TREATMENT OF SYSTEMIC ARTERIAL
HYPERTENSION
. TREATMENT OF
SYSTEMIC ARTERIAL HYPERTENSION
Essential Assessments:
1. Establish the presence of hypertension
2. Assess the severity and prognosis to select proper therapy
3. Search for presence of secondary hypertension if indicated.
Three
important measures in treatment
1. Life style modification and general measures
2. Drug therapy
3. Treatment of secondary hypertension
Life
style modification and general measures
Exercise:
Regular dynamic physical exercise:
brisk walking/ swimming/ cycling -30 -45 min 5dys a wk
Salt restriction
2-4gms /day
DASH
diet
(Dietary Approach to Stop Hypertension)
Dash diet –rich in fruits, vegetables, whole grains and low fat
dairy foods
Fruits and vegetables: Adequate
intake; maintain adequate K, Ca and
Magnesium.low salt
Avoidance /control/treatment of risk
factors –
-smoking - alcohol,
obesity, cholesterol and saturated fat.
Recent
advances New reports highlight
the risk of hypertension with regular drinking
Alcohol is most controllable and preventable risk factor for
hypertension
General measures
a. Patient
education
b. Reassurance
Follow up after non pharmacological therapy
.Who should be treated with pharmaco
therapy? JNC 8guidline
Patients;<;60 years of age: start pharmacotherapy at140/90
mmHg.
Patients
with diabetes: start pharmacotherapy at140/90 mmHg.
Patients
with CKD:
start pharmacotherapy at140/90 mmHg.
Patients 60
years
of
age and older: start pharmacotherapy at150/90 mmHg
Standard target BP –less than
140mm systolic in overall population group
Lower targets previously recommended in
diabetes, CKD,
and CAD
are of unproven benefit.
Use clinical judgement and consider
risk/benefit ratio
In addition continue lifestyle changes
Thus similar treatment goals have been defined
for all hypertensive population and no distinction between uncomplicated
hypertension and hypertension with comorbid conditions like diabetes or chronic
kidney disease (CKD) has been made
Essentials
of JNC 8 recommendations 2013
1. Less aggressive targeting
of blood pressures No BP goals<140 font="">
2. BP goal for patients 65+
year old, < 150/90 mm Hg
3. In patients between 18-60
yrs old with DM or CKD initiation goals140/90
In these patients-ACEI or ARB
is used
(initial or add on drug)
4. Thiazide-type diuretics no
longer indicated as the initial therapy in most patients
1st Line therapy can be: ACEI
or ARB or CCB or Thiazide type diuretic
5. Home BP or
ambulatory BP encouraged
Treatment Plan -JNC8
For all hypertensive population similar treatment goals have been
defined
No distinction between uncomplicated hypertension and hypertension with
comorbid conditions like DM or CKD.
De-emphasis
on choice of agent for
compelling indications;
focus is
on BP
control using
four
medication
Choice of drugs
All
4drug classes beneficial
1st
Line therapy can be:
ACEI or ARB
or CCB or
Thiazide type diuretic-Chlorthalidone is
thiazide of choice
NOTE:Thiazide-type diuretics no longer indicated as the initial therapy in
most patients
Chlorthalidone favoured over
hydrochlor thiazide
Precautions
1.β-blocker not a 1st
line choice for HTN: Vaso-dilating
β-blockers- drugs of choice
2.Calcium
channel blockers “Short acting CCBs not recommended”
·
3.ACEI and ARB should not be combined no added benefit, more side
effects (e.g., hyperkalemia)not to combine K sparing diuretics
Treatment
regime
Initial Mono
therapy in Hypertension:
3
groups of drugs useful;
1
thiazide diuretics
2.Long
acting calcium channel blockers
3.ACE
inhibitors/ARB
B
blockers not indicated for initial
monotherapy (high risk of CVS complications)except when there are specific
indications like angina,rate control
2drug regime
is required in most patients especially if systolic is >20mm above goal
or diastolic>10 mm above goal
·
Choose once-daily or combination products
to simplify the regimen
·
In general, if goal in not reached wait two
to three weeks
before increasing dose or adding new drug.
·
continue to assess BP and adjust treatment regime until goal BP is
reached
·
If 2 drugs are not adequate,3rd drug from the above
list added and dose titrated
3 drug regimen-ACEI/ARB+CCB+diuretics beneficial
·
ACI and ARB should not be combined;βblockers and diuretics are not
to be combined
·
if goal BP is not reached with only above 4 drugs
recommended,drugs from other classes can be used
·
If not successful-refer to hypertension specialist
·
Note:for HTN, beta- and alpha-blockers have bad CV outcomes data
·
Thiazides
and CCBs reduce systolic BP more
than
diastolic BP
Isolated
Systolic hypertension:
·
this is most common form of
uncontrolled hypertension
·
It is important risk factor for vascular complications
Diastolic
Hypertension:may be clinical marker of hypertensive emergencies and urgencies
Hypertension
in elderly patients must be treated to avoid complications
Other anti
hypertensives; (apart from first line
drugs )
A
variety of vasodilators are available
1.
Alpha -blockers (selective alpha1adrenoceptor antagonists)
2. Drugs acting directly on vascular smooth muscles
3Centrally acting drugs
4and loop diueretics,aldosterone diuretics
These other antihypertensives use is eliminated in JNC8 guideline
But take caution in patients who are already stabilized with these
SPECIAL
SITUATIONS
Diabetes:
In type 2 diabetes – 20% have hypertension
In type 1 diabetes - 30-50%
have hypertension
ACE inhibitors are first line drugs in these patients with or without
microalbuminuria and/ nephropathy.
