Mastering Hypertension Treatment

ACE inhibitors and ARBs

All of the above

All of the above

i. ACE inhibitors and Angiotensin II receptor blockers (ARBs) ii. Diuretics iii. Calcium channel blockers iv. b1-Adrenoceptor antagonists

Clinic BP and ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) average daytime

Dizziness, headache

Flushes, headaches, ankle edema

Persistent dry cough, dizziness, tiredness, headaches

Dizziness, tiredness, headaches

Dizziness, tiredness, headaches

Gout, renal impairment, hyperkalemia, impotence

Back/leg pain, hyperkalemia, renal impairment, teratogenic, risk of angioedema (Afro-Caribbean), hyponatremia, risk of hyperkalemia

Gout, renal impairment, hyperkalemia, impotence

Carotid Sinus: Baroreceptor - reacts to change in arterial blood pressure Carotid Body: Chemoreceptor - monitors the partial pressure of CO2

Carotid Sinus: Afferent - glossopharyngeal nerve Carotid Body: Afferent - glossopharyngeal nerve

Internal Carotid Artery

Intracranial structures, superficial parts of face and neck

The potential spaces between the fascias are the carotid sheath, pretracheal space, alar fascia, and prevertebral space.

The retropharyngeal space is a major pathway for the spread of infection to the mediastinum. Retropharyngeal abscesses can occur as a result of infections in the nasopharynx, paranasal sinuses, or middle ear. Dental abscesses can also spread into the mediastinum through the retropharyngeal space.

The borders of the posterior triangle of the neck are the anterior border of the trapezius muscle, the posterior border of the sternocleidomastoid muscle, and the middle third of the clavicle.

The neck is composed of vertical columns surrounded by fascial sheets. These columns contain various structures such as muscles, blood vessels, nerves, and lymph nodes. The fascial sheets create potential spaces between the columns, allowing for movement and accommodation of these structures.

The neck can be divided into two triangles: the anterior triangle and the posterior triangle. The anterior triangle is bounded by the midline of the neck, the lower border of the mandible, and the anterior border of the sternocleidomastoid muscle. The posterior triangle is bounded by the posterior border of the sternocleidomastoid muscle, the anterior border of the trapezius muscle, and the middle third of the clavicle.

The common carotid artery is a major blood vessel located in the neck. It arises from the brachiocephalic trunk on the right side and the aortic arch on the left side. It travels vertically in the neck, giving off branches along its course. The internal carotid artery is a branch of the common carotid artery and supplies blood to the brain. The internal jugular vein is a major vein located in the neck. It runs alongside the common carotid artery and drains blood from the head, face, and neck.

Diabetes mellitus, Hypertension, Chronic obstructive pulmonary disease, Amyloidosis, Rheumatoid arthritis, Vasculitides & SLE, Thyroid disease, Sarcoidosis, Nutrition, Drugs

Cardiovascular complications

Hyperglycemia, Hypertriglyceridemia, Hypercholesterolemia, Hypoalphalipoproteinemia, Increased levels of advanced glycation end products, Glycated and oxidized lipoproteins

Hypertension can cause cardiovascular damage

Elevated oxidative stress

Diabetes, familial disease, and hypertension cause vascular damage.

People with Rheumatoid Arthritis have a 50% to 70% higher risk for cardiovascular disease than the general population.

People with Osteoarthrosis face a 24% higher risk for cardiovascular disease than the general population.

Exposure to under-nutrition during postnatal periods of development, including adolescence, may affect cardiovascular health in adult life.

The cardiovascular safety of non-steroidal anti-inflammatory drugs was studied in a network meta-analysis.

The four classes of drugs used in the treatment of hypertension are ACE inhibitors, beta blockers, calcium antagonists, and diuretics.

The recommended treatment sequence for hypertension in patients ≤ 55 years old is to start with an ACE inhibitor (A), then add a calcium antagonist (C) if necessary, followed by a diuretic (D) if necessary, and finally consider adding a beta blocker (B) or an alpha-blocker if necessary.

The recommended treatment sequence for hypertension in patients > 55 years old is to start with a calcium antagonist (C), then add an ACE inhibitor (A) if necessary, followed by a diuretic (D) if necessary, and finally consider adding a beta blocker (B) or an alpha-blocker if necessary.

The four pillars of drug treatment for chronic heart failure are ACE inhibitors or ARBs, beta blockers, aldosterone receptor blockers (e.g., spironolactone or eplerenone), and SGLT2 inhibitors.

The common drug classes used in the treatment of hypertension, heart failure, angina, myocardial infarction, atrial fibrillation, and strokes include ACE inhibitors, beta blockers, calcium antagonists, diuretics, and anti-thrombotic drugs.

1. Cardiac Resynchronisation Therapy (Biventricular Pacing) for long QRS patients. 2. Implantable Cardiac Defibrillators for highly selected patients. 3. Sacubitril-Valsartan to replace ACEI/ARB in severe heart failure.

To relieve symptoms: 1. Beta Blocker 2. Calcium Antagonist or Nitrates 3. New antianginals (Ivabradine, Ranolazine) 4. Coronary artery surgery 5. Coronary Angioplasty. To prolong survival: 1. Aspirin or Anti-platelet 2. Statin 3. ACE Inhibitor 4. Beta Blocker

For Cardiac Troponin Positive (MI): Emergency treatment, including Aspirin, Angioplasty (if near hospital), Thrombolysis (if far away), Low MW Heparin or Fondaparinux, Statin, ACE Inhibitor, Beta Blocker. For Non Cardiac Troponin Negative (Unstable Angina/ACS): Aspirin or Anti-platelet, Statin, ACE Inhibitor, Beta Blocker.

1. Prevent emboli: Warfarin/Rivaroxaban/NOACs. 2. Control Rate: Beta Blocker, Digoxin. 3. Control Rhythm (seldom done): DC Cardioversion acutely, Amiodarone if heart failure, Sotalol (II/III) possible, Flecainide (Ic) only if heart structure/function normal, Radioablation.

For Cerebral Thrombosis or Cerebral Embolus: Thrombolysis, Thrombectomy, Aspirin (acutely & for 2 weeks), Anti-platelet, Statin, ACE Inhibitor. For Cerebral Haemorrhage: CT scan to differentiate haemorrhage from clot, emergency management, Aspirin (acutely & for 2 weeks), Anti-platelet, Statin, ACE Inhibitor.

Left Jugular Lymph Trunk

Left Subclavian Lymph Trunk

Left Bronchiomediastinal Trunk

Right Jugular Lymph Trunk

Right Subclavian Lymph Trunk

Right Bronchiomediastinal Trunk

Thoracic Duct

Cisterna chyli

Between the aorta and azygos vein in the posterior mediastinum

Pulsation of the Aorta