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Lesson Plan

• • • • • • • • • • Introduction Initiation of drug therapy Goal of drug therapy Choice of drug Mono/combination therapy Causes of refractoriness to drug therapy Pregnancy Emergency Ethnicity & drug response Non drug therapy: renal denervation

Initiation of treatment
140/90, grade 1 & 2, risk factors, life style measures

Risk= stroke, myocardial infarction Stop smoking, reduce weight, salt, exercise, alcohol, reduce cholesterol, stress, control TOD: TARGET Organ Damage diabetes, antiplatelet ACC: Associated Clinical Conditions: cardiovascular/renal disease

Goal of therapy
• To reduce cardiovascular morbidity/mortality • tight blood pressure control [144/82] substantial reduction in the risk of major cardiovascular events compared to less tight blood pressure control [154/87 ] achieve optimal or normal blood pressures in young, middle aged or diabetic subjects[below 130/85 ] and at least high normal blood pressures in elderly patients [below 160/100 mmHg]=>60 Y

Choice of drug…ABCD

2 .choice….

or 12-22 mmHg systolic and 7-14 mmHg diastolic for patients with blood pressure of 160/95 mmHg . of the order of 8-15%.Monotherapy • 7-13 mmHg systolic and 4-8 mmHg diastolic 8/4. 12/6 • Drug combination therapy • twice as great as those obtained with a single drug.

• calcium antagonist and ACE inhibitor. . • calcium antagonist (DHP) and beta-blocker.Effective drug combinations • diuretic and beta-blocker. • diuretic and ACE inhibitor (or A-II antagonists). • alpha-blocker and beta-blocker.

weight gain .heavy alcohol intake (binge drinking) • Volume overload due to .progressive renal insufficiency .high sodium intake • Causes of Apparently Refractory Hypertension Isolated office ("white coat") hypertension • Failure to use large cuff on large arm FOLLOW UP .Refractory Hypertension • • • • Unsuspected secondary cause (renal and endocrine) Poor adherence intake of drugs that raise blood pressure (NSAIDS) Failure to modify lifestyle including .inadequate diuretic therapy .

hydralazine. oligohydramnios. Pre-eclampsia. Magnesium sulphate chronic : beta-blockers. 170/110 ? acutely : Labetalol. atenolol (fetal growth retardation when used throughout pregnancy) prazosin. neonatal renal failure. nifedipine. methyldopa Antihypertensive agents avoided : ACE inhibitors: fetal growth retardation. nifedipine. isradipine. hydralazine. oxprenolol.Special Groups PREGNANCY: Essential. and possibly abnormal fetal morphology ("fetal hypotensive syndrome") A II receptor antagonists Diuretics reduce the already compromised plasma volume . labetolol. pindolol.

Phentolamine .Clevidipine IV lipid(clinidipine…oral…L&N CCB) .Labetalol .Nitroglycerin .Hypertensive urgency & emergency Intravenous .Enalaprilat .Sodium nitroprusside .nesiritide .Fenoldopam .Esmolol .nicardipine .

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Respond less to angiotensin inhibitors .ethnicity • African americans .Respond less to beta blockers .

surgery • In patients in whom nothing works .Renal denervation .

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continued .