Hypertension PPT PDF

HYPERTENSION PRESENTATION ON: 14-08-24  TABLE OF CONTENTS ▪ Introduction and Epidemiology ▪ Symptoms, Types, Triggers ▪ Risk factors, Complications, Etiology ▪ Pathophysiology, Diagnosis, Management & Treatment ▪ Case study ▪ Monitoring parameters ▪ References ...

HYPERTENSION PRESENTATION ON: 14-08-24  TABLE OF CONTENTS ▪ Introduction and Epidemiology ▪ Symptoms, Types, Triggers ▪ Risk factors, Complications, Etiology ▪ Pathophysiology, Diagnosis, Management & Treatment ▪ Case study ▪ Monitoring parameters ▪ References  INTRODUCTION High blood pressure is a common condition affecting the arteries of the body. It is also known as hypertension. High blood pressure occurs when the force of blood pushing against the artery walls is consistently excessive. Pumping blood requires more effort from the heart. Blood pressure readings consist of two numbers: Systolic (pressure during heartbeats) and Diastolic (pressure between beats).  Systolic Blood Pressure (SBP) & Diastolic Blood Pressure (DBP) ▪ Systolic Blood Pressure (SBP) Definition: Systolic pressure is the pressure in the arteries when the heart contracts (beats) and pumps blood into the arteries. It is the higher of the two numbers in a blood pressure reading. When It Occurs: During the contraction phase of the heart, known as systole. What It Indicates: Systolic blood pressure reflects how much pressure your blood is exerting against your artery walls when the heart beats. Higher systolic readings may indicate hypertension or an increased risk of cardiovascular events. ▪ Diastolic Blood Pressure (DBP) Definition: Diastolic pressure is the pressure in the arteries when the heart rests between beats. It is the lower of the two numbers in a blood pressure reading. When It Occurs: During the relaxation phase of the heart, known as diastole. What It Indicates: Diastolic blood pressure reflects how much pressure your blood is exerting against your artery walls while the heart is resting between beats. Elevated diastolic pressure may also indicate hypertension and potential cardiovascular risks.  EPIDEMIOLOGY GLOBAL DATA: ENL affects individuals with BL leprosy and lepromatous leprosy (LL). It may also occur in a small percentage of individuals with borderline (BB) leprosy. Approximately 10% of people with BL leprosy and up to 50% of those with LL will develop ENL. A systematic review of the epidemiological data on ENL reveals incidence rates ranging from 1 to 8 per 100 person years at risk. INDIAN DATA: Indian population has 7.6 person year at risk (PYAR). CLASSIFICATION OF HYPERTENSION Millimeters of mercury (mmHg) is the unit used to measure it. Image ©Byju’s  TYPES OF HYPERTENSION ▪ Primary (Essential) Hypertension: This is the most common type of hypertension, accounting for about 90-95% of cases. It develops gradually over many years and does not have a specific, identifiable cause. ▪ Secondary Hypertension: This type occurs as a result of another underlying condition. It usually appears suddenly and causes higher blood pressure than primary hypertension. ▪ Further classified into: ▪ Resistant hypertension: This type of hypertension remains high despite the use of three or more antihypertensive medications from different classes, including a diuretic. ▪ Malignant hypertension: Also known as hypertensive crisis, this is a severe and rapid rise in blood pressure. ▪ White-coat hypertension: This occurs when a patient's blood pressure is elevated in a clinical setting but normal at home or in other non-clinical settings. ▪ Masked hypertension: The opposite of white coat hypertension, this condition occurs when a patient's