UK Hypertension Guidelines Starting Treatment threshold Group Treatment Target >160/100All those with such persisting readings >160/100.<140/90 >140/90 Have established cardiovascular disease, or Have C.V. Risk (>20% per 10 years), or Have evidence end-organ damage without D.M., or Ch. renal dis., without Macroalbuminuria (or D.M.) <140/90 >130/80Type-2 Diabetes alone.<130/80 >135/85Type-1 Diabetes alone.<130/80 >130/80 Type-1 or 2 Diabetes with microalbuminuria. Type-1 or 2 Diabetes with renal, eye or CV damage. <130/80 >130/80Chronic renal disease with Macroalbuminuria.<125/75
Definition: [ GFR 60 ml / min / 1.73 m 2 (= serum creatinine 1.5 mg / dL or 1.3 mg / dL ) ] [ Albuminuria 300 mg/day (macroalbuminuria) ]. Treatment Goal: Aggressive BP Lowering 125/75 Compelling Drug: ACEIs or ARBs (Diabetic or non-Diabetic Nephropathy). N.B. GFR ( serum creatinine) up to 35% from baseline is acceptable, And is NOT a reason to withhold treatment unless hyperkalemia develops. In Advanced Renal Disease: [ = GFR 30 ml / min / 1.73 m 2 (serum creatinine mg / dL) ] : Increasing dose of loop diuretic is usually needed with ARBs or ACEIs) CHRONIC RENAL DISEASE
CEREBRO-VASCULAR STROKE Risks & Benefits of ACUTE Lowering of BP DURING acute CV Stroke are still unclear. Control of BP at intermediate levels (approximately 160/100 mmHg) is appropriate until condition is stabilized or improved. Stroke rates are lowered better by ACEIs / ARBs + Thiazide.
ISCHEMIC HEART DISEASE Asymptomatic Angina: BBs or CCBs Symptomatic Angina: ACE-Is / ARBs (ARBs in Patients can’t tolerate ACE-Is) Acute MI (elevated ST segment) : ACE-Is / ARBs + BBs (ARBs in Patients can’t tolerate ACE-Is) N.B. CCBs if given there should be extreme cautious to avoid heart failure.
o β 2 : Bronchodilation. Vasodilatation. Affect Glycogen Breakdown in Liver & Skeletal muscles o β 3 : Lipolysis. Renin Release BP. Stimulation of β -adrenergic Receptors: o β 1 : +ve Chronotropic on heart muscle. +ve Inotropic on heart muscle.
o Management of cardiac arrhythmias o Antihypertensive.
Other Side Effects of β -blockers : o Hyperkalemia. o Erectile dysfunction. o Bradicardia, heart failure, heart block. o Hypotension, orthostatic hypotension. o Tremors. o Insomnia
Mode of Action : Disrupt the calcium ions (Ca +2 ) transport at calcium channels: o In vascular smooth muscles o In cardiac muscle INDICATIONS : o Hypertension o Atrial flutter & AF o Angina
o At high doses CCBs block the effect of insulin.
Glomerular Corpuscle Juxta glomerular cells macula densa Afferent arteriole Efferent arteriole Distal convoluted tubule Urinary chamber Bowman’s capsule Basement membrane - Podocytes Proximal convoluted tubule Urinary excretion: Fluid & electrolyte filtration from capillary side to urinary side through the basement membrane & podocytes to the urinary chamber of the glomerulus.
Direct Na + H 2 O retention water retention Blood
Direct Na + H 2 O retention water retention
Direct Na + H 2 O retention water retention
Direct Na + H 2 O retention water retention Blood water retention
Magdi El-ShalakanyMagdi El-Shalakany Mean Arterial Pressure (mm Hg) Intraglomerular Pressure Chronic hypertension with chronic renal disease Chronic hypertension Normal Low High with normal renal function
1. Bradykinin & inflammatory related S.E: o Persistent Dry Cough o Angio-edema o Rash o Inflammation-related Pain 2. GFR Creatinine Clearance Rate (Ccr or C C ) serum Creatinine GFR ( serum creatinine) up to 35% from baseline is acceptable & is NOT a reason to withhold treatment unless hyperkalemia develops. 3.Hyperkalemia 4.Metallic Taste (sulfhydryl part in Captopril molecule)
1. No Bradykinin & inflammatory related S.E: o Persistent Dry Cough o Angio-edema o Rash o Inflammation-related Pain 2.ARBs prevent excessive GFR Creatinine Clearance Rate which serum creatinine. It Keeps the Drop in GFR & C cr (if occur) 35% from baseline which is acceptable & So No Need to Withhold treatment. 3.No Decline of Anti-Hypertensive Effect 4. No Metallic Taste (sulfhydryl part in Captopril molecule)
-blockers -blockers Calcium antagonists AT 1 -receptor blockers Diuretics ACE inhibitors ESH Guidelines. J Hypertens. 2007;25: ESH= European Society of Hypertension
o CRD = Chronic Renal Disease. o GFR = Glomerular Filtration Rate. o BUN = Blood Urea Nitrogen = Uremia = Azotemia. o ESRD = End Stage Renal Disease (= Need for Dialysis or Kidney Transplant)
o Plasma concentrations of creatinine and urea ( BUN = Blood Urea Nitrogen) are used to measure renal function. o Creatinine clearance rate ( C Cr or Cr Cl): “A measure for GFR”. o BUN and serum creatinine will not be raised normal Until 60% of total kidney function is lost. o Creatinine clearance ( C Cr or Cr Cl) is then more accurate to measure suspected renal disease.
o Proteinuria (elevated level of protein (albumin) in urine) : It is an important Prognostic marker for renal disease. o Albumin level 30 mg/24 hr urine is diagnostic for chronic kidney disease o Microalbuminuria is a level of mg/24 hr urine; (can not be detected by usual urine dipstick methods). o Macroalbuminuria is a level 300 mg/24 hr urine.
1. In patients 50 yr : SBP ( 140 mmHg) is much more important Risk Factor for CVD than DBP. 2. CVD Risk doubles with each increment of 20/10 mmHg (above normal). 3. Pre-hypertensive patients (SBP / DBP 80-89) Require Lifestyle modifications to CV Risk.
4. Thiazide diuretic is drug of First choice for most patients with uncomplicated hypertension. 5. Certain Risk conditions are Compelling Indications For Other Anti-hypertensive Agents (e.g. ACE-Is, ARBs, CCBs, BBs …. etc) 6. Most hypertensive patients will require 2 or more antihypertensive agents to Achieve Treatment Goals: ( 140/90 mmHg, or 130/80 mmHg for Diabetic or Chronic Renal disease patients ) 7. If BP is 20/10 mmHg above Goal, consider additional agent therapy, one of which should be thiazide.
8.Empathy & Motivating Patients are very important to reach Treatment Goal. 9.Responsible Physician’s Judgment remains paramount in the presence of these guidelines.