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Case Report 1: Hypertension
Group : 7 :
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MUHAMMAD AZZIM BIN IZUDDIN MUHAMMAD HAMDI BIN ISMAIL MURSHIDA BT IBRAHIM MUSLIHAH BT RAFFLI NABILAH BINTI JAMALUDIN NG KAI YEONG NGU CHIEW PIN NIK NUR NASEELA FATHIN BINTI NIK MOHD SABRI NOOR AQIDAH BINTI ROSLI NOOR FARAHIN BINTI HANIZA (L)
15 July 2010
including presence of target organ damage.• To describe the definition and classification of hypertension based on current guidelines • To explain the general approach to the management of hypertension • To evaluate the factors that affect management of hypertension. other cardiovascular risk factors or concomitant disorders • To suggest appropriate pharmacological and non-pharmacological management for hypertension • To provide counselling information for pharmacological agents involved in the management of hypertension CASE 1 Mrs. 1. She has no other cardiovascular risk factors. The classification of blood pressure based on the Clinical Practice Guidelines Management of Hypertension 3rd edition. What is the classification of Mrs. She lives with her husband and has five grown children. Minoh blood pressure (138/88 mmHg) is classified as Prehypertension. She’s slightly overweight (height= 5’5’’ weight = 76kg) but does not drink alcohol or smokes cigarettes. Minoh’s blood pressure? Mrs. including presence of target organ damage. February 2008 is as follow: . Minoh is a 52 year-old housewife whose blood pressure (BP) has been found to be sustained around 138/88 mmHg. other cardiovascular risk factors or concomitant disorders • To evaluate the factors that affect management of hypertension.
February 2008: . which is taken from Clinical Practice Guidelines Management of Hypertension 3rd edition. presence of target organ damage and others is as follow.The risk stratification based on cardiovascular risks factors.
The classification of . Minoh is classified as having low risk of cardiovascular events. Mrs. Minoh is in prehypertension stage without any risk factors or target organ damage. heart v) Peripheral vasculature (peripheral arterial disease) Based on the above.The major cardiovascular risk factors include: i) ii) iii) iv) v) vi) vii) viii) ix) Physical inactivity Hypertension Cigarette smoking Central obesity Dyslipidemia Diabetes mellitus Kidney disease (microalbuminuria / estimated GFR less than 60ml/min) Age more than 55 years (men) / 65 years (women) Family history of premature cardiovascular disease (men < 55 years old/ women < 65 years old) The target organ damage may involved: i) ii) iii) iv) Kidney (chronic kidney disease) Brain (stroke or transient ischemic attack) Eyes (retinopathy) Heart failure) (left ventricular hypertrophy (LVH). according to JNC VII. Minoh? Since Mrs. the ideal management of her condition would be non-pharmacological approach through lifestyle modifications. 2. prior myocardial infarction. What would you suggest to manage Mrs. prior coronary revascularization. angina.
It would be good for her to achieve BP < 120/80mmHg (normal range). The non-pharmacological approach management of hypertension according to JNC VII are as follow: .hypertension and their management according to JNC VII is as follow: The suitable lifestyle modifications for Mrs. regular exercise and DASH eating plan. Minoh would be weight reduction. reduction of dietary sodium intake.
For Mrs.91 kg/m2 Ideal BMI = at max 25 Target weight = 25 X Height2 (m2) = 25 X 1.652 =27.652 = 68 kg or lower . the current BMI of Mrs. Minoh weight reduction plan. Minoh is calculated as follow: BMI = weight (kg) Height2 (m2) = 76/1.
