View
221
Download
4
Category
Tags:
Preview:
Citation preview
Manar & Samah1
Supervised by:
Dr. Seema
King Faisal Specialist Hospital and Research Center
(2007-1428)
Presented by: Manar LashkarSamah Al-shehriPharm.D candidates
Manar & Samah 2
Manar & Samah 3
Outline• Hypertension• JNC VII Guidelines• Resistant hypertension• Pheochromocytoma• Case Scenario• Points of Discussion
Manar & Samah 4
• Hypertension affects more than 20% of the adult Saudi population with expected increasing prevalence
• It is an important modifiable risk factor for cardiovascular diseases
• Despite overwhelming evidence that lowering BP reduces morbidity and mortality, its management remains frequently sub-optimal
Manar & Samah 5
Hypertension
• It is defined as persistent elevation of systolic blood pressure SBP ≥ 140 mm Hg and/or diastolic blood pressure DBP ≥ 90 mm Hg in adults not on anti-hypertensive medications
• It can be classified as either essential (primary) or secondary Essential hypertension indicates that no specific medical cause
can be found to explain a patient's condition
Secondary hypertension indicates that the high blood pressure is a result of (i.e. secondary to) another condition
Manar & Samah 9
Identifiable Causes of Hypertension
• Chronic kidney disease• Coarctation of the aorta• Cushing’s syndrome and other glucocorticoid
excess states including chronic steroid therapy• Drug induced or drug related• Obstructive uropathy• Pheochromocytoma• Primary aldosteronism and other mineralocorticoid
excess states• Renovascular hypertension• Sleep apnea• Thyroid or parathyroid disease
Manar & Samah 10
Blood Pressure Classification
SBP mm Hg DBP mm HG
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Stage 1 Hypertension
140-159 or 90-99
Stage 2 Hypertension
> 160 or > 100
Classification of Blood Pressure for Adults
Manar & Samah 11
Resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic
Resistant Hypertension
Manar & Samah 12
■ Nonadherence■ Inadequate doses■ Inappropriate combinations■ Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors■ Cocaine, amphetamines, other illicit drugs■ Sympathomimetics (decongestants, anorectics)■ Oral contraceptive hormones■ Adrenal steroid hormones■ Cyclosporine and tacrolimus■ Erythropoietin■ Licorice (including some chewing tobacco)■ Selected over-the-counter dietary supplements and medicines(e.g., ephedra, bitter orange)
Causes of Resistant Hypertension
■ Excess sodium intake■ Volume retention from kidney disease■ Inadequate diuretic therapy
Volume overload
Drug-induced or other causes
■ Obesity■ Excess alcohol intake
Associated conditions
Manar & Samah 13
Manar & Samah 14
Manar & Samah 15
Manar & Samah 16
Class Drug Usual Dose Range (mg/d)
Daily Frequency
Thiazide Diuretics HydrochlorothiazideIndapamideMetolazone
12.5-501.25-2.52.5-5
ODODOD
Loop Diuretics Furosemide 20-80 BID
Potassium Sparing Diuretics
AmilorideTriamterene
5-1050-100
OD/BIDOD/ BID
Aldosterone receptor blocker
Spironolactone 25-50 OD/BID
Adverse Effects Special Precautions
hyperurecimia, glucose intolerance, dyslipidemia, sexual dysfunction, dehydration, increase Ca, decrease (K, Na, Mg), skin rash and photosensitivity
Gout, renal failure, digoxin, lithium
Adverse Effects Special Precautions
Loop diuretics Similar to thiazide diuretics except hypocalcemia
Effect in patients with renal insufficiency
Class Adverse Effects Special Precautions
Potassium Sparing Diuretics
Triamterene urinary sediment, nephrolithiasis
Renal dysfunction, Diabetes, ACEI
Aldosterone receptor blocker
Gynecomastia, impotence, hirsutism, menstrual irregularities, GI symptoms.
