TREATMENT OF HYPERTENSION Aim of treatment BP Goals Main items of treatment Lifestyle modification When to start drug Rx Pharmacological therapy 1. Relief of symptoms 2. Prevention of complications and target organ damage 3. Improve quality of life 4. Improve mortality Benefits of Lowering BP: Average Percent Reduction Ø Stroke incidence 35-40% Ø Myocardial infarction 20 25% Ø Heart failure 50% All be treated to <140/90 mm Hg Except : diabetes (<85 mm Hg diastolic) In 80 years age, SBP:140-150 mmhg, can go <140 mmhg if the patient is fit and healthy- mentally & physically 1. Life style modifications 4. Treatment in special situations: 2. Diagnosis and treatment of the cause in secondary Ø Elderly HTN Ø Children 3. Drug therapy Ø Diabetics Ø Chronic kidney disease 1. Diet: Weight reduction Salt restriction the degree depends on the severity of HTN High K and Ca intake 2. Exercise and increase physical activity 3. STOP Smoking and alcohol intake 4. Relaxation therapy Consider BP level and correlate with overall risk: Cardiovascular risk factors Overt cardiovascular disease Asymptomatic organ damage Diabetes Chronic kidney disease. First line drugs Second line drugs 1. Diuretics especially thiazide 2. ACE Inhibitor & ARBs 3. Calcium channel blockers 4. B- Blockers 5. Alfa 2 blockers 1. Centrally acting drugs alfa- methyl dopa 2. Direct vasodilators hydralazine, minoxidil 3. Other anti- adrenergic drugs reserpine, guanithidine, alfa 1 blockers 4. Others Thiazide and thiazide like Chlorothalidone Hygertone 25-50mg Hydrochlorothazide Esidrex 25-50 Indapamide Natrilex 1.5mg Diuretics Loops diuretics Furosmide Lasix 40 80 mg Torsemide Examide 5 20 mg K retaining diuretics Spironolactone Aldactone 25 100 mg Amiloride Midamor 5 mg B- Blockers Propranolol Inderal 40-320mg Atenolol Tenornin 50-100 mg Bisoprolol Concor 5-10 mg Carvidelol Dilatrend 25-50 mg Metaprolol Betaloc 50-100 mg Sotalol Betacor 40-80 mg
ACE Inhibitors Captopril Capoten 25-150mg Enalapril Ezapril 5-40 mg Lisinopril Zestril 10-40 mg Ramipril Tritace 2.5-10 mg Prindopril Coversyl 5-10mg Fosinopril Monopril 10-40 mg Calcium channel blockers Angiotensin receptor blockers Alfa- blockers Centrally acting drugs Nifidepine Adalate or epilate 10-40 mg Amlodopine Norvasc 5-20 mg Verapamil Isoptin 80-240 mg Deltiezem Altiezem 120-240mg Losartan Cozaar 50-100 mg Valsartan Tareg 80-320 mg Candisartan Atacand 8-32mg Irbesartan Approval 150-300mg Prazocin Minipress 6-15 mg Doxazocin Cardura 1-4 mg Alfa methyl DOPA Aldomet 500-2000 mg Clonidine Catapress 0.2-0.8 mg ESC guidelines 2013 Treatment and Risk
ESH Guidelines 2013: Drug combinations Selection of anti- HTN drugs Subclinical organ damage Clinical events LVH ACEI,CA,ARB Stroke Any Asympt. AS CA,ACEI MI BB,ACEI,ARB Microalbuminuria ACEI,ARB Angina BB,CA Renal dysfunction HF D,BB,ACEI,ARB, Aldo A Conditions AF ARB,ACEI,BB,CA ISH D,CA ESRD ACEI,ARB,D MS ACEI,ARB,CA PAD CA DM ACEI,ARB LV dysfunction ACEI Pregnancy CA,MD,BB Black D,CA Treatment algorism
BP Control in Adult ACC 2013
Definition Causes Drugs in HTN emergencies Hypertensive emergencies It is a state of severe HTN that need rapid BP control with parenteral therapy. Cardiac Brain Renal Others 1. Hypertensive 1. Acute renal failure encephalopathy 2. Malignant HTN 2. Cerebral stroke thrombotic or hemorrhagic 1. Acute LVF and pulmonary edema 2. Acute aortic dissection 3. Acute coronary syndrome 1. Eclampsia of pregnancy 2. Postoperative 3. Crises of pheochromocytoma 4. Drug withdrawal clonidine, B- Blockers 5. Acute intermittent porphyria Drug Dose Onset Side effects Uses Furosemide 20-40mg/1-2h 2-3h Volume depletion With other drugs IV Nitroglycerine 5-100 µg /min 2-5 min. Headache CAD Na nitroprusside 0.25-10 µg/kg Immediate Thiocynate toxicity All case Labetalol 20-80mg /10min 5-10 Nausea, vomiting HB All except acute HF Diazoxide 5mg/ kg over 15 min 5-10 Salt retention Not in CAD, Ao dissection Esmolol 200-500 µg/kg bolus + 50-300 µg/kg/min 5-10 Hypotension Aortic dissection post- operative HTN Hydralazine 20-40 mg IM/IV 10-30 min Headache, flushing Eclampsia