HEAD OF THE CARDIOLGY UNIT MEDICAL RESEARCH INSTITUTE ALEX.
UNIVERSITY
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Easy to diagnose OFTEN remains undetected Simple to treat OFTEN
remains untreated Despite availability of potent drugs, treatment
is too OFTEN ineffective Hypertension even today is a triple
paradox which is:
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European Society of Hypertension European Society of Cardiology
JNC 7 Canadian Guidelines Egyptian Guidelines
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ComorbidityRelationship to Hypertension Coronary artery disease
50% of patients with coronary artery disease have hypertension Left
ventricular hypertrophy 15% to 20% of hypertensive adults have an
increased left ventricular mass Ischemic stroke 77% of patients who
have a first stroke have a blood pressure >140/90 mm Hg Chronic
kidney disease 8% to 15% of hypertensive adults have decreased
renal function Diabetes 75% of added cardiovascular risk in
diabetic patients is attributable to hypertension Peripheral artery
disease 74% of patients with peripheral artery disease have
hypertension Rosamond W, et al. Circulation. 2007;115:69-171 ;
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Hypertension is a major health problem in Egypt with a
prevalence rate of 26.3% among the adult population (> 25
years). Its prevalence increases with aging, pproximately 50% of
Egyptians above the age of 60 years suffer from hypertension..
Poor understanding of the magnitude of the risk. Poor
communication (doctor-patient) Patient forgetfulness. Lack of
motivation. Logistic barrier..Cost. Side effects. Complex regimen.
Poor follow up.
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Normal100 BP ClassificationSBP mmHgDBP mmHg
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BHS classification of blood pressure levels
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o Allow the patients to relax for several minutes o Take at
least two measurements spaced by 1-2 min and additional
measurements if the first two are quite different [use phase I and
V (disappearance) Korotkoff sounds to identify SBP and DBP] o Use a
standard bladder but have a larger for fat arms and a smaller one
for thin arms and children o Have the cuff at the heart level o
Measure BP in both arms at first visit to detect possible
differences due to peripheral vascular disease. In this instance,
take the higher value as the reference one o Measure BP 1 and 5 min
after assumption of the standing position in elderly subjects,
diabetic patients and in other conditions in which postural
hypotension may be frequent or suspected (e.g. heart, renal
failure, SNS dysfunction, use of vasodilative agents)
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Self-measurement of BP at home should be encouraged Response to
antihypertensive therapy Improving adherence with therapy
Evaluating white-coat HTN On the contrary, Self-measurement of BP
should be discouraged when: it causes anxiety to the patient it
induces self-modification of the treatment regimen
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ABPM is warranted for evaluation of white-coat HTN in the
absence of target organ injury. Ambulatory BP values are usually
lower than clinic readings. Awake, individuals with hypertension
have an average BP of >135/85 mmHg and during sleep >120/75
mmHg. BP drops by 10 to 20% during the night; if not, signals
possible increased risk for cardiovascular events.
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24-Hour Blood Pressure (n = 19)
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Signs suggesting secondary hypertension Features of Cushing
syndrome Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidneys) Auscultation of
abdominal murmurs (renovascular hypertension) Auscultation of
precordial or chest murmurs; Diminished and delayed femoral pulses
femoral BP (aortic coarctation or aortic disease)
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Routine Tests Electrocardiogram Urinalysis Blood glucose, and
hematocrit Serum potassium, creatinine, or the corresponding
estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast,
that includes high-density and low-density lipoprotein cholesterol,
and triglycerides Optional tests Measurement of urinary albumin
excretion or albumin/creatinine ratio More extensive testing for
identifiable causes is not generally indicated unless BP control is
not achieved
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Blood pressure target values for treatment of hypertension
Condition Target SBP and DBP mmHg Isolated systolic
hypertension
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To reduce the possibility of becoming hypertensive, Reduce
sodium intake to less than 2300 mg / day Healthy diet: high in
fresh fruits, vegetables, low fat dairy products, dietary and
soluble fiber, whole grains and protein from plant sources, low in
saturated fat, cholesterol and salt in accordance with Canada's
Guide to Healthy Eating. Regular physical activity: accumulation of
30-60 minutes of moderate intensity cardiorespiratory activity
(e.g. a brisk walk) 4-7/week in addition to routine activities of
daily living Maintenance of ideal body weight (BMI 18.5-24.9 kg/m 2
) Waist Circumference Men Women - Europid, Sub-Saharan African,
Middle Eastern
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 Thiazide
diuretic ACE-I Long-acting CCB Beta- blocker* TARGET 20 mmHg
systolic or > 10 mmHg diastolic above target
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Thiazide diuretics ACE inhibitors -blockers Angiotensin
receptor antagonists Calcium antagonists - blockers The preferred
combinations in the general hypertensive population are represented
as thick lines.