Diuretics
Manar & Samah 17
Class Drug Usual Dose Range (mg/d)
Daily Frequency
b-Blockers AtenololBisoprololMetoprololPropranolol
25-1002.5-1050/10040/160
ODODOD/BIDBID
b-Blockers with ISA
Acebutolol 200-800 BID
Combined a/b Blocker
carvedilolLabetalol
12.5-50200-800
BIDBID
a1 Blocker DoxazocinPrazocin
1-162-20
ODBID/TID
Central a2 agonist ClonidineMethyldopaReserpine
0.1-1.8250-10000.05-0.25
BIDBIDOD
Adverse Effects Special Precautions
Fatigue, insomnia, nightmare, depression, sexual dysfunction, dyslipidemia, rash, withdrawal rebound coronary heart disease, bradycardia, GI upset, mask symptoms of hyperglycemia
Asthma, COPD, Decompensated CHF, heart block, DM, peripheral vascular disease.
Less bradycardia and dyslipidemia, drug-induced Lupus Erythematosus
Orthostatic hypotension, hepatotoxiciy No dyslipidemia
Class Adverse Effects Special Precautions
a1-Blocker Syncope after first dose or dose increase, orthostatic hypotension, headache, dizziness, drowsiness, tachycardia, sodium and fluid retention.
Advanced age, first dose
Central a2
agonist
Sedation, dry mouth, sexual dysfunction, withdrawal rebound hypertension, impaired mental concentrationMethyldopa (hepatitis, Coombs-positive hemolytic anemia, colitis, drug-induced lupus erythematosus)
Depression, taper dosage when discontinue to avoid rebound.
Adrenergic Blockers
Manar & Samah 18
Class Drug Usual Dose Range (mg/d)
Daily Frequency
Angiotensin Converting Enzyme Inhibitor
CaptoprilEnalapril
25-1002.5-40
BIDOD/BID
Angiotensin II Antagonist
CandesartanIrbesartanLosartanValsartan
8-32150-30025-10080-320
ODODOD/BIDOD/BID
Calcium Channel Blocker
AmlodipineNifedipine LAVerapamil LADiltiazem LA
2.5-1030-60120-360120-540
ODODOD/BIDOD
Direct Vasodilator Hydralazine 25-100 BID
Adverse Effects Special Precautions
Hyperkalemia, cough, hypotension, angioedema, loss of taste, renal failure, neutropenia, cholestasis, rash, blood dyscrasias.
Renal failure, pregnancy, renal artery stenosis
Similar to ACEI but do not cause cough
Class Adverse Effects Special Precautions
Calcium Channel Blocker
Headache, flushing, hypotension, dizziness, palpitation, rashDihydropyridines (edema, tachycardia)Diltiazem (Lupus-like rash)Verapamil (Constipitation, bradycardia, AV block)
Congestive heart failure, heart block
Direct Vasodilator
Headache, dizzines, sodium and fluid retention, positive antinuclear antibody, lupus-like syndrome, hepatitis, nasal congestion, GI disturbance.
ACE-I, ARBs, CCB, and Direct Vasodilator
Manar & Samah 19
After age 50, high systolic blood pressure (> 140 mm Hg) is much more important than high diastolic pressure as a risk
factor for cardiovascular events
People who are normotensive at age 55 still have a 90% lifetime risk for developing hypertension.
People with a systolic blood pressure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg should be considered
prehypertensive and should undertake health promoting lifestyle modifications to prevent cardiovascular disease.
Thiazide-type diuretics should be used to treat most patients with uncomplicated hypertension, either alone or combined
with drugs from other classes, but certain high risk conditions constitute compelling indications for the initial use of other
types of antihypertensive drugs
Most patients with hypertension need two or more antihypertensive medications to achieve their goal pressure
(< 140/90 mm Hg or < 130/80 mm Hg for patients with diabetes or chronic kidney disease).