blood pressure is normal in the clinic but elevated at home or during daily activities. RISK FACTORS  COMPLICATIONS Cardiovascular disorders Nervous system disorders Renal diseases Ocular changes Peripheral vascular diseases  ETIOLOGY OF SECONDARY HYPERTENSION Kidney Disorders: Chronic Kidney Disease (CKD): Impaired kidney function leads to fluid retention and increased blood pressure. Renovascular Hypertension: Narrowing of renal arteries reduces blood flow, triggering hypertension. Endocrine Disorders: Primary Aldosteronism: Excess aldosterone causes sodium retention, increasing blood pressure. Cushing’s Syndrome: Overproduction of cortisol elevates blood pressure through sodium retention. Pheochromocytoma: Adrenal gland tumors release excessive catecholamines, causing episodic hypertension. Vascular Causes: Coarctation of the Aorta: Congenital narrowing of the aorta increases pressure in upper extremities. Vasculitis: Inflammation of blood vessels leads to narrowing, raising blood pressure. Obstructive Sleep Apnea (OSA): Intermittent hypoxia during sleep activates sympathetic nervous system, increasing blood pressure. Medications and Substances: Oral Contraceptives, NSAIDs, Steroids, Decongestants: Can cause fluid retention or vasoconstriction, leading to hypertension. PATHOPHYSIOLOGY  DIAGNOSIS ▪ Measurement of BP by sphygmomanometer. ▪ Basic laboratory studies are performed to:- * identify and rule out cases of secondary hypertension. * evaluate TOD * determine risks for other cardiovascular diseases. ▪ Measurement of serum electrolytes especially potassium levels. ▪ Blood glucose levels in diagnosis of diabetes mellitus. ▪ Lipid profile provides information about addition risk factors. ▪ ECG and echocardiography provide information about the cardiac status.  MEASUREMENT OF BLOOD PRESSURE Failure to consider these factors, including body position, cuff size, device selection, and dietary intake prior to the visit, may lead to misclassification. Clinicians should instruct patients to avoid exercise, alcohol, caffeine, or nicotine 30 minutes before BP measurement. Steps to be followed: ✓ Patients should be sitting comfortably with their back supported ✓ Arm free of constrictive clothing. ✓ Legs uncrossed and feet flat on the floor for a minimum of 5 minutes. ✓ The arm should be supported and positioned at heart level. ✓ To reduce deviations in BP measurement in the clinic, the patient and clinician should not talk during measurement. ✓ A minimum of two readings at least 1 minute apart are then averaged. If measurements vary by more than 5 mm Hg between the two readings, then one or two additional BP measurements are collected and the multiple readings averaged.  MANAGEMENT OF HYPERTENSION Lifestyle Modifications Dietary Changes: Low sodium, high potassium (DASH diet). Physical Activity: 150 minutes of moderate exercise per week. Weight Loss: Achieve and maintain a healthy weight. Alcohol Limitation: Moderate or avoid alcohol. Smoking Cessation: Quit smoking and avoid tobacco. Pharmacological Therapy First-Line Agents: ACE Inhibitors: e.g., Lisinopril ARBs (Angiotensin Receptor Blockers): e.g., Losartan Calcium Channel Blockers: e.g., Amlodipine Thiazide Diuretics: e.g., Hydrochlorothiazide Combination Therapy: If single-agent treatment is insufficient. Monitoring and Follow-Up Regular Blood Pressure Checks: Track effectiveness and adjust as needed. Adherence Support: Ensure patient compliance with therapy. Adjustments: Modify treatment based on response and side effects.  