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New components and functions of the (RAS) system Since then, an
expanded view of RAS has gradually emerged. Local tissue RAS
systems have been identified in most organs. Evidence for an
intracellular RAS has been reported. The new expanded view of RAS
therefore covers both endocrine, paracrine and intracrine
functions.
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ISCHEMIC HEART DISEASE
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ANTI- Hypertensive V.D., Vascular Media (Hypertrophy)
sympathetic activity ANTI - Ischemic NO, oxidation of LDL-C ANTI -
Thrombotic TF., PAI, Platelet Aggregation ANTI Inflammatory IL6, Hs
CRP, ICAM, VCAM ANTI- Proliferative SMC Prol., MMP, Collagen,
Medial HTN ANTI - LVH Myocytic Hypertrophy Reno Protective
MicroAlbumninurea, Glomerular pressure Progress to ESRD Improved
Insulin Sensitivity LA Size, LVH, Collagen in LA New Onset Diabetes
Mellitus Recurrence of Atrial Fibrillation
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Improvement of insulin sensitivity Decreased hepatic insulin
clearance Antiinflammatory effect Improved blood flow to pancreas
Effect on abdominal fat Increase skeletal muscle blood flow
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BP lowering itself may cause reduction of perfusion of genital
organs. B blockers, diuretics, and centrally acting drugs have been
associated with ED. While ACEIs, ARBs, and CCBs have not been
observed to increase its incidence.
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If ED appears after institution of antihypertensive drug
therapy, the offending agent should be discontinued and treatment
restarted with another agent.
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SILDENAFIL OR other phosphodiesterase-5 inhibitors may be
prescribed without a significant likelihood of adverse reactions in
those with concomitant antihypertensive therapy so long as nitrates
are avoided. ERECTIL DYSFUNCTION
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ANTIHYPERTENSIVE DRUGS AND PREGNANCY Methyldopa. Preferred
based on long-term followup studies supporting safety BBs. Reports
of intrauterine growth retardation (atenolol) Generally safe
Labetalol. Increasingly preferred to methyldopa due to reduced side
effects
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No short-term adverse effects have been reported from exposure
to methyldopa or hydralazine. Propanolol and labetalol are
preferred if a BB is indicated. Diuretics may reduce milk volume
and thereby suppress lactation. ACEIs and ARBs should be
avoided,
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Calcium antagonists. Limited data. No increase in major
teratogenicity with exposure Diuretics. Not first-line agents.
Probably safe ACEIs, angiotensin II receptor antagonists
Contraindicated . Reported fetal toxicity and death
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Assess and manage hypertensive patients for smoking, unhealthy
eating, physical inactivity, abdominal obesity, dyslipidemia and
diabetes
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Vascular Protection for Hypertensive Patients: ASA Consider low
dose ASA Caution should be exercised if BP is not controlled.
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In addition to current Canadian recommendations on management
of dyslipidemia, statins are recommended in high-risk hypertensive
patients with established atherosclerotic disease or with at least
3 of the following criteria: Male Age 55 or older Smoking
Total-C/HDL-C ratio of 6 mmol/L or higher Family History of
Premature CV disease LVH ECG abnormalities Microalbuminuria or
Proteinuria ASCOT-LLA Lancet 2003;361:1149-58