Her weight now is 80kg. sedentary lifestyle. poor diet control and stress. Since she is in prehypertension stage. The other compensatory mechanism is secretion of renin may leads to release of aldosterone from the adrenal gland. She was started on two antihypertensive agents by her physician: T.CASE 2 After a few months. Minoh BP was found to be around 160/100 mmHg on several occasions. constant higher blood pressure may damage kidney and leads to secretion of renin due to low GFR. Increased blood volume results in increased preload. Angiotensin II have vasoconstriction activity on renal efferent tubule causing increased GFR. Renin secretion will activates angiotensin converting enzyme which in turn converts angiotensin I to angiotensin II. a lot of fatty and oily food in her diet. leading to increased blood volume. This can be seen from the increasing body weight from 76 kg to 80kg. Aldosterone will cause sodium and water retention. The failure of nonpharmacological management may include unsuccessful weight reduction. Mrs. angiotensin II also have vasoconstriction activity in other peripheral blood vessels resulting in increased total peripheral resistance and hence blood pressure. Minoh might have taken too much food rich in sodium. The other possible factor is due to compensatory mechanism leading to increased blood pressure. hence increases the stroke . Chlorothiazide 500mg qd T. Mrs. Metoprolol 100mg bd 1. What are the possible reasons for her elevated BP? The possible reasons for her elevated BP include non adherence to non-pharmacological management. However at the same time. Poor diet control and sedentary lifestyle may leads to increased body weight and eventually increase in BP.
BB.volume and increases cardiac output. BP = CO X TPR. Minoh’s current blood pressure is 160/100 mmHg. Minoh? The reason why 2 antihypertensive agents are used is because Mrs. CO = SV X HR 2. Since there is no compelling indication. the heart rate is lowered. as well as reduced contractility of the heart. the combination of beta blocker and thiazide diuretic also reduces the side effects of the drugs. Why did the prescriber choose the two antihypertensive agents for Mrs. At the same time. Pharmacologically. Due to increased cardiac output. thiazide diuretic chlorothiazide is used because it is the most effective diuretic to be used. which is metoprolol. thiazides is also clinically proven to be the most efficacious the elderly patient and also less expensive than other antihypertensive drugs. Besides. . Metoprolol is a cardioselective beta blocker. This will reduce the fluid volume hence reduce preload and subsequently cardiac output and blood pressure. cardiac output will decrease. which is stage 2 hypertension. which requires 2 agents according to the algorithm for managing the condition. which exerts its effect mainly in the heart on the beta 1 receptor. It is cheap and effective. leading to increased volume of water loss in urine. By antagonising action of catecholamine on the heart. A beta blocker is used here. The combination of beta blocker and thiazide diuretic here also can increase the BP lowering effects as they work synergistically. Here. thiazides act at the proximal renal tubule and block sodium reabsorption. and blood pressure can be lowered. Hence. ARB or CCB is used. blood pressure increases. usually a thiazide diuretic combined with one of either ACEI.
The compelling indications of each class of antihypertensives are as follow: The algorithm for the treatment of hypertension according to the Malaysian Clinical Practice Guideline is as follow: .
The algorithm for management of hypertension according to JNC VII is as follow: .
heart failure. Then it is important also to explain to her the importance of taking the medication despite not having any symptoms of hypertension. What counselling information would you provide to Mrs. Minoh regarding her antihypertensive agents. We need to tell patient that she may experience . retinopathy. This will increase her compliance to the drug regimen Besides. The counselling information needed for Mrs. Minoh includes the purpose of the drugs prescribed is to lower her blood pressure. renal failure and so one.3. we also need to explain the possible side effects of the drugs taken. We need to emphasis more on the implication of uncontrolled hypertension which can results in target organ damages such as stroke.
For chlorothiazide. 1. intracranial or subarachnoid hemorrhage. Other than that. nausea/vomiting. She previously complained of headache. Hypertensive emergencies Hypertensive urgencies Noncompliance and rebound hypertension following withdrawal of therapy should always be considered as an etiologic Similarity: Severely elevated blood pressure (diastolic >120mmHg) Differences: Potentially life threatening Not life threatening End-organ damage present or Minimal end-organ damage with high risk: no pending complications CNS (dizziness. dizziness (due to hypotension) and bradycardia. The attending physician found evidence of retinal changes (grade III) but no overt organ failure.frequent urination due to taking of chlorothiazide. it is best to be taken daily in the morning everyday. What are the recommended antihypertensive agents for Mrs. hypertension weakness. together with food since metoprolol absorption is increased by food. factor. Minoh? Acute hypertensive disorders are divided into two general categories: hypertensive emergencies and hypertensive urgencies. while metoprolol should be taken twice a day. Besides. we need to tell the patient to take the medications on time. confusion. Minoh was admitted to the hospital since her BP was found to be 220/126 mmHg. Signs and symptoms for these disorders are nonspecific and may overlap. CASE 3 Today Mrs. weakness and dizziness for the past week. Optic disc edema stroke) malignant . Accelerated encephalopathy. we also need to advice that metoprolol may cause weakness.