MANAGEMENT OF HYPERTENSION Management of Secondary Causes Identify and Treat Underlying Conditions: Such as thyroid disorders, renal disease, or hormonal imbalances. Special Considerations Comorbid Conditions: Tailor management for patients with diabetes, kidney disease, or cardiovascular issues. Elderly Patients: Consider age-related factors and adjust treatment accordingly.  PHARMACOLOGICAL THERAPY ❖ A- ACE Inhibitors/Angiotensin receptor blockers/Alpha blockers ❖ B- Beta Blockers ❖ C- Calcium channel blockers/Central α2 agonist. ❖ D- Diuretics/Direct renin inhibitors ❖ Vasodilators  PHARMACOLOGICAL THERAPY ACE Inhibitors Mechanism of action: ACE inhibitors prevent an enzyme in the body from making angiotensin-II, a substance that narrows blood vessels. This narrowing can cause high blood pressure and forces the heart to work harder. Angiotensin-II also releases hormones that raise blood pressure. ADR: Cough, Hyperkalemia, Renal insufficiency, Angioedema. Drug/Dose: Enalapril: 5 to 10 mg once daily, Maximum dose: 40 mg/day. Captopril: 6.25 to 25 mg 2 to 3 times daily. Lisinopril: 5 to 10 mg once daily. Maximum dose: 40 mg/day, Ramipril: 2.5 mg once daily, Maximum dose: 20 mg/day.  PHARMACOLOGICAL THERAPY Angiotensin receptor blockers ▪ Mechanism of action: Drugs that blocks the angiotensin receptor and antagonize the effect of angiotensin II, a potent vasoconstrictor. ▪ ADR: Cough, Hyperkalemia, Renal insufficiency, Angioedema. ▪ Drug/Dose: Losartan: 25 to 50 mg once daily Valsartan: 80 to 160 mg once daily. Maximum dose: 320 mg once daily Telmisartan: 20 to 40 mg once daily Irbesartan: 150 mg once daily  PHARMACOLOGICAL THERAPY Alpha blockers ▪ Mechanism of action: Alpha blockers lower blood pressure by keeping a hormone called norepinephrine from tightening the muscles in the walls of smaller arteries and veins. ▪ ADR: Low blood pressure and dizziness. ▪ Drug/Dose: Doxazosin (Cardura). Prazosin (Minipress). Terazosin.  PHARMACOLOGICAL THERAPY Beta blockers ▪ Mechanism of action: Beta blockers are medications that have beta-adrenergic blocking properties, meaning they block sympathetic nervous system activity and effect Vagal tone. ▪ ADR: Bradycardia and hypotension. ▪ Drug/Dose: Acebutolol, Atenolol (Tenormin), Bisoprolol.  PHARMACOLOGICAL THERAPY Calcium channel blockers Mechanism of action: Calcium channel blockers reducing the amount of calcium entering cells of the heart and blood vessel walls. ADR: Bradycardia, reflex, tachycardia, arrhythmias. Drug/Dose: Amlodipine: 2.5 to 5 mg once daily. Maximum dose: 10 mg once daily. Nifedipine: 30 or 60 mg once daily. Verapamil: 120 or 180 mg once daily. Maximum dose: 480 mg once daily. Diltiazem: 60 to 120 mg twice daily or 120 to 240 mg once daily.  PHARMACOLOGICAL THERAPY Central α2 agonist ▪ Mechanism of action: central α2-adrenergic stimulation is thought to reduce sympathetic outflow and enhance parasympathetic activity, thereby reducing heart rate, CO, and total PVR. ▪ ADR: Drowsiness, Fatigue, Dizziness. ▪ Drug/Dose: Clonidine-0.075 to 0.1 mg twice daily-Resistant Hypertension Methyldopa-Initial: 250 mg 2 to 3 times daily Guanfacine, Guanabenz.  PHARMACOLOGICAL THERAPY Diuretics Loop diuretics Thiazide diuretics Potassium sparring diuretics Aldosterone Antagonist Carbonic anhydrase inhibitors Osmotic diuretics  PHARMACOLOGICAL THERAPY Diuretics - Loop diuretics Loop diuretic efficacy is superior to that of thiazides, potassium-sparing diuretics, and aldosterone antagonists because this region reabsorbs over ~40% of filtered sodium. ▪ Mechanism of action: Inhibits sodium and chloride reabsorption in the renal distal convoluted tubule ▪ ADR: Metabolic effects: hyponatremia, hypotension, hypokalaemia, hypomagnesemia, hypocalcaemia may develop