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HTN
  1. SPECIFIC INDICATION AND HYPERTENSIVE GROUP
  2. HYPERTENSION EMERGENCIES
  3. TREATMENT OF HTN EMERGENCIES
  4. SECONDARY HTN
  5. ANTIHYPERTENSIVE TREATMENT [2]
  • 1/ THIAZIDE DIURETICS:LOW DOSE

    PERSON WITH NORMAL ECG THIAZIDES DIURETICS:

    LOWER BP

    METALOZONE AND INDAPAMIDE ARE MORE EFFECTIVE IN MODERATE RENAL INSUFFICIENCY.

    THIAZIDES INCREASE LDH CHOLESTEROL IN THE SHORT TERM .

    DIURETICS AND BETA BLOCKERS: PROVOKE GLUCOSE INTOLERENCE =-==>CONTRAINDICATED IN DIABETICS,

    EFFECTIVE IN ELDERLY PERSONS.

    AFRICAN AMERICAN HYPERTENSIVE : DIURETICS ARE BETTER OPTION: RESPOND LESS WELL TO TREATMENT BETA BLOCKERS THAN WHITE,

    IF THIAZIDE DOSE INCREASED TO > 25MG , ADD POTASSIUM SPARING DIURETIC [ DYAZIDE]

    1. CONGESTIVE HEART FAILURE
    2. EDEMATOUS STATES
    3. BLACK PATIENTS.
    4. LEAST EXPENSIVE
    1. DECREASES IN POTASSIUM AND MAGNESIUM
    2. INCREASES IN CALCIUM , URIC ACID , GLUCOSE, LDH CHOLESTEROL.
    3. GYNECOMASTIA [SPINOLACTONE]



      2/
      BETA BLOCKERS
    ACEBUTOLOL

    TIMOLOL

    METOPROLOL

    PINDOLOL

    CARDIOSELECTIVE BETA BLOCKERS NON CARDIOSELECTIVE BETA BLOCKERS
    METOPROLOL = LOPRESSOR PROPANOLOL LA =INDERAL LA
    ATENOLOL = TENORMIN TIMOLOL=BLOCADREN
    NADOLOL=CORGARD
    PINDOLOL=VISKEN
    CARTEOLOL=CARTROL


    LABETALOL [COMBINED ALPHA/BETA BLOCKER].

    SPECIFIC INDICATION:

    1. MYOCARDIAL INFARCTION
    2. SUPRAVENTRICULAR ARRHYTHMIAS
    3. MIGRAINE HEADACHE
    4. GLAUCOMA
    5. ANXIETY
    6. RESTING TACHYCARDIA
    7. MAJOR SIDE EFFECTS:
    1. ASTHMA
    2. COPD
    3. ATRIOVENTRICULAR CONDUCTION DEFECTS
    4. CONGESTIVE HEART FAILURE FROM SYSTOLIC DYSFUNCTION
    5. DIABETES BECAUSE MASKING HYPOGLYCEMIA.

    3/Angiotensine Converting Enzyme Inhibitors [ACE]

    AFRICANS RESPOND LESS WELL.

    REVERSIBLE RENAL INSUFFICIENCY

  • .

    CALCIUM ENTRY BLOCKERS
    DILTIAZEM SR =CARDIZEM SR
    NIFEDIPINE XL =PROCARDIA XL - ADALAT CC
    VERAPAMIL = CALAN -COVERA
    AMLODIPINE=NORVASC
    FELODIPINE = PLENDIL
    ISRADIPINE =DYNACIRC
    NICARDIPINE =CARDENE

    5/ALPHA 1 BLOCKERS

    ALPHA-1 RECEPTOR BLOCKERS





    ALPHA 1 RECEPTOR BLOCKERS
    DOXAZOSIN =CARDURA
    TERAZOSIN =HYTRIN
    PRAZOSIN =MINIPRESS









    COMBINATION AGENTS



    LOTREL = AMLODIPINE / BENAZEPRIL

    LOTENSIN=BENAZEPRIL/HCTZ

    HYZAAR =LOSARTAN/HCTZ

    VASERETIC = ENALPRIL /HCTZ

    6/COMBINED ALPHA1-BETA BLOCKERS

    FROM PUBLIC POLICY, GENERIC DIURETICS AND BETA BLOCKERS ARE PREFFERED

    THE CEI OFFER A LOW SIDE EFFECTS PROFILE, MAY PREVENT NEPHROPATHY IN DIABETICS.






