principles of pharmacotherapy in hypertension (2013).pdf
TRANSCRIPT
-
Principles of Pharmacotherapy in Hypertension
. .
...., , PPhhaarrmm..DD..,, PPhh..DD..
1.
(cardiovascular diseases)
2.
3. the Seventh
Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood
Pressure (JNC 7)
4.
(compelling indications)
5.
6.
7.
-
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(hypertension)
systolic / diastolic 140/90 mm Hg
..
2545 1 7.1
Prospective Studies Collaboration
Group ( 1 2) meta-analysis
observational studies 61
ischemic heart disease stroke
systolic 115 mm
Hg diastolic 75 mm Hg (40-89 )
systolic 20 mm
Hg diastolic 10 mm Hg
1 10
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2 10
hemodynamic parameters 2
cardiac output (CO) total peripheral resistance (TPR) 2 parameters
arterial blood pressure (ABP) ABP = CO x TPR
CO ABP 3 Cardiac output (
) (heart rate)
(stroke volume) heart rate
sympathetic parasympathetic stroke volume
(ventricular force of contraction cardiac contractility
) (venous return)
(venous capacitance)
(intravascular volume) Venous capacitance
intravascular volume
(total
peripheral resistance) 2 (arteriolar radius)
(blood viscosity)
(local regulation) (regional regulation) (systemic regulation)
TPR
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3
early response, intermediate response late response
1. Early response
sympathetic parasympathetic
baroreceptor
vasomotor center brainstem (medulla)
sympathetic outflow
TPR () CO
( heart rate venous capacitance) sympathetic
outflow parasympathetic outflow
baroreceptor reflex
chemoreceptor reflex volume receptor reflex
2. Intermediate response
renin-angiotensin-aldosterone system (RAAS) antidiuretic hormone (ADH)
hypothalamus renin (
afferent arteriole baroreceptor reflex, sympathetic outflow macula
Force of contraction Venous Return
Venous capacitance
Intravascular volume
Stroke Volume Heart Rate
Cardiac Output Total Peripheral Resistance
3
ARTERIAL BLOOD PRESSURE
X
X
X
Force of contraction Venous Return
Venous capacitance
Intravascular volume
Stroke Volume Heart Rate
Cardiac Output Total Peripheral Resistance
3
ARTERIAL BLOOD PRESSURE
X
X
X
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densa) Renin angiotensinogen
angiotensin I angiotensin II angiotensin converting enzyme (ACE)
Angiotensin II
aldosterone
ADH hypothalamus
baroreceptor reflex angiotensin II
3. Late response
arterial pressure CO TPR
2
1. Primary hypertension
(no identifiable cause) 90-95%
primary hypertension
2. Secondary hypertension
(lesion)
oral contraceptives, oral decongestants
secondary hypertension 1
Primary hypertension secondary
hypertension (risk factors) primary hypertension 2
1. (Hereditary factors)
(genetic defect)
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1 secondary hypertension
Renal and Genitourinary Disease
Renoparenchymal disease
Renovascular disease
Chronic kidney disease
Obstructive uropathy
Vascular causes
Coarctation of Aorta
Vasculitis
Endocrine causes
Primary aldosteronism
Pheochromocytoma
Thyrotoxicosis
Neurogenic causes
Psychogenic
Increased intracranial pressure
Drug-induced causes
Adrenocorticosteroids
Alcohol
Appetite suppressants
Cyclosporine
Estrogens
Erythropoietin
Monoamine oxidase inhibitors
Non-steroidal anti-inflammatory drugs
Oral contraceptives
Oral decongestants
Tacrolimus
Tricyclic antidepressants (TCAs)
- sodium
- sodium/calcium transport
- angiotensino-
gen renin
catecholamines, insulin, endothelin (receptor)
2. (environmental factors) (smoking),
(obesity) (hyperlipidemia), (excessive salt intake),
(physical inactivity), (emotional stress),
(excessive alcohol intake)
primary hypertension 4
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target organ damage
atherosclerosis
arteriosclerosis
(cardiac hypertrophy)
arteriosclerosis afferent arteriole,
glomerulosclerosis (tubulointerstitial injury)
2
Defect in sodium excretion
Defect in sodium/calcium transport of smooth muscle cell