ACE inhibitors reduce microalbuminuria.
Renin angiotensin system blockade retards decline in renal
function by mechanism other than reducing BP.
. Specific therapy recommendation
provided for African Americans
Nonblack, including those with
diabetes:
Thiazide,
CCB, as1st line & ACEI, or ARB as add on drugs
HYPERTENSIVE CRISIS
Hypertensive crisis is defined as BP more than 180/110 mm of Hg.
Hypertensive crisis
consists of
I. Hypertensive emergencies
II Hypertensive
urgencies
HYPERTENSIVE
EMERGENCY:
This is severe hypertension with acute impairment of end organ
(E.g. Brain,
heart, kidney and eyes)
Includes accelerated
hypertension and malignant hypertension
(By definition Systolic BP above 180 systolic and 110 diastolic)
In these conditions, the BP should be lowered aggressively but
carefully
to prevent death or severe
end organ damage
HYPERTENSIVE URGENCY
In this the BP is a potential risk but has not yet caused acute
end-organ damage,
Urgency is defined as severely elevated BP (e.g. systolic above
220mm of Hg or diastolic above 120mm of Hg) with no evidence of target organ damage.
Initial goal in treatment is to attain a diastolic BP of 100-110
mmHg within several hours.
Normal BP can be attained over several days gradually with oral
drugs
Precipitous fall in BP is to be avoided to prevent cerebral
ischemia or coronary insufficiency.
Level of
Hypertension and vascular damage
A persistent diastolic BP above 120mm of Hg is often associated
with acute vascular damage: Some patients suffer vascular damage from lower
levels of BP; others withstand high levels without harm.
So rapidity of rise is
more important than absolute levels.
In practice
DBP above 120mm of Hg must be treated –some rapidly with parenteral drugs some
slowly with oral drugs
HYPERTENSIVE
CRISIS :Flow chart
Principles of treatment in crisis
Urgency:
Outpatient
Oral medication
BP reduction in 24 -48 hrs
Emergency
Inpatient
Intravenous
Immediate BP reduction less than 25% within minutes to 1 hour.
160/100 in 2-6 hrs
Intravenous antihypertensives
Nitroglycerine
Sodium nitroprusside
Enalaprilat (only ACE inhibitor in Intravenous form)
Nicardipine
Clevidepine
Esmelol
Labetalol
Oral drug for Hypertensive urgency
Amlodipine 5-10mg 12th hrly
Captopril 12.5-25mg 6th hrly
Nicardipine 20-30mg 6-8 hrly
Labetalol 200-400 mg 8-12 hrly
Lasix 20-40mg 8-12 hrly
Conditions
in which severe hypertension occurs
1.
Essential hypertension( Asymptomatic uncontrolled hypertension)
2.
Renal disorders
3.
Pregnancy
4.
Drugs
5.
Substance abuse: Acute cocain,amphetamine poisoning(acute
sympathetic crisis)
6.
Acute post operative hypertension(Often BP is 220/130)
Target organ
damages that may occur in hypertensive emergencies
Acute coronary syndrome
Pulmonary edema
Acute Aortic dissection
Acute Cerebral infarction, intracerebral /subarachnoid hemorrhage
Hypertensive encephalopathy
Eclampsia
Acute renal failure,
Severe hypertension was formally called as malignant hypertension
Hypertensive crisis is associated with excess circulating
catecholamines
it is acute BP elevation.
Note: Definition
of emergency and urgency do not specify absolute BP levels
Both may occur in a normotensive with a modest increase in BP as
in
Eclampsia or acute cocaine or
amphetamine intoxication.
Sub
lingual nifedapine therapy is now obsolete because
ischemic complications can occur from sudden fall of BP.
Genetics in hypertension treatment
New research shows genetic variants
play a role in determining CVD outcomes. In hypertension
two variants in a gene called NPPA-that encodes
for (ANP)atrial natriuretric plypeptide discoveredThis can lead to methods to
regulate ANP and so prevent or control hypertension
NEW
DEVELOPMENTS IN PHARMACOLOGICAL TREATMENT OF HYPERTENSION
There are broad ranges of new possible therapeutic targets for
hypertension described belo
Number of new molecules described below are being investigated
Vaso
peptidase inhibitors:
1.Dual ACE/NEP inhibitor.
2.dual angiotensinreceptor(AT1)/NEP inhibitor
3.Dual NEP/endothelin inhibitionand angiotensin receptor(AT1)/endothelin blockade
Phospho diesterase inhibition
Vaso active intestinal peptide agonist
Natriuretic peptide receptor A agonist
Protective RAAS
Angiotensin A2 receptor agonist
ACE2/Ang(1-7)Mas receptor Axis agonist
SYSTEMIC ARTERIAL HYPERTENSION-ABSTRACT
Definition
–BP greater than 140/90 and persistent
Usually
diagnosed during a routine check up in
asymptomatic person
Integral part of
evaluation is proper technique of BP measurement
Ambulatory BP measurement
is gaining impotance
Certain
criteria (conditions) are set for recording of BP
Etiology –Idiopathic or Secondary95% is essential hypertension
Treatment is
important to avoid morbidity and mortality of complications
Since
majority of patients are asymptomatic, careful early evaluation is needed
Malignant hypertension is
high BP associated with target organ damage
First
step in treatment of hypertension is
life style modifications
Amongst several classes of antihypertensives are available-JNC8
recommends
1.ACE inhibitors or ARB
3.Diuretics
4.Calcium Channel Blockers
Start with a low dose and
then increase
Regular monitoring of
blood pressure is essential.
Hypertensive crisis consists of Hypertensive emergency and urgency
Hypertensive emergency is
high BP associated with acute target organ damage
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