If blood pressure is more than 20/10 mm Hg above goal, one should consider starting therapy with two agents, one of which
usually should be a thiazide-type diuretic
Manar & Samah 20
Pheochrmocytoma
• Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells (medulla)
• Because of excessive catecholamine secretion, pheochromocytomas may precipitate life-threatening hypertension or cardiac arrhythmias
Manar & Samah 22
Symptoms and Signs
Symptoms• Headache • Diaphoresis • Palpitations • Tremor • Nausea • Weakness • Anxiety
Clinical signs• Hypertension (50% paroxysmal)
• Postural hypotension• Hypertensive
retinopathy • Pallor • Fever • Tachyarrhythmias • Pulmonary edema
Manar & Samah 24
Risk Factors
• Precipitants of a hypertensive crisis – Anesthesia induction – Opiates – Dopamine antagonists – Cold medications – Radiographic contrast media – Drugs that inhibit catecholamine reuptake, such
as tricyclic antidepressants and cocaine – Childbirth
Manar & Samah 28
Manar & Samah 29
Interventions:CAD CABG (2002, KFMH)PCI LCX (5/2006)PCI RCA (12/2006)
Labs: (7/2007)Ejection Fraction= 40-45%Negative Thallium
A 75-year-old female with a history of:
Past Medical History:HypertensionLeft Bundle Branch BlockDiabetes MellitusChronic renal impairment (Serum Cr = 127umol/L)Bronchial AsthmaOsteoporosis
Social History:Quit smoking 3 years ago
Manar & Samah 30
Past Medication History
• Aspirin 81 mg PO OD• Clopidogrel 75 mg PO OD• Carvedilol 12.5 mg PO BID• Atorvastatin 40 mg PO OD• Amlodipine 10 mg PO OD• Irbesartan 300 mg PO OD• Furosemide 60 mg PO BID• Isosorbide dinitrate retard 40 mg PO OD
Manar & Samah 31
On 10/12/2007
• Came to arrhythmia clinic complaining of recurrence syncope and blood pressure of 206/100 mm Hg
• Admitted to N2 (cardiology ward)
Manar & Samah 32
During whole admission period she was on
• Aspirin 81 mg PO OD• Gabapentin 400 mg PO BID• Clopidogrel 75 mg PO OD• Atorvastatin 40 mg PO OD• Insulin regular SC (Sliding Scale) Q6h <8.3 ------------- none 8.4-11.1 --------2 units 11.2-13.9-------4 units 14-16.7----------6 units 16.8-19.4-------8 units 19.5-22.2------10 units >22.3-----------notify MD and do STAT blood sugar, urine ketone
Manar & Samah 33
11\12 18\1217\1216\1215\1214\1213\1212\12
Hyp
ertensio
n A
sthm
aO
thers
11\12 18\1217\1216\1215\1214\1213\1212\12
11\12 18\1217\1216\1215\1214\1213\1212\12
Surgery for single chamber pacemaker
implantation
Recurrence Syncope
She started to have tremor
Manar & Samah 35
Hyp
ertensio
nC
OP
D/ A
sthma
Others
11\12 18\1217\1216\1215\1214\1213\1212\12
11\12 18\1217\1216\1215\1214\1213\1212\12
Irbesartan
300 mg PO OD
Isosorbide dinitrate retard
20 mg PO BID
Amlodipine
PO OD
carvedilol
12.5 mg PO BID
Furosemide
40 mg IV
40 mg PO OD
10 mg 5 mg
11\12 18\1217\1216\1215\1214\1213\1212\12
010
203040
5060
708090
100110120
130140150
160170
180190200
210220
11/12/2007
11/12/2007
11/12/2007
11/12/2007
12/12/2007
12/12/2007
13/12/2007
13/12/2007
13/12/2007
14/12/2007
14/12/2007
14/12/2007