Defect causing increased in humoral factors e.g. angiotensin II, renin,
catecholamines, insulin, endothelin or their receptors
+
Excess salt intake
Salt and water retention Increased vascular reactivity
Increased plasma &
extracellular fluid volume
Vasoconstriction
Increased cardiac output Increased total peripheral
resistance
HYPERTENSION
4 Hypothetical theory for pathogenesis of primary hypertension
autoregulation
Defect in sodium excretion
Defect in sodium/calcium transport of smooth muscle cell
Defect causing increased in humoral factors e.g. angiotensin II, renin,
catecholamines, insulin, endothelin or their receptors
+
Excess salt intake
Salt and water retention Increased vascular reactivity
Increased plasma &
extracellular fluid volume
Vasoconstriction
Increased cardiac output Increased total peripheral
resistance
HYPERTENSION
4 Hypothetical theory for pathogenesis of primary hypertension
autoregulation
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2
Ischemic heart disease (angina, myocardial infarction)
Heart failure
Left ventricular hypertrohy
Cerebrovascular disease (stroke, transient ischemic attack)
Hypertensive encephalopathy
Dementia
Chronic nephrosclerosis
Hypertensive retinopathy
Peripheral arterial disease
Dissecting aortic aneurysm
systolic pressure diastolic
pressure systolic diastolic pressure pulse
pressure 50 mm Hg aorta
(aortic compliance) pulse pressure
systolic pressure diastolic
pressure systolic pressure/diastolic pressure 140/90 ( /
over) mean arterial pressure
(MAP)
MAP = diastolic pressure + 1/3 pulse pressure
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()
sphygmomanometry sphygmomanometer
brachial artery
(cuff) stethoscope
cuff systolic pressure
turbulent flow
Korotkoff sound
systolic blood pressure (SBP) cuff
diastolic blood pressure (DBP)
diastolic pressure Korotkoff sound auscultatory method
systolic palpatory method
SBP radial artery stethoscope
cuff SBP DBP palpatory method
non-mercury sphygmomanometer
JNC 7 3
5 sphygmomanometer
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(blood pressure classification) JNC 7
4 4
2 (visit) 1
SBP DBP category category
category 160/92
stage 2 hypertension prehypertension
prehypertension
(lifestyle modification)
hypertension
140/90 mm Hg stage 1 2
(target organ damage)
JNC 7
5
isolated
systolic hypertension SBP 140 mm Hg DBP
90 mm Hg SBP
50 SBP DBP
diastolic hypertension 50 systolic hypertension
50 SBP
JNC 7 Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Controlled Onset Verapamil
Investigation of Cardiovascular Endpoints (CONVINCE) DBP
90 SBP 60-
70
(primary care physicians) 75 SBP
140-159 mm Hg SBP 140 mm Hg
DBP SBP
SBP
JNC7
European Society of Hypertension (ESH) European Society of Cardiology (ESC) 6
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3 JNC 7
30
5
cuff cuff bladder 80%
cuff
SBP palpatory method radial artery
auscultatory method cuff palpatory method 20-
30 mm Hg
(cuff deflation) 2 mm Hg Korotkoff sound
2 systolic pressure
diastolic pressure
2 2 2
5 mm Hg
(postural hypotension) postural
hypotension
postural hypotension
4 18 JNC 7
BP classification SBP (mm Hg) DBP (mm Hg)
Normal
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5
target organ damage
(mm Hg)
Normal 2
Prehypertension 1
()
target
organ damage
Stage 1 hypertension 2
Stage 2 hypertension 1
180/110 mm Hg
1
6 18 ESH/ESC
BP classification SBP (mm Hg) DBP (mm Hg)
Optimal
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(1) (identifiable cause) (2)
target organ damage
(3)
target organ damage
(vital signs) JNC 7 optic fundi, body mass index
(BMI), auscultation carotid artery , abdominal aorta, femoral artery
, ,
blood chemistry
sodium, potassium, glucose, blood urea nitrogen (BUN), creatinine, calcium, magnesium, lipid profile
urinary albumin excretion albumin-to-creatinine ratio
serum thyroid
thyroid disease
6 target organ damage JNC
7
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6 target organ damage