over time and contribute to the potential for cardiac arrhythmias. Electrolyte-related effects: hyperglycaemia, dyslipidaemias, and hyperuricemia ▪ Drug/Dose: furosemide-40mg/BID, bumetanide-1 mg/BID, torsemide -10mg/OD  PHARMACOLOGICAL THERAPY Diuretics - Thiazide diuretics Mechanism of action: Inhibits sodium and chloride reabsorption in the renal distal convoluted tubule. ADR: Metabolic effects- hyperlipidemia and hyperglycemia. Electrolyte-related effects- hypokalemia, hypomagnesemia, hyperuricemia, and hypercalcemia Drug/Dose: Thiazide diuretics are administered orally as tablets. Hydrochlorothiazide -25 to 50mg/OD & Chlorthalidone -25mg/OD (1.5 to 2 times more potent)  PHARMACOLOGICAL THERAPY Diuretics - Potassium sparring Diuretics Mechanism of action: It acts to prevent sodium reabsorption in the collecting tubule ADR: Hyperkalemia (increased levels of potassium in the blood), Nausea and vomiting, Abdominal discomfort. Drug/Dose: Triamterene - 100 mg/OD OR BD, Amiloride - 20mg/OD OR BD)  PHARMACOLOGICAL THERAPY Diuretics - Aldosterone Antagonist Mechanism of action: Aldosterone antagonists block the action of aldosterone, which is a hormone your adrenal glands make. ADR: Decreases the blood pressure and a reduction in fluid around the heart. Drug/Dose: Spironolactone-25- 50mg/day/BD or OD, Eplerenone- 50- 100mg/day/BD or OD.  PHARMACOLOGICAL THERAPY Diuretics - Carbonic anhydrase inhibitors Mechanism of action: These drug works to cause an accumulation of carbonic acid by preventing its breakdown. ADR: Use of carbonic anhydrase inhibitors may increase the risk of acidosis(shortness of breath, troubled breathing). Drug/Dose: Acetazolamide, methazolamide.  PHARMACOLOGICAL THERAPY Diuretics - Osmotic diuretics Mechanism of action: Inhibit water reabsorption in the proximal convoluted tubule and the thin descending loop of Henle and collecting duct, regions of the kidney that are highly permeable to water. ADR: As mannitol is cleared by the kidneys, water follows, leading to dehydration and hypernatremia; nausea and vomiting, chest pain, and chills may occur. Drug/Dose: Mannitol, glycerin, and isosorbide.  PHARMACOLOGICAL THERAPY Vasodilators Mechanism of action: They primarily act to relax smooth muscles in arterioles and activate baroreceptors. ADR: Reflex tachycardia Drug/Dose: Isosorbide dinitrate, Hydralazine, Minoxidil. PHARMACOLOGICAL THERAPY PHARMACOLOGICAL THERAPY PHARMACOLOGICAL THERAPY PHARMACOLOGICAL THERAPY - PREGNANCY CASE STUDY  SUBJECTIVE ▪ Name : Ms. ABC Past medical history : A K/C/O SHT on irregular medication ▪ Sex : Female Past medication history : T. Amlodipine – 2.5 mg ▪ Age: 45 Year Social history: Cooley Family history: Father’s hypertensive ▪ Date of Admission : 30/04/2024 at 8:34 pm Patient Allergy (drug): Nil Allergy (food): Brinjal ▪ Ward : FM ▪ I.P. No.: 3369 ▪ Chief complaint: C/O headache since today morning ▪ H/O nausea ▪ No H/O blurring of vision  OBJECTIVE On examination:- BP -200/120mmHg PR - 80 beats / minute CVS - NAD RS -NAD  LABORATORY INVESTIGATION REPORTS: ▪ CLINICAL HEMATOLOGY Hemoglobin (Hb) : 12.4 g/dl Total count (Tc): 7.5 × 10^5 cells/mm^3 Differential count : Polymorphs – 62 % Lymphocytes – 33 % Monocytes – 5 % Platelet count: 251×10^3 /mm^3 Red blood cells (RBC’s) : 5.81 × 10^6 /mm^3 Hematocrits (Hct) / Packed cell volume (PCV): 41.2 % Mean cell volume (MCV) : 70.9 FL Mean cell hemoglobin (MCH) : 21.3 pg/cell Mean cell hemoglobin concentration (MCHC) : 30.1 g/dl  LABORATORY INVESTIGATION REPORTS: ▪ RENAL FUNCTION TEST ▪ Blood urea: 30 mg/dl ▪ Serum creatinine (Sr Cr.): 1.2 mg/dl ▪ LIVER FUNCTION TEST ▪ AST – Aspartate amino transferase (SGOT): 16 U/L ▪ ALT – Alanine amino transferase (SGPT): 6 U/L ▪ Alkaline Phosphates (SGPT): 64 U/L ▪ Bilirubin: Total – 0.4 mg/dl Direct – 0.2 mg/dl Indirect – 0.2 mg/dl  LABORATORY INVESTIGATION REPORTS: ▪ URINE ANALYSIS ▪ Urine sugar: Nil ▪ Urine albumin: Trace ▪ Deposits: Pus cells (pc): 6-8 /h p f ▪ Epithelial pus cells (e p c): 10-12/h p f  ASSESMENT: (Diagnosis and Drug related problems) Drugs Dose Frequency Day1 Day2 Day3 T. Amlodipine 25mg 4od T. Atenolol 50mg 1 | do T. Ranitidine 150mg 1 do Inj. Furosemide 40mg 10 stat  ASSESMENT DAY 2 DAY 3  ASSESMENT ▪ UNTREATED INDICATION ▪ Headache is untreated for this patient. ▪ INTERVENTION ▪ * Monitor heart rate and blood pressure ▪ * Paracetamol should be given to treat headache ▪ * The BP goal should be maintained at 140/90mmHg MY PLAN  PATIENT COUNSELLING POINTS Disease Related Points :- ▪ Hypertension is curable in the early stages if treated. If left untreated ,it might lead to further complications like stroke, retinopathy, renal failure, chronic heart disease, peripheral vascular disease. ▪ * Patient was advised on the need to cure hypertension at the early stages and it’s complications if left untreated. ▪ * Patient was advised on how stress can lead to hypertension and necessity of relaxation therapy. ▪ * Frequent check ups are suggested for this patient to check the medication adherence.  PATIENT COUNSELLING POINTS Drug Related points:- ▪ Combination therapy including Amlodipine, thiazide diuretics and ACE Inhibitors is suggested as the best therapy for this patient according to JNC-8 Guidelines. ▪ *Patient was advised to take T. Amlodipine at night to avoid dizziness and light headedness. ▪ *Patient was advised to take T. Enalapril only at night. ▪ *Patient was advised that ACE Inhibitors and Thiazide diuretics are given for their additive hypotensive action. ▪ * Patient was advised to take T. Hydrochloride thiazide at night. ▪ * Pill count method was suggested to ensure that the patient adheres to the medication. ▪ Lipid profile, Liver function test and Renal function tests should be done periodically to ensure effectiveness of the treatment. Once the BP levels drop, combination of three drugs can be reduced to two.  PATIENT COUNSELLING POINTS Lifestyle Related Points:- ▪ * Patient is strictly advised to follow DASH diet, involving fish intake, intake of fruits and vegetables, intake of water and fluids( 6-8 glasses of water a day), reduction of sodium ( to less than 6 gms per day) and salt to less than 2.4 g/day in diet, restriction of alcohol and tobacco. ▪ * Patient was advised to do physical activities like brisk walking ( for 30 minutes) or jogging, swimming. ▪ * High water intake should be there to reduce the elevated pus cells.  REFRENCES ▪ 1. Drugs. com. iOS 15.5. Medication Guide.2.10.6.NewZealand.Drug.com.2013. ▪ 2. 2003. SEVENTH REPORT OF THE JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION, AND TREATMENT OF HIGH BLOOD PRESSURE. [online] Available at: [Accessed 25 July 2022]. ▪ 3. 2. Dipiro J, Yee G, Posey L, Haines S, Nolin T, Ellingrod V. Pharmacotherapy. New York [I pozostałe]: McGraw Hill; 2020. ▪ Some websites:- ▪ https://eduwavepool.unizwa.edu.om/lmsdatapool/00011824/LearningObjects/Cardiovascular.pdf ▪ https://web.s.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=00029270&AN=160646 59&h=4gDCZBhnNkw ▪ https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=hydrochlorothiazide+and+enalapril&oq=hydrochlorothiazide+and +e#d=gs_qabs&t=1678862725565&u=%23p%3DSFElwKZ2l-IJ ▪ Images: https://stock.adobe.com/ Thank You Christine Anna Anil Pharm-D PB IVth Year JSS College of Pharmacy, Ooty - 643001