blurred Postor perioperative vision. Besides. angina. loss of sight) hypertension Heart (left ventricular failure. MI.Eyes (ocular hemorrhage or Coronary artery disease fundoscopic changes. cocaine or LSD Drug interaction-induced hypertension Clonidine withdrawal Eclampsia (complicated pregnancy) Requires reduction immediate pressure Treated over several hours to day Oral therapy or slower-acting parenteral drugs preferred Requires IV therapy From the table above. pulmonary edema. . she also has retinal changes.or postkidney transplant aortic dissection) Renal failure/insufficiency Phaeochromocytoma Drug-induced crisis: hypertensive MAOI-tyramine interactions Overdose with PCP. Pre. we can tell that Mrs Minoh is suffering from hypertensive emergency since she is having symptoms of weakness and dizziness.
000 mL of D5W to produce a solution for IV administration at a concentration of 200.5 mg/hr Q 5 min to desired BP (max.3 mcg/kg/min <5 min 30 min mg/mL 20 mg/2 mL 50 mg/5 mL Hydralazineg (generic) 20 10–20 mg IV 5–20 min 2–6 hr mg/mL Labetalolh (Normodyne) 20 2 mg/min IV or 20–80 mg Q 10 min 2–5 min 3–6 hr mg/4 mL 40 mg/8 mL 100 up to 300 mg total dose mg/20 mL 200 mg/20 mL Nicardipinei (Cardene IV) 25 IV loading dose 5 mg/hr increased 2–10 min 40–60 min mg/10 mL by 2.25 mg IV Q 6 hr 15 min 6–12 hr mg/mL 2. hr) infusion followed by maintenance infusion of 3 mg/hr Nitroglycerinj (Tridil. Nitro-Stat IV) 5 mg/mL 5 after D/C mg/10 mL25 mg/5 mL 50 infusion mg/10 mL 100 mg/20 mL Trimethaphan (Arfonad) 500 IV infusion pump 0.5–5 mg/min 1–5 min 10 min mg/10 mL after D/C infusion Phentolamine (Regitine) 1–5 mg IV initially.5 mg/2 mL (max.1–0.5 mcg/kg/min after D/C used) Usual: 2–5 mcg/kg/min infusion Max: 8 mcg/kg/min Diazoxide (Hyperstat IV) 300 50–150 mg IV Q 5 min or as infusion 1–5 min 4–12 hr mg/20 mL of 7.5–30 mg/mind Enalaprilate (Vasotec IV) 1. Nitro-Bid IV infusion pump 5–100 mcg/min 2–5 min 5–10 min IV. repeat as needed Immediate 10–15 min Nitroprusside is the drug of choice for acute hypertensive emergencies.25 0. 500. yielding a red-brown solution. or 1.500 mg/10 mL 50–300 mcg/kg/min concentrate Fenoldopam (Corlopam) 10 0. The contents of the vial are added to 250.625–1.The available agents to treat her condition include the following: Table 20-2 Parenteral Drugs Commonly Used in the Treatment of Hypertensive Emergencies Onset of Duration Drug (Brand Name) Dose/Route Action of Action Nitroprussidea (Nitropress) 50 IV infusiona Sec 3–5 min mg/2 mL (most commonly Start: 0. 8–12 after D/C or a max of 15 mg/hr Q 15 min. 100. 1–4 hr) Esmololf (Brevibloc) 100 250–500 mcg/kg over 1 minute then 1–2 min 10–20 min mg/10 mL 2. It is supplied as 50 mg of lyophilized powder that is reconstituted with 2–3 mL of 5% dextrose in water (D5W). or 50 .
