DR. HUSSEIN SAAD (MRCP) ASSISTANT PROFESSOR CONSULTANT FAMILY MEDICINE COLLEGE OF MEDICINE KING SAUD UNIVERSITY MANAGEMENT OF HYPERTENSION

DR. HUSSEIN SAAD (MRCP) ASSISTANT PROFESSOR

CONSULTANT FAMILY MEDICINE

COLLEGE OF MEDICINE

KING SAUD UNIVERSITY

MANAGEMENT OF

HYPERTENSION

EPIDEMIOLOGY

■ In developed and developing countries alike, Essential Hypertension affects 25-35% of the adult population. Up to 60-70% of those beyond the seventh decade of life.

■ Each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors.

Prevalence of Hypertension in Obese and non-Obese Saudis

The study group: 14.805

males: 6225

females: 8580

The age: 14 – 70 years

Non-obese prevalence: 4.8 % males

2.8 % females

Obese prevalence: 8 % males

8 % femalesMohsen A El-Hazmi, Saudi Medical Journal 2001; vol 22 (1): 44-48

Hypertension among attendants of primary health care centers in Al-Qassim region

Saudi Arabia. Khalid A,et al Saudi Med J 2001; Vol. 22 (11) 960-963

The study sample: 1114

The prevalence: 30 %

Higher in: ● Age > 40 years

● Overweight and obese people

● illiteracy

Awareness: 20 % 0f hypertensive women

25 % of hypertensive men

EPIDEMIOLOGY

In the Framingham Heart Study:

◊ Those below Age of 55 diastolic Bp is the strongest predictor of cardiovascular risk

◊ Above 55 years, diastolic Bp was negatively related to the risk of coronary events, so the pulse pressure became superior predictor to the systolic Bp.

What happens to blood pressure with aging?

• Systolic pressure increases with age

• Diastolic pressure increases with age but peaks between 55 and 60 years then

starts to decrease.

• Arterial stiffness: cause of elevated systolic and lower diastolic pressure

with agingDiastoli

c

43

2

1

9

5

9

0

8

5

8

0

7

5

7

0

6

5

Dia

stoli

c p

ress

ure

(m

m

Hg

)

30

-3

43

5-

39

40

-4

44

5-

49

50

-5

45

5-

59

60

-6

46

5-

69

70

-7

47

5-

79

80

-8

4

Age (y)

30

-3

43

5-

39

40

-4

44

5-

49

50

-5

45

5-

59

60

-6

46

5-

69 70

-7

47

5-

79

80

-8

4

Age (y)

Systolic175

165

155

145

135

125

115

105

Sys

toli

c p

ress

ure

(m

m

Hg

)

BP values over lifetime period in population studies

• Entire cohort

study

•Study cohort with

deaths, myocardial

infarctions and congestive heart

failures excluded

Franklin SS, Fustin W 4th, Wong ND, et al. Circulation. 1997;96:308-315.

Pulse Pressure and Total Mortality

0

5

10

15

20

25

30

35

40

45

Mitchell, G.F. & Pfeffer, M.A., Curr Opin Cardiol 1999; 14: 361-9

pulse pressure (mm Hg)

even

t ra

te %

< 25 30 40 50 60 > 65

P<0.00001

Franklin, S.S. et al., Circulation 1999; 100: 354-60

diastolic blood pressure (mm Hg)

CH

D h

azar

d r

atio

60 80 100 11070 90

0,5

1.0

1.5

2.0

2.5

3.0

SBP 170 mm Hg (p=0.8129)SBP 150 mm Hg (p=0.0228)SBP 130 mm Hg (p=0.0559)SBP 110 mm Hg (p=0.0294)

Pulse Pressure and Coronary Risk

Are we achieving adequate control

Up to 65% of Americans with hypertension do not achieve adequate blood pressure control.

The World Health Organization now projects that by 2030, ischemic heart disease and stroke will become the second and third leading causes of death worldwide.

Trends in awareness, treatment, and control of high BP in adults ages 18 -74

Awareness

51

73

68

70

Treatment 31 55 54

59

Control 10 29 27 34

National Health and Nutrition Examination Survey, Percent

II(1976- 80)

III (Phase 11988- 91)

III (Phase 21991- 94) 1999- 00

DIAGNOSIS

Two or more elevated readings are obtained on at least two visits over a period of one to several weeks.

Blood Pressure Assessment:Patient preparation and posture

Standardized technique:

Posture

The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart.

His or her feet should touch the floor and legs should not be crossed.

