Lesson Plan

Introduction Initiation of drug therapy Goal of drug therapy Choice of drug Mono/combination therapy Causes of refractoriness to drug therapy Pregnancy Emergency Ethnicity & drug response Non drug therapy: renal denervation

Initiation of treatment
140/90, grade 1 & 2, risk factors, life style measures

Risk= stroke, myocardial infarction Stop smoking, reduce weight, salt, exercise, alcohol, reduce cholesterol, stress, control TOD: TARGET Organ Damage diabetes, antiplatelet ACC: Associated Clinical Conditions: cardiovascular/renal disease

Goal of therapy
To reduce cardiovascular morbidity/mortality tight blood pressure control [144/82] substantial reduction in the risk of major cardiovascular events compared to less tight blood pressure control [154/87 ] achieve optimal or normal blood pressures in young, middle aged or diabetic subjects[below 130/85 ] and at least high normal blood pressures in elderly patients [below 160/100 mmHg]=>60 Y

Choice of drugABCD

choice.2

Monotherapy
7-13 mmHg systolic and 4-8 mmHg diastolic 8/4, 12/6 Drug combination therapy twice as great as those obtained with a single drug, of the order of 8-15%, or 12-22 mmHg systolic and 7-14 mmHg diastolic for patients with blood pressure of 160/95 mmHg

Effective drug combinations

diuretic and beta-blocker. diuretic and ACE inhibitor (or A-II antagonists). calcium antagonist (DHP) and beta-blocker. calcium antagonist and ACE inhibitor. alpha-blocker and beta-blocker.

Refractory Hypertension
Unsuspected secondary cause (renal and endocrine) Poor adherence intake of drugs that raise blood pressure (NSAIDS) Failure to modify lifestyle including - weight gain - heavy alcohol intake (binge drinking) Volume overload due to - inadequate diuretic therapy - progressive renal insufficiency - high sodium intake Causes of Apparently Refractory Hypertension Isolated office ("white coat") hypertension Failure to use large cuff on large arm FOLLOW UP

Special Groups
PREGNANCY: Essential, Pre-eclampsia, 170/110 ?
acutely : Labetalol, nifedipine, hydralazine, Magnesium sulphate chronic : beta-blockers; oxprenolol, pindolol, atenolol (fetal growth retardation when used throughout pregnancy) prazosin, labetolol, nifedipine, isradipine, hydralazine, methyldopa

Antihypertensive agents avoided :

ACE inhibitors: fetal growth retardation, oligohydramnios, neonatal renal failure, and possibly abnormal fetal morphology ("fetal hypotensive syndrome") A II receptor antagonists Diuretics reduce the already compromised plasma volume

Hypertensive urgency & emergency

Intravenous - Sodium nitroprusside - Nitroglycerin - Fenoldopam - Esmolol - Labetalol - nicardipine - Clevidipine IV lipid(clinidipineoralL&N CCB) - Enalaprilat - Phentolamine - nesiritide

ethnicity
African americans - Respond less to angiotensin inhibitors - Respond less to beta blockers

surgery
In patients in whom nothing works - Renal denervation

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