    BETA BLOCKERS
    • DECREASE CAD MORTALITY IN NON SMOKERS
    • DECREASE INCIDENCE OR PROGRESION OF CAD
    • DECREASE MORTALITY AFTER MYOCARDIAL INFARCTION
    • MORE EFFECTIVE IN WHITE AND YOUNGER PATIENT
    • PROPANOLOL IS THE LEAST EXPENSIVE
    • MAY LOWER HDL CHOLESTEROL
    • CAN PRECIPITATE GLUCOSE INTOLERENCE
    • SEXUAL DYSFUNCTION IN MEN
    THIAZIDE TYPE DIURETICS
    • PROTECT AGAINST STROKE IN SMOKERS AND NON SMOKERS
    • MORE EFFECTIVE IN AFRICAN AMERICAN AND ELDERLY
    • MAY RAISE LDL AND TOTAL CHOLESTEROL FOR <1 YEAR
    • HYPOKALIEMIA
    • IMPOTENCE - FATIGUE
    • PROTECT ELDERLY PERSONS FROM HIP FRACTURE
    • INCREASE MORTALITY WHEN USED IN DIABETICS, ABNORMAL ECG
    CALCIUM CHANNEL BLOCKERS
    • MORE EFFECTIVE IN AFRICAN AMERICAN AND ELDERLY PATIENT
    • EFFECTIVE FOR CAD BUT LITTLE BENEFIT FOR POST -MI
    • NO ADVERSE EFFECT ON LIPID OR GLUCOSE TOLERANCE
    • PREVENT PROGRESSION OF ATHEROSCLEROSIS
    • EXPENSIVE
    CONVERTING ENZYME IHIBITOR [CEI]
    • MORE EFFECTIVE IN WHITE AND YOUNGER PATIENT
    • NO ADVERSE EFFECT ON LIPID OR GLUCOSE TOLERENCE
    • MAY RAISE K+ AND CAUSE RENAL INSUFFICIENCY
    • COUGH AS SIDE EFFECT
    • BEST QUALITY LIFE
    • MAY HELP TO PREVENT PROGRESSION OF NEPHROPATHY IN DIABETES
    • EXPENSIVE
     




    CATEGORY SYSTOLIC DIASTOLIC RECOMMENDED FOLLOW UP
    NORMAL <130 mmHg <85mmHg RECHECK IN 2 YEARS
    HIGH NORMAL 130-139 85-89 RECHECK IN 1 YEAR
    STAGE I HTN 140-159 90-99 REEVALUATE WITHIN 2 MONTHS
    STAGE II HTN 160-179 100-109 EVALUATE AND TREAT WITHIN 1 MONTH
    STAGE III HTN 180-209 110-119 EVALUATE AND TREAT WITHIN 1 WEEK
    STAGE IV HTN >210 >120 EVALUATE AND TREAT IMMEDIATLY
       

    1. Diabetics: should be treated with ACE INHIBITORS: they prevent the development of nephropathy.
    2. Post myocardial infarction :ischemic heart disease should be treated with beta blockers.
    3. Diminished left ventricular systolic function [ congestive heart failure or post myocardial infarction ] should be treated with ACE INHIBITORS.
    4. BLACK PATIENT: EFFECTIVE TO DIURETICS OR CALCIUM CHANNEL BLOCKERS, LEAST EFFECTIVELY TREATED WITH ACE INHIBITORS.
    5. PREGNANT PATIENT:BEST TREATED WITH LABETOLOL [BETA BLOCKERS] OR HYDRALAZYNE [VASODILATATORS]
      • .HYPERTENSIVE EMERGENCIES:
        • END ORGAN DAMAGE:
        • DIASTOLIC >120-130 mmHG
        • 1% OF HYPERTENSIVE PATIENT.
        • PRESENTATION:
          • NEUROLOGIC:
          • Encephalopathy
          • headache
          • Confusion
          • Seizures
          • Subarachnoid or intracerebral hemorrhage.
          • CARDIAC
          • Chest pain
          • myocardial infarction
          • palpitation
          • dyspnea
          • pulmonary edema
          • jugular distension and gallops
          • NEPHROPATHY:
          • ACUTELY PROGRESSIVE HEMATURIA
          • PROTEINURIA
          • RENAL DYSFUNCTION
          • RETINOPATHY
          • PAPILLEDEMA
          • HEMORRHAGES
          • BLURRED EYES
      • TREATMENT OF EMERGENCY HTN:
        • IV[INTRA VENOUS] NITROPRUSSIDE [VASODILATATOR] AND LABETOLOL
        • NITROGLYCERIN IS PREFERABLE IN THOSE WHO HAVE MYOCARDIAL ISCHEMIA.
        • IV ENALAPRILAT
        • LESS USED: ESMOLOL . DIAZOXIDE, TRIMETHAPHAN