Definitions and classification of blood pressure

2007 guidelines for the management of arterial hypertension

The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

SYSTOLIC DIASTOLIC

OPTIMAL <120 And <80

NORMAL 120–129 And/or 80–84

HIGH NORMAL 130–139 And/or 85–89

GRADE 1 HTN 140–159 And/or 90–99

GRADE 2 HTN 160–179 And/or 100–109

GRADE 3 HTN 180 And/or 110

Dr. HUSSEIN SAAD

Definitions and classification of blood pressure

2007 guidelines for the management of arterial hypertension

The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

ISOLATED SYSTOLIC HTN ≥140 AND <90

SYSTOLIC DIASTOLIC

GRADE 1 ISOLATED HTN 140–159 And <90

GRADE 2 ISOLATED HTN 160–179 And <90

GRADE 3 ISOLATED HTN 180 And <90

Dr. HUSSEIN SAAD

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

Diagnosis

When using the following to confirm diagnosis, ensure:

ABPM:at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosis

HBPM:two consecutive seated measurements, at least 1 minute apartblood pressure is recorded twice a day for at least 4 days and preferably for a weekmeasurements on the first day are discarded average value of all remaining is used.

Diagnosis

Home measurement of blood pressure

For the diagnosis of hypertension Suspected non adherence White coat hypertension Masked hypertension

Which patients?

Average BP equal to or over 135/85 mmHg should be considered elevated

Morning and Evening, for an initial 7-day period.

Suggested use of ABPM in the Management of Hypertension

Adapted from White W, NEJM 348:24, June 12, 2003ABPM: Ambulatory Blood Pressure Monitoring BP: Blood Pressure

Office BP > 140/90 mmHgin low risk patients (with no target-organ disease)

Perform ABPM

Mean awake BPLess than 135/85 mmHg

Follow-up with periodic home-BP measurement

Mean awake BP equals or over 135/85 mmHg

Life style ModificationInitiate antihypertensive therapy

ABPM

Measurement method

Threshold for Stage 1 hypertension

Threshold for Stage 2 hypertension

Clinic BP 140/90mmHg 160/100mmHg

Ambulatory BP 135/85mmHg 150/95mmHg

ABPM has to be considered:

Suspected white coat hypertensionSuspected episodic hypertensionHypertension resistant to increasing medication

Hypotensive symptoms while taking antihypertensive medications

Blood Pressure Measurement

Patients should be seated with back supported and arm bared and supported.

Measurements should begin after at least 5 minutes of rest.

Appropriate size of Cuff. Why?

Update in NICE 2011

Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmHg or

higher and ABPM or HBPM average is 135/85 mmHg or

higher.

Stage 2 hypertension: Clinic BP 160/100 mmHg is or higher and ABPM or HBPM daytime average is 150/95 mmHg

or higher.

Severe hypertension: Clinic BP is 180 mmHg or higher or Clinic diastolic BP is 110 mmHg or higher.

White-Coat Hypertension is it Innocent?

Raised clinic blood pressure in the presence of a normal daytime ambulatory blood pressure.

Results of Event-Based Studies have shown that the risk of cardiovascular disease is lower in patients with white-coat hypertension.

Check for any Metabolic risk factor, if present you have to start medication.

BENEFITS OF LOWERING BLOOD PRESSURE

The Clinical Trials had shown:

Reduction in • STROKE 35 – 40 %

• MI 20 – 25 %

• HEART FAILURE > 50%

Increase in wall to lumen ratio

Decreased lumen

Functional occlusion

Rarefaction

Levy BI. J Hypertens. 2006;24(suppl 5):6-9.

NormotensiveNormotensive

HYPERTENSIVEHYPERTENSIVE

Microvascular remodelling leads to capillary rarefaction

Endothelial dysfunction, Mechanical trauma,Release of growth factors,Proliferation of smooth muscle cells

Risk Factors

SmokingDyslipidaemiaDiabetes MellitusObesityAge older than 60 yearsSex (men or postmenopausal women)F.H. of cardiovascular disease

How to approach a patient with Hypertension?

Medical HistoryPhysical ExaminationRoutine Laboratory TestsOptional TestsNon-Pharmacological

TreatmentDrug Treatment

Patient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.