15/12/2007
15/12/2007
15/12/2007
16/12/2007
16/12/2007
16/12/2007
17/12/2007
17/12/2007
17/12/2007
18/12/2007
18/12/2007
18/12/2007
11\12 18\1217\1216\1215\1214\1213\1212\12
SrCr160 umol/L
Manar & Samah 36
11\12 18\1217\1216\1215\1214\1213\1212\12
Hyp
ertensio
nA
sthm
aO
thers
11\12 18\1217\1216\1215\1214\1213\1212\12
11\12 18\1217\1216\1215\1214\1213\1212\12
Irbesartan
300 mg PO OD
Isosorbide dinitrate retard
20 mg PO BID
Amlodipine
PO OD
carvedilol
12.5 mg PO BID
Furosemide
40 mg IV
40 mg PO OD
10 mg 5 mg
Fluticasone/salmeterol
250/25 mcg/ puff BID
Budesonide nebulizer
500 mcg TID
Ipratropium nebulizer
500 mcg TID
Asthma
Attack
Manar & Samah 38
Irbesartan
300 mg PO OD
Isosorbide dinitrate retard
PO BID
Amlodipine
10 mg PO OD
Nifedipine LA
60 mg PO STAT
Captopril
6.25 mg PO TID
carvedilol
12.5 mg PO BID
Metoprolol
12.5 mg PO BID
Clonidine
100 mcg PO OD
Furosemide
IV BID
20 mg PO
40 mg PO
Hyp
ertensio
n19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
20 mg 40 mg
40 mg 60 mg 40 mg
0102030405060708090
100110120130140150160170180190200210220230240
19/12/2007
20/12/2007
21/12/2007
22/12/2007
23/12/2007
24/12/2007
25/12/2007
26/12/2007
27/12/2007
28/12/2007
29/12/2007
30/12/2007
31/12/2007
01/01/2008
01/02/2008
01/03/2008
01/04/2008
01/05/2008
01/12/2008
13/1/2008 Series1
Series2
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
SrCr107 umol/L
?
Manar & Samah 39
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
Methylprednisolone
60 mg IV OD
Prednisolone
PO OD
Magnesium Sulphate
2 g IV
Different inh/neb
60 mg 50 mg 15 mg30 mg 20 mg 10 mg 5 mg40 mg
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
Ca polystyrene Sulphonate
30 g PO OD
Heparin Sodium
5000 U S.C BID
Asth
ma
Oth
ersH
yperten
sion
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
K 5.3 mmol/L K 5.4 mmol/LK 5.5 mmol/L
CO
PD
Manar & Samah 40
Patient was distress, tachypnic, wheezing, complaining of shortness of breath, orthopnea, bilateral chest crepitation
Manar & Samah 41
Transferred to ICU
Manar & Samah 42
Hyp
ertensio
nC
OP
D/ A
sthm
aO
thers
5\1 10\19\18\17\16\1
5\1 10\19\18\17\16\1
5\1 10\19\18\17\16\1
Manar & Samah 43
Hyp
ertensio
n
Irbesartan
300 mg PO OD
Amlodipine
10 mg PO OD
Nitroglycerin
5 mg SL stat
200 mcg/ml INF
Clonidine
100 mcg PO OD
Enalapril
5 mg PO OD
Furosemide
IV BID
5\1 10\19\18\17\16\1
60 mg 40 mg 40 mg 40 mg80 mg80 mg
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
5\1 10\19\18\17\16\1
Manar & Samah 44
Oth
ers
5\1 10\19\18\17\16\1
5\1 10\19\18\17\16\1
Hydrocortisone
IV stat
IV TID
Different Neb/Inh
Aminophylline
IV 250 mg stat
80 mg 40 mg
20 mEq 40 mEq
Piperacillin/Tazobactam
2.25 mg IV Q6h
Potassium Chloride
IV over 2h
40 mEq PO
Heparin (PROTECT study)
5\1 10\19\18\17\16\1
Hyp
ertensio
nIrbesartan
300 mg PO OD
Amlodipine
10 mg PO OD
Nitroglycerin
5 mg SL stat
200 mcg/ml INF
Clonidine
100 mcg PO OD
Enalapril
5 mg PO OD
Furosemide
IV BID60 mg 40 mg 40 mg 40 mg80 mg80 mg
K 3.5 mmol/L K 2.9 mmol/L
