/or Grade 3 HTN 180 &/or 110 ISH 140 & <90

14 13 JNC-7 Blood Pressure Classification BLOOD PRESSURE CLASSIFICATION SYSTOLIC (mmhg) DIASTOLIC (mmhg) Normal < 120 & < 80 Pre-hypertension or Stage 1 hypertension or Stage 2 hypertension > 160 or > 100

15 14 JNC 8 Recommendations PATIENT SUBGROUP TARGET SBP (mmhg) TARGET DBP(mmHg) >/= 60 y <150 <90 < 60 y <140 <90 >18 y w/ckd <140 <90 >18 y w/diabetes <140 < JNC 8

16 15 DEFINITIONS Category Systolic (mmhg) Diastolic (mmhg) OFFICE BP a 140 &/or 90 AMBULATORY BP b Daytime (awake) mean 135 &/or 85 Night-time (asleep) mean 120 &/or h mean 130 &/or 80 HOME BP mean c 135 &/or 85 a: Blood Pressure measurement in primary care setting. b: Blood Pressure measurement at regular intervals. It is able to reduce white coat hypertension. c: Self Measurement of Blood Pressure at home.

17 16 OFFICE BP TREATMENT TARGET AGE SBP(mmHg) + Diabetes + CKD +Stroke/TIA DBP(mmHg) y y 80 y 130 or lower if tolerated Not < 120 <140 to 130 if tolerated < 140 to 120 if tolerated 130 or lower if tolerated Not < 120 < 80-70

18 17 TREATMENT RECOMMENDATIONS GRADE 1 HTN GRADE 2,3 HTN HIGH NORMAL LIFESTYLE ADVICE LIFESTYLE ADVICE IMMEDIATE DRUG TREATMENT IN HIGH OR VERY HIGH RISK PATIENTS WITH CV DISEASES, RENAL DISEASES OR HMOD LIFESTYLE ADVICE IMMEDIATE DRUG TREATMENT IN ALL PATIENTS Drug Treatment (CAD) DRUG TREATMENT IN LOW- MODERATE RISK AFTER 3-6 MONTHS OF LIFESTYLE CHANGES IF BP NOT CONTROLLED AIM FOR BP CONTROL WITHIN 3 MONTHS CAD: Coronary Artery Disease, CVD: Cardio-vascular disease, HMOD: Hypertension mediated organ damage.

19 18 LIFESTYLE CHANGES Prevent or delay the onset of HTN. Reduce cardio-vascular risk. Delay or prevent the need for drug therapy in patients with Grade 1 HTN. Augment the effects of BP-lowering therapy. Should not delay the initiation of drug therapy in patients with HMOD or at a high level of CV risk. Drawback: Poor persistence over time.

20 19 HEALTHY LIFESTYLE CHOICES NO SMOKING AVOID BINGE DRINKING SALT RESTRICTION <5g/DAY REGULAR AEROBIC EXERCISES ( 30 mins of moderate dynamic exercise for 5-7 days/week) > VEGETABLES, FRUITS, FISH, NUTS, UNSATURATED FATTY ACIDS, < RED MEAT, AND CONSUMPTION OF LOW FAT DAIRY PRODUCTS. BODY WEIGHT CONTROL IS INDICATED TO AVOID OBESITY. AIM AT A HEALTHY BMI (20-25 KG/M 2 ) AND WC VALUES (<94 CM IN MEN AND <80 CM IN WOMEN) TO REDUCE BP AND CV RISK.

21 20 DRUG TREATMENT STRATEGY FOR HYPERTENSION WITH CO- MORBIDITIES.

22 21 1 pill 1 pill UNCOMPLICATED HYPERTENSION INITIAL THERAPY DUAL COMBINATION STEP 2 TRIPLE COMBINATION ACEi or ARB + CCB or Diuretic ACEi or ARB + CCB or Diuretic Consider monotherapy in low risk Grade 1 Hypertension or in very old ( 80 yrs) or frailer patients. 1 pill 1 pill STEP 3 TRIPLE COMBINATION + SPIRONOLACTONE OR OTHER DRUG. Resistant Hypertension Add spironolactone (25-50 mg O.D.) or other Diuretic, Alpha blocker or Beta blocker. Consider referral to a specialist centre for further investigation. The core algorithm is also appropriate for most patients with HMOD, CV diseases, diabetes or PAD. ACEi: Angiotensin-converting enzyme inhibitor, ARB: Angiotensin receptor blocker, CCB: Calcium-channel blocker, HMOD: Hypertension-mediated organ damage, O.D.: Omni die (every day), PAD: Peripheral artery disease. Beta-blocker Consider Beta-blocker at any treatment step, when there is a specific indication for their use e.g., Heart failure, angina, post-mi, atrial fibrillation or younger women with or planning pregnancy.

23 22 1 pill 1 pill Initial Therapy Dual Combination Step 2 Triple Combination HTN WITH CAD (ACEi or ARB + Betablocker) or (CCB + Diuretic or Betablocker) or (Betablocker + Diuretic.) Triple Combination of above Consider monotherapy in low risk Grade 1 Hypertension or in very old ( 80 yrs) or frailer patients. Consider initiating therapy when systolic BP is 130 mm Hg in case of very high-risk patients with established CVD. 1 pill 1 pill Step 3 Triple combination + Spironolactone or other drug. Resistant Hypertension Add spironolactone (25-50 mg O.D.) or other Diuretic, Alpha blocker or Beta blocker. Consider referral to a specialist centre for further investigation. ACEi: Angiotensin-converting enzyme inhibitor, ARB: Angiotensin receptor blocker, CCB: Calcium-channel blocker, CVD: Cardiovascular diseases.

24 23 HTN AND CKD a Beta-blocker 1 pill 1 pill 1 pill 1 pill Initial Therapy Dual Combination Step 2 Triple Combination Step 3 Triple combination + Spironolactone or other drug. a: CKD is defined as an egfr <60 ml/min/1.72m2 with or without proteinuria. ACEi or ARB + CCB or ACEi or ARB + Diuretics (or loop diuretics) (b) ACEi or ARB + CCB + Diuretics (or loop diuretics) (b) Resistant Hypertension Add spironolactone ( c ) (25-50 mg O.D.) or other diuretic, Alpha blocker or Betablocker. b: Use of loop diuretics when egfr is <30 ml/min/ 1.72m2 because thiazide/thiazide-like diuretics are much less effective/ineffective when egfr is reduced to this level. c: Caution: risk of hyperkalemia with spironolactone, especially when egfr is <45 ml/min/1.72 m2 or baseline K mmol /L. Consider beta-blocker at any treatment step, when there is a specific indication for their use e.g., Heart failure, angina, post- MI, atrial fibrillation or younger women with or planning pregnancy. A reduction in egfr and rise in serum creatinine is expected in patients with CKD who receive BP-lowering therapy, especially in those treated with ACEi or ARB but rise in serum creatinine of > 30% should prompt evaluation of the patients for possible renovascular disease.

25 THANK YOU