    Pathophysiology of Hypertensive Crisis
  • Emergency Medicine: Hypertensive Emergencies


    Emergency Medicine: Hypertensive Emergencies

    Myocardial Ischemia / Infarction

    The goal of treatment is to reduce systemic vascular resistance and improve coronary perfusion. You don't want to decrease coronary perfusion and cause the conversion of ischemia to infarction. Likewise, you don't want to decrease coronary perfusion in an infarcted patient and cause further damage.

    The target diastolic BP is 100 mm HG. This should be reached by using IV nitroglycerin. Nitroglycerin is the drug of choice because it is a good coronary vasodilator, and it also works on the capacitance vessels on the venous side which lowers BP. IV labetalol is a reasonable alternative choice. It has both alpha and beta blocking capacity. Avoid hydralazine and diazoxide because they increase myocardial oxygen consumption.

    SECONDARY HYPERTENSION:

    Renal Artery stenosis is the most common cause of secondary HTN.

    I/ RENAL ARTERY STENOSIS:

    CAUSES:

    ***ARTHROSCLEROSIS DISEASE IN THE ELDERLY.

    ***FIBROMUSCULAR DYSPLASIA IN YOUNG WOMEN.

    SIGNS:

    ***UPPER ABDOMINAL BRUIT RADIATING LATERALLY [50-70%]

    DIAG:

    ***BEST INITIAL SCREENING TESTS ARE THE ABDOMINAL ULTRASOUND

    ***CAPTOPRIL RENOGRAM.= THE BEST NON INVASIVE METHOD TO CONFIRMING THE DIAG OF RENAL ARTERY STENOSIS.

    ARTERIOGRAM = STILL THE BEST METHOD OF CONFIRMING THE DIAGNOSIS.

    ***INTRAVENOUS PYELOGRAPHY

    ***DUPLEX DOPPLER ULTRASONOGRAPHY

    ***SELECTIVE RENAL VEIN RENIN DETERMINATION.

    TREATMENT:

    BEST INITIAL TREATMENT IS PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY.

    SURGICAL RESECTION IF ANGIOPLASTY FAILED.

    ACE TREATMENT FOR THOSE WHOM ANGIOPLASTY AND SURGERY FAILED OR CONTRINDICATED.

    II/PRIMARY HYPERALDOSTERONISM [CONN'S SYNDROME]

    MOST COMMONLY DUE TO A UNILATERAL ADENOMA

    BILATERAL HYPERPLASIA

    CANCER RARE.

    SIGNS:

    Hypertension in association with hypokaliemia

    hypokaliemia symptomes [muscular weakness and polyuria , polydipsia from nephrogenic diabetes insipidus.

    DIAG:

    ELEVATED ALDOSTERONE LEVELS IN URINE AND BLOOD.

    TRT:

    SURGICAL RESECTION

    POTASSIUM SPARING DIURETICS ===> SPIROLACTONE IN THOSE WITH HYPERPLASIA.

    III/ PHEOCHROMOCYTOMA:

    10% BILATERAL

    10% MALIGNANT

    10% EXTRA ADRENAL

    SIGNS:

    EPISODIC HYPERTENSION

    HEADACHE

    SWEATING

    PALPITATION AND TACHYCARDIA

    PALLOR, FLUSHING

    DIAG:

    BEST INITIAL TEST = URINARY VANILLYLMANDELIC ACID[ VMA ]

    METANEPHINE

    FREE URINARY CATECHOLAMINES

    CT + MRI

    TRT:

    ALPHA ADRENERGIC BLOCKADE FOLLOWED BY SURGICAL REMOVAL

    IV/CUSHING SYNDROME

    V/ COARTATION OF THE AORTA

    VI/ORAL CONTRACEPTIVE

    VII/ACROMEGALY

    VIII/ CONGENITAL ADRENAL ENZYME DEFICIENCIES

    IX/CHRONIC RENAL DISEASE [GLOMERULONEPHRITIS-POLYCYSTIC DISEASE-DIABETIC NEPHROPATHY-CHRONIC PYELONEPHRITIS].