Hospital Acquired Pneumonia
CO
PD
Manar & Samah 45
Returned to Cardiology Ward
Manar & Samah 46
11/1 12/1 14/1 15/1 16/1 17/1 18/1 19/1 20/1 21/1 22/113/1
Irbesartan
300 mg PO OD
Amlodipine
10 mg PO OD
Nifedipine LA
60 mg PO OD
Nitroglycerin
200 mcg/ml INF
Isosorbide dinitrate
40 mg PO BID
Spironolactone
25 mg PO OD
Hydralazine
25 mg PO BID
Enalapril
PO
Furosemide
40 mg IV BID
40 mg PO OD
10 mg BID10 mg QD
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
Series1
Series2
Hyp
ertensio
n
11/1 12/1 14/1 15/1 16/1 17/1 18/1 19/1 20/1 21/1 22/113/1
Manar & Samah 47
Hyp
ertensio
nC
OP
DO
thers
11/1 12/1 14/1 15/1 16/1 17/1 18/1 19/1 20/1 21/1 22/113/1
PrednisolonePO QD
Different Neb/Inh
20 mg 10mg 5 mg
Heparin Sodium 5000 U S.C BIDPotassium Chloride40 mEq IV40 mEa PO OD
K 2.8 mmol/L
K 3.2 mmol/L
11/1 12/1 14/1 15/1 16/1 17/1 18/1 19/1 20/1 21/1 22/113/1
10 mg BID10 mg QD
Irbesartan
300 mg PO OD
Isosorbide dinitrate
40 mg PO BID
Amlodipine
10 mg PO OD
Nifedipine LA
60 mg PO OD
Spironolactone
25 mg PO OD
Hydralazine
25 mg PO BID
Enalapril
PO
Nitroglycerin
200 mcg/ml INF
Furosemide
40 mg IV BID
40 mg PO OD
11/1 12/1 14/1 15/1 16/1 17/1 18/1 19/1 20/1 21/1 22/113/1
Hyp
ertensio
n
Manar & Samah 49
Hypertension/CV ProblemsCOPD
Daibetes/ComplicationsOsteoporosis
was on
• Insulin NPH SC 32 Units BID• Gabapentin 400 mg PO BID
Same Medicationswas on
Was not managed before
• Alfacalcidol 0.5 mcg PO OD• Calcium carbonate 500 mg
PO BID
Problems List/Medications
carvedilol 12.5 mg PO BIDSpironolactone 25 mg PO ODIrbesartan 300 mg PO ODFurosemide 40 mg PO BIDNifedipine LA 60 mg PO BIDEnalapril 10 mg PO BIDHydralazine 25 mg PO BIDIsosorbide dinitrate retard 20 mg PO BIDAspirin 81 mg PO ODClopidogrel 75 mg PO ODAtorvastatin 40 mg PO OD
carvedilol 12.5 mg PO BID
Irbesartan 300 mg PO ODFurosemide 60 mg PO BID
Isosorbide dinitrate retard 40 mg PO ODAspirin 81 mg PO ODClopidogrel 75 mg PO ODAtorvastatin 40 mg PO ODAmlodipine 10 mg PO OD
Was not managed before
• Prednisolone 5 mg PO OD (for 15 days)
• Fluticasone/ Salmetrol inhaler 2 puffs TID
• Albuterol 2 puffs inhaler PRN
DischargeMedications
Manar & Samah 50
Points of Discussion
Manar & Samah 60
I) Prednisolone Side Effect and Tapering
Manar & Samah 61
Corticosteroids Side Effects
Prolonged therapy can lead to suppression of pituitary-adrenal function
Too rapid withdrawal of long-term therapy can cause acute adrenal insufficiency (e.g. fever, myalgia, arthralgia and malaise)
• Adverse reactions:Dose and duration related side effects include fluid and electrolyte disturbance (e.g. hypokalemia with possible edema and hypertension), hyperglycemia, peptic ulcer disease, osteoporosis, euphoria, psychosis, myopathy, and infections
In our case the patient suffered from:
• Myopathy
• Uncontrolled hypertension
• Hypokalemia
• Hospital acquired pneumonia
• The patient is predisposed to osteoporosis
Manar & Samah 62
Corticosteroids Tapering Off
There are many regimens for tapering off corticosteroids.
