Causes of Resistant Hypertension

nImproper BP measurement

nExcess sodium intake

nInadequate diuretic therapy

nMedication

n– Inadequate doses

n– Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs

n(NSAIDs), illicit drugs, sympathomimetics, oral contraceptives), Over-the-counter (OTC) drugs and herbal supplements

nExcess alcohol intake

nIdentifiable causes of hypertension

Compelling indications for Individual Drug Classesv

nHeart failure THIAZ, BB, ACEI, ARB, ALDO ANT

nPost myocardial infarction BB, ACEI, ALDO ANT

nHigh CVD risk THIAZ, BB, ACEI, CCB

nDiabetes THIAZ, ACEI, ARB, BB, CCB

nChronic kidney disease ACEI, ARB

nRecurrent stroke prevention THIAZ, ACEI

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The key messages

nIn those older than age 50, systolic blood pressure (SBP) of >140 mmHg is a more important cardiovascular disease (CVD) risk factor than diastolic BP (DBP);

nBeginning at 115/75 mmHg, CVD risk doubles for each increment of 20/10 mmHg;

nThose who are normotensive at 55 years of age will have a 90 percent lifetime risk of developing hypertension;

nFor uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes;

nTwo or more antihypertensive medications will be required to achieve goal BP

nfor patients whose BP is >20 mmHg above the SBP goal or 10 mmHg above the DBP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered;

nRegardless of therapy or care, hypertension will only be controlled if patients are motivated to stay on their treatment plan

Treatment of chronic hypertension in pregnancy

nMethyldopa

nPreferred based on long-term follow up studies supporting safety

nBBs

nReports of intrauterine growth retardation (atenolol), Generally safe

nLabetalol

nIncreasingly preferred to methyldopa due to reduced side effects

nCalcium antagonists

nLimited data, No increase in major teratogenicity with exposure

nDiuretics

nNot first-line agents, Probably safe

nACEIs, angiotensin II receptor antagonists

nContraindicated

nReported fetal toxicity and death

Ischemic Heart Disease- Stable angina and silent ischemia

nUnless contraindicated, pharmacologic therapy should be initiated with a BB

nTreatment should also include

nsmoking cessation, management of diabetes,

nLipid lowering, antiplatelet agents, exercise training,

nand weight reduction in obese patients

nIf angina and BP are not controlled by BB therapy alone, or if BBs are contraindicated, either long-acting dihydropyridine or nondihydropyridine type CCBs may be used

nIf angina or BP is still not controlled on this two-drug regimen, nitrates can be added

nNondihydropyridine CCBs also can decrease heart rate; when in combination with a BB, they may cause severe bradycardia or high degrees of heart block. Therefore, long acting dihydropyridine CCBs are preferred for combination therapy with BBs

nShort-acting dihydropyridine CCBs should not be used because of their potential to increase mortality.

HEART FAILURE:http://heartfailureinhuman.blogspot.com/

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