2. Reveal identifiable Causes of high BP.

3. Assess the presence or absence of Target Organ Damage and CVD.

MEDICAL HISTORY

Patient History of Cardiovascular Disease

Current and Previous MedicationsSmokingLifestyle FactorsFamily History

PHYSICAL EXAMINATION

Blood Pressure (Readings ?)Height, Weight and PulseExam. Of Neck, Heart, Lungs, Abdomen and Extremities

Funduscopic Examination (Arterial narrowing “copper wiring”,

A-V nipping, Flame shaped haemorrhages,

Soft exudates, Papilloedema)

ROUTINE LAPORATORY TESTS

CBCUrine Analysis and MicroalbuminuriaUrea , Creatinine, Electrolytes, Uric

Acid and CalciumFasting Plasma GlucoseLipid Profile (T.ch, Trig, LDL and HDL)

ECGChest X-ray ??

Who should be screened for causes of secondary hypertension?

Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Heart failure

Brain Stroke or transient ischemic attack

Chronic kidney diseasePeripheral arterial diseaseRetinopathy

High/Very high risk subjects

► BP 180 mmHg systolic and/or 110 mmHg diastolic

► Systolic BP > 160 mmHg with low diastolic BP (<70

mmHg)

► Diabetes mellitus

► Metabolic syndrome

► ≥ 3 cardiovascular risk factors

High/Very high risk subjects

One or more of the following subclinical organ damages:

► ECG with LVH and strain ► Echo. of concentric LVH ► U/S evidence of carotid artery wall

thickening or plaque ► Moderate increase in serum creatinine ► Reduced creatinine clearance ► Microalbuminuria or proteinuria ► Established cardiovascular or renal disease

OPTIONAL TESTS24-hour Urinary ProteinCreatinine ClearanceEchocardiographyUltrasonographyThyroid Stimulating Hormone24-hour Urinary Vanyl Mandelic Acid24-hour Urinary Catechleamines 24-hour Urinary Free Hydrocortisol

What is the goal of management of hypertension?

Treating (Non-Diabetic) SBP and DBP to targets

that are < 140 / 90 is associated with decrease in CVD Complications.

Hansson et al, Principal results of the Hypertension Optimal treatment,

HOT Study Group, Lancet 1998; 351: 1755 – 62.

The Target for Blood pressure Control < 140/80 mmHg for people with diabetes .

Limited data suggest possible worsening of both renal and CVD outcomes if systolic blood pressure is lowered to < 110 mmHg.

GUIDELINES: JNC 7 & ESH/ESC 2007,BHS 2004, Canada 2010 &NICE 2011

1. All support combination therapy +++

2. Support initiation of therapy with drug

combinations

3. Approve low-dose fixed combinations for

initiation of therapy

CLASSES OF ANTIHYPERTENSIVE DRUGS

■ BETA BLOCKERS • Atenolol • Bisoprolol • Carvedilol

■ ACE Inhibitors • Captopril • Lisinopril • Enalapril

Angiotensin-receptor blocker

ARB therapy may cut the risk of Alzheimer's disease (AD) by reducing amyloid deposition in the brain.

890 hypertensive patients with available brain autopsy data.

The risk for AD was 24% lower in those prescribed ACE inhibitor.

Ihab Hajjar, MD, and colleagues from University of Southern CaliforniaArchives of Neurology, September 13, 2012

CLASSES OF ANTIHYPERTENSIVE DRUGS

Angiotensin II Receptor Blockers

• Losartan • Candesartan

• Valsartan • Irbesartan

■ Calcium Channel Blockers ( Long Acting)

• Nifedipine Retard

• Amlodipine

• Felodipine

■ Diuretics ( Thiazides, Indapamide SR)

■ Vasodilators

Step 4

NICE 2011

Aged over 55 years or black person of any age

Aged under

55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

Updated Guideline issued by NICE 2011

In hypertensive patients aged 55 or older or black patients of any age:

The first choice for initial therapy should be either a calcium-channel blocker or a Thiazide-type diuretic. If a third drug is needed an ACE inhibitor or ARB is a choice.

NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk


In hypertensive patients younger than 55, the first choice for initial therapy should be:

An ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated).

Adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa are logical combinations).



Beta-blockers may be considered in younger

people, particularly:Those with an intolerance or contraindication to ACE

inhibitors and ARB orChild-bearing potential or People with evidence of increased sympathetic

drive.



If therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a Thiazide-type diuretic to reduce the patient’s risk of developing Diabetes.


Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence• Secondary HTN• Interfering drugs or

lifestyle• White coat effect

Dual Combination

Triple or Quadruple Therapy

Lifestyle modification

Thiazidediuretic

ACEI Long-actingCCB

Beta-blocker*

TARGET <140/90 mmHg

ARB

*Not indicated as first line therapy over 60 y

Initial therapy

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

CANADIAN 2010

Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-actingDHP CCB

Lifestyle modificationtherapy

ARB

TARGET <140 mmHg

CANADIAN 2010

Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy

1. ACE Inhibitor or ARB or

2. Thiazide diuretic or Dihydropyridine CCB

IF ACE Inhibitor and ARB and DHP-CCB and Thiazide are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB* or• Long-acting NON DHP-CCB

More than 3 drugs may be needed to reach target values for diabetic patients* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Combination of first line agents

Addition of one or more of:Cardioselective BB orLong-acting CCB

DiabeteswithoutNephropathy

DHP: dihydropyridine

Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the absence of proteinuria

CANADIAN 2010

Treatment of Hypertension in association with Diabetes Mellitus: Summary

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Diabetes

withNephropathy

> 2-drug combinations

ACE Inhibitoror ARB

withoutNephropathy

1. ACEInhibitor or ARB

or

2. Thiazide diuretic or DHP-CCB

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

CANADIAN 2010

A meta-analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new-onset diabetes mellitus.

S. Bangalore et. Al. American journal of cardiology, may 2007.

■ Β blockers are associated with an increased

risk for new-onset DM by 22%.

■ No benefit for the end point of death or mi.

■ Increased risk for stroke by 15%.

■ This risk was greater in patients with higher

baseline BMI and higher baseline FPG. DR. HUSSEIN SAAD

Relative risks of drugs (Base Case Studies)Outcome Thiazides

DC C blockers

CB. Blockers

BACEi / ARB

A

Unstable Angina

0.893 0.881 0.984 0.970

MI 0.780 0.796 0.855 0.816

Diabetes* 0.985 0.808 1.137 0.720

Stroke* 0.690 0.656 0.851 0.731

Heart Failure 0.530 0.731 0.761 0.642

Death 0.910 0.883 0.939 0.902

NICE GUIDELINES 2006 Dr. HUSSEIN SAAD

Evidence of use of B BlockersConditions Weak to

NoneSome

EvidenceStrong

Evidence

Hypertension (uncomplicated)

√

Heart Failure √Acute Coronary Syndrome

√

Post MI √Stable Angina without MI

√

Perioperative (non cardiac)

√

HOCM √

Source: Cardiosource , 2008 American College of Cardiology

There is a paucity of data or an absence of evidence to support the use of beta-blockers as Monotherapy or as First-line agents in uncomplicated HTN.

► Given the risk of stroke.

► Lack of cardiovascular morbidity and mortality

benefit.

► Numerous adverse effects.

► Lack of regression of target end-organ effects of

hypertension (e.g., left ventricular hypertrophy and

endothelial dysfunction).

DIURETICS■ Meta-analysis of all RCTs support diuretics as first

line agent.

■ 62 clinical trials including 192, 478 patients clearly supports using Diuretics as first line treatment for HTN including those with Diabetes, co-existing risk factors for CVD and asymptomatic LVH.

■ Dose of Diuretic cannot be higher than an equivalent dose of 25 mg HCZ.

Jama 2003; 289:2534-44

ANTIPLATELET AGENTS for HYPERTENSION

Primary Prevention: For patients with elevated blood pressure and no

cardiovascular disease, ASA cannot be recommended since the magnitude of benefit is negated by a harm of similar magnitude.

(ARI 0.6 %, NNH 167 for 3.8 years)

Database of Systematic Reviews, Cochrane Library, Issue 2, 2005.Chichester, UK.

INITIAL DRUG CHOICES

■ Isolated Systolic Hypertension: ● Thiazides

● Calcium Channel Blockers ( Long Acting )

■ Peripheral Arterial Disease ● Calcium Channel Blockers ( Long Acting )

INITIAL DRUG CHOICES

■ Heart Failure: • ACE Inhibitors

• Angiotensin II Receptor Blockers

• Diuretics

• B-Blockers

■ IHD and MI: • B-Blockers

• ACE Inhibitors / Angiotensin II Receptor Blockers

• Calcium Antagonists ( Diltiazem )

B.P. and DIABETES MELLITUS

Diabetic patients with Bp > 140/80 are candidate for antihypertensive treatment.

Patients should be checked to confirm the presence of hypertension.

Proceed to:

● Behavioral Approach / Lifestyle Modific.