. Thiocyanate levels rise gradually in proportion to the dose and duration of administration. and the drug should be discontinued if levels exceed 10–12 mg/dL. The appearance of a dark brown. When changing to a new b bag. Concurrent β-blockers may be protective. the administration rate may require adjustment. tinnitus. and the smell of almonds on the breath. Diazoxide is administered as a bolus dose (13 mg/kg Q 5 min to a max of 150 mg/injection) or as a slow infusion (15–20 mg/min) until a diastolic pressure of 100 mmHg is reached. or blue color indicates loss in activity. seizures. tachycardia. Food and Drug Administration for treatment of hypertension. It can be given IV or intramuscularly. Significant fluid retention following diazoxide can cause HF and pulmonary edema. The t1/2 of thiocyanate is 2. Concurrent loop diuretics are recommended (e. A change in color to yellow does not indicate effectiveness. Reflex in heart rate and stroke volume are potentially dangerous in patients with angina or MI. altered consciousness. hyperreflexia. hypoxemia. acute f g Approved for intraoperative and postoperative treatment of hypertension. Under these conditions. c Signs of cyanide toxicity include lactic acidosis. Toxicity occurs after 7– 14 days in patients with normal renal function and 3–6 days in renal failure patients.S. seizures. furosemide 40 mg IV) if diazoxide is given by rapid IV bolus. and coma. e Not approved by the U. The container should be wrapped with metal foil to prevent light-induced decompensation.7 days with normal renal function and 9 days in patients with renal failure. Parenteral hydralazine is an intermediate treatment between oral agents and more aggressive therapies such as nitroprusside or diazoxide. Concurrent administration of sodium thiosulfate or hydroxocobalamin may reduce d the risk of cyanide toxicity in high-risk patients. the solution is stable for 4 to 24 hr. Thiocyanate toxicity causes a neurotoxic syndrome of toxic psychosis. confusion. The drug is more effective if the head of the bed is slightly raised. but there is no appreciable difference in onset of action (20–40 min) between the two routes. Thiocyanate serum levels should be measured after 3–4 days of therapy.. A rising BP may indicate loss of potency. respectively. weakness. This slow onset minimizes hypotension. green.mcg/mL.g.
Also not j see Chapters 16 and 17 for further information regarding nitroglycerin. Dipiro et al. Applied Therapeutic: The Clinical Use of Drugs (9th edition). A solution for continuous infusion is prepared by adding two 100-mg ampules to 160 mL of IV fluid to give a final concentration of 1 mg/mL. Young. Lloyd Y. Ca. San Francisco. Na. Koda-Kimble. blood pressure. MI. Minoh? To improve long-term hypertension control in Mrs. Minoh to self-monitor her blood pressure and record the reading according. it is also important to ensure the compliance of Mrs. It is also encourage that Mrs. ACE. London 3. Applied Therapeutic Inc. HF. sodium. Joint National Committee on Prevention. IV. Joseph T. How would you improve long-term hypertension control in Mrs. Requires special delivery system due to drug binding to PVC tubing. intravenous. i Indicated for short-term treatment of hypertension when the oral route is feasible or desirable. A pathophysiologic Approach. Evaluation and Treatment of High Blood Pressure (JNC VII). every. Arch Intern Med 1997. 2. myocardial infarction. angiotensin-converting enzyme. discontinued. heart failure. Also. The target blood pressure for her is below 140/100 mmHg.2413-1446. Infusions start at 2 mg/min and are titrated until a satisfactory response or a cumulative dose of 300 mg is achieved. 2.157. Minoh. calcium. JAMA 2003. Pharmacotherapy. Elsevier. Detection.h Labetalol is contraindicated in acute decompensated HF due to its β- blocking properties. REFERENCE 1. Minoh towards her medication. Minoh continues her lifestyle modifications management of hypertension that is discussed earlier. (latest edition).289 . it important for us to encourage Mrs. D/C. Q. BP.
Malaysia . Clinical Practice Guidelines on the management of Hypertension 2002.4. Ministry of Health.
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