Example of prednisone tapering schedule:Dosage (mg) Duration (wks)
20 2
17.5 3
15 4
15 alternating with 12.5
2-4
15 alternating with 10 2-4
15 alternating with 7.5 2-4
15 alternating with 5 2-4
15 alternating with 2.5 2-4
20 alternating with 0 4
17.5 alternating with 0 4
15 alternating with 0 4
However, corticosteroids can be rapidly tapered and
discontinued abruptly if used for less than 2 to 3 weeks
Manar & Samah 63
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
Methylprednisolone
60 mg IV OD
Prednisolone
PO OD
Magnesium Sulphate
2 g IV
Different inh/neb
60 mg 50 mg 15 mg30 mg 20 mg 10 mg 5 mg40 mg
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
Ca polystyrene Sulphonate
30 g PO OD
Heparin Sodium
5000 U S.C BID
Guaifenesin/ Dextromethorphan
10 ml PO BID
Asth
ma
Oth
ersH
yperten
sion
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
myopathy
CO
PD
This is not a prednisolone tapering off. The goal of decreasing the dose was to seek for the lowest effective and tolerated dose that can manage her COPD with minimum myopathy and fluid retention
Manar & Samah 64
• II) b-Blocker Withdrawal
Manar & Samah 65
b-Blocker Withdrawal
Withdrawing b-blockers may produce b-adrenergic supersensitivity. Both abrupt cessation and gradual withdrawal over 4 to 8 days have caused overshoot hypertension and cardiovascular complications within within 48 to 72 hours after the last b-blocker dose
To prevent b-adrenergic supersensitivity, the b-blocker dosage should be reduced over 7 to 10 days to the equivalent of 30 mg/day of propranolol and then maintained at this low dosage
for 2 additional weeks
b-blocker Withdrawal in patient who are free of CHD resulted in fourfold increase in onset of CHD
Manar & Samah 66
Irbesartan
300 mg PO OD
Isosorbide dinitrate retard
PO BID
Amlodipine
10 mg PO OD
Nifedipine LA
60 mg PO STAT
Captopril
6.25 mg PO TID
carvedilol
12.5 mg PO BID
Metoprolol
12.5 mg PO BID
Clonidine
100 mcg PO OD
Furosemide
IV BID
20 mg PO
40 mg PO
Hyp
ertensio
n19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
20 mg 40 mg
40 mg 60 mg 40 mg
0102030405060708090
100110120130140150160170180190200210220230240
19/12/2007
20/12/2007
21/12/2007
22/12/2007
23/12/2007
24/12/2007
25/12/2007
26/12/2007
27/12/2007
28/12/2007
29/12/2007
30/12/2007
31/12/2007
01/01/2008
01/02/2008
01/03/2008
01/04/2008
01/05/2008
01/12/2008
13/1/2008 Series1
Series2
19/12 20/12 31/1222/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/1221/12 1/1 4/12/1 3/1
Titration of the cavedilol 12.5 mg to metoprolol 12.5 mg Then D/C b-blocker after 8 days
Manar & Samah 67
Manar & Samah 68
References• Chobanian AV, Bakris GL, Black HR, et al and the National High Blood Pressure Education
Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA 2003; 289:2560–2572.
• Vidit D, Borazanian R. Treat high blood pressure sooner: Tougher, simpler JNC 7 guidelines. Cleveland Clinic Journal of Medicine 2003; 70(8):721-728
• Saudi Hypertension Management Society. Saudi hypertension guidelines. 2007; 1-46
• Helms R, Quan D, Herfindal E eds. Textbook of therapeutics. Drug and disease management. Eighth Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2006: 451-471
• Herfindal E and Gourley D. Textbook of therapeutics. Drug and disease management. Seventh Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2000: 795-823
• http://www.emedicine.com/MED/topic1106.htm
Recommended