● Drug Treatment

B.P. and DIABETES MELLITUS

Drug Treatment ● ACE Inhibitors

● Angiotensin II Receptor blockers

■ In Microalbuminuria and Nephropathy

lower Bp to ≤ 140/80

The goal of Bp for those having IHD or at high risk to develop IHD is

<130 / 80

UKPDS=United Kingdom Prospective Diabetes Study; MDRD=Modification of Diet in Renal Disease; UKPDS=United Kingdom Prospective Diabetes Study; MDRD=Modification of Diet in Renal Disease; HOT=Hypertension Optimal Treatment; AASK=African American Study of Kidney Disease; HOT=Hypertension Optimal Treatment; AASK=African American Study of Kidney Disease; RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan Diabetic Nephropathy Trial; MAP=mean arterial pressure.Diabetic Nephropathy Trial; MAP=mean arterial pressure.

Bakris et al. Bakris et al. Am J Kidney DisAm J Kidney Dis. 2000;36:646-661; Brenner et al. . 2000;36:646-661; Brenner et al. N Engl J MedN Engl J Med. . 2001;345:861-869; Lewis et al. 2001;345:861-869; Lewis et al. N Engl J MedN Engl J Med. 2001;345:851-860.. 2001;345:851-860.

Hypertension in High Risk Patients: Number

of Agents Required to Achieve BP Goal

Number of BP Medications

UKPDS (<85 mm Hg,

diastolic)

4321

MDRD (92 mm Hg, MAP)

HOT (<80 mm Hg, diastolic)

AASK (<92 mm Hg, MAP)

RENAAL (<140/90 mm Hg)

IDNT (135/85 mm Hg)

Lifestyle modifications to prevent and manage hypertension

Approximate

SBP Reduction

Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2).

5–20 mmHg/10kg

Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat.

8–14 mmHg

Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride).

2–8 mmHg

Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).

4–9 mmHg

DASH, Dietary Approaches to Stop Hypertension; SBP, systolic blood pressureFor overall cardiovascular risk reduction, stop smoking.

WCHWhite coat hypertension is defined when a

patient has a persistently elevated clinic BP ≥ 140/90 and a normal HBPM or ABPM day time average, i.e. <135/85 White coat hypertension is present in as

many as 25% of patients, possibly leading to: Incorrect diagnosis of hypertension. Diagnosis of uncontrolled hypertension (receive

inappropriate dose titrations or additional antihypertensive agents)

Resistant hypertension, with a reported prevalence of 37 to 44 % in some studies.

Case 1

A 49 year old lady, a known case of OA of knees, incidentally discovered to have high Bp in two visits, 156 / 106 and 164 / 100 respectively.

What is the target of Bp for this lady?What additional history you need from this lady?What investigations are you going to request?Mention one medication are you going to start with?

Case 2

Abdullah a 53-year old man presents to your clinic to be control his blood pressure. He is regular on Atenolol 50 mg OD for the last 3 years.

PMH is unremarkable.

FH: his father is hypertensive.

Bp:162/98 P. 62/m BMI 31

O/E: nothing is significant apart from A-V nipping on retinal examination.

What is your comment on his medication based on guidelines? What action plan are you going to take? Non-pharmacological management is an important aspect,

Explain.

Case 3

Saleh a 64-year old man who is a known case of hypertension, came for follow up. He is regular on Hydrochlorthiazide 25mg daily. BP is 176 / 82.

On reviewing his file the BP is ranging from

162 / 76 to 180 / 88U and E: within normalFBS: 6.4 mmol/L 2hpp: 9.56 mmol/LECG: LVH What is/are the diagnosis of Saleh?Based on evidence, which medication of choice are you

going to choose?

Case 4 Mofleh a 55 year old man, who is a known case of

diabetes on insulin. He came for routine follow up. BP: 154 / 106 P. 92 / min. BMI 33 O/E:* reduced sensation to pin pricks in lower Limb up to the middle of his legs. * Funduscopy: background retinopathy24hr urine for protein : o.438 gmurea : 8.7 mmol/L ( 2.5 – 6.4 )creatinine: 144 mmol/L ( 62 – 115 )sodium : 138 mmol/L ( 135 – 145 )potassium : 4.7 mmol/L ( 3.5 – 5.1 )ECG : LVH and inverted T waves in V4,5 and 6 What problems mofleh has?What is your target(s) for this case?What medication are you going to give?

Documents

DR. HUSSEIN SAAD (MRCP) ASSISTANT PROFESSOR CONSULTANT FAMILY MEDICINE COLLEGE OF MEDICINE KING SAUD UNIVERSITY MANAGEMENT OF HYPERTENSION