( 55 65 )
LDL-C ( total cholesterol) HDL-C
(estimated GFR) 60 ml/
( 55
65 )
albumin (microalbuminuria)
(BMI 30 kg/m2) ()
(physical inactivity)
Target organ damage
Left ventricular hypertrophy
Angina/myocardial infarction
Prior coronary revascularization
Heart failure
Stroke/transient ischemic attack
Dementia
Chronic kidney disease
Peripheral arterial disease
Retinopathy
1
1. 45 3 5
1 BP 140/98 mm Hg
2 BP 150/100 mm Hg
3 BP 146/98 mm Hg
BUN 12 mg/dL, Scr 1.1 mg/dL, Total cholesterol 180 mg/dL HDL-C 55 mg/dL, LFTs: within
normal limit
2. 46 2 5
1 BP 152/100 mm Hg
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2 BP 150/96 mm Hg
3. 42 2 5
160/100 mm Hg 3 5
1 BP 152/98 mm Hg
2 BP 146/92 mm Hg
3 BP 154/100 mm Hg
4. 220/120 mm Hg
5. 45 ST-depression inverted
T-wave 200/110 mm Hg troponin T (+)
6. 40 2 5 130/80 mm Hg
total cholesterol 210 mg/dL, triglyceride 200 mm Hg, HDL-C 35 mg/dL, FBS 118 mg/dL, electrolytes
are within normal limit
(goal of therapy) (1)
(2)
(goal blood pressure)
140/90 mm
Hg (chronic kidney disease)
130/80 mm Hg JNC 7 National Kidney Foundation
Guideline
140/80 mm Hg American Diabetes Association
.. 2013
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JNC 7
140/90 mm Hg
( 120/80 mm Hg normal blood pressure)
European Society of Cardiology/European Society of Cardiology (2007)
130/80 (World Health
Organization)
130/80
target organ damage
(lifestyle modification)
JNC 7 7
7
JNC 7
6 8
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7
systolic BP
BMI 18.5-22.9* kg/m2 5-20 mm Hg
10 kg
DASH
saturated fat
8-14 mm Hg
100 (2.4 6
)
2-8 mm Hg
aerobic 30
4-9 mm Hg
30
720 (4.5%), 300 (10%), 90 80-
proof (40%)
2-4 mm Hg
DASH = Dietary Approach to Stop Hypertension Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the
Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med. 2001; 344: 3-10.
* JNC 7 BMI 18.5-24.9 kg/m2
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8
()
Thiazide diuretics
Chlorthalidone 12.5-25 1 Hypokalemia, Hypomagnesemia,
Hyperuricemia, Hyperglycemia,
Dyslipidemia, Impotence
Hydrochlorothiazide 12.5-50 1
Indapamide
1.25-2.5 1
Loop diuretics
Bumetanide 0.5-2 1-2 Hypokalemia, Hypomagnesemia,
Hyperuricemia, Hyperglycemia, Impotence
Furosemide 2080 1-2
Potassium-sparing diuretics
Amiloride 5-10 1-2 Hyperkalemia, Impotence
Triamterene
50-100 1-2
Aldosterone receptor antagonists
Eplerenone 50-100 1 Hyperkalemia, Gynecomastia
Spironolactone
25-50 1
Beta-blockers (BBs)
Atenolol 25-100 1 Bradycardia, Bronchoconstriction,
Hyperglycemia, Dyslipidemia,
Negative inotropic effect,
Decreased peripheral blood flow,
Impotence, Masking hypoglycemia
symptoms in diabetes
Bisoprolol 2.5-10 1
Metoprolol 50-200 1-2
Propranolol 40-160 2-3
Propranolol long-acting 60-180 1
Alpha-1-blockers
Doxazosin 1-16 1 First-dose hypotension,
Orthostatic hypotension,
Dizziness, Headache, Edema
Prazosin 2-20 2-3
Terazosin
1-20 1-2
Combined alpha- and beta-blockers
Carvedilol 12.5-50 2 First-dose hypotension,
Orthostatic hypotension, Dizziness,
Bronchoconstriction, Hyperglycemia
Labetalol 200-800 2 Bradycardia
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8 ()
()
Calcium channel blockers (CCBs)-Dihydropyridines
Amlodipine 2.5-10 1 Headache,
Dizziness,
Orthostatic hypotension,
Peripheral edema
Felodipine 2.5-20 1
Isradipine 2.5-10 2
Nicardipine long acting 60-120 2
Nifedipine long acting 30-60 1
Calcium channel blockers (CCBs)-
Nondihydropyridines
Diltiazem long acting 120-540 1 Bradycardia, Dizziness, Headache,
Peripheral edema
Constipation ( verapamil),
Negative inotropic effect
Verapamil long acting 120-480 1-2
Verapamil 80-320 2-3
Angiotensin-converting enzyme inhibitors (ACEIs)
Captopril 25-100 2-3 Hyperkalemia,
Dry cough,
Taste disturbances,
Angioneurotic edema,
Worsening renal function
Enalapril 5-40 1-2
Fosinopril 10-40 1
Lisinopril 10-40 1
Peridopril 4-8 1
Quinapril 10-80 1
Ramipril 2.5-20 1
Angiotensin receptor blockers (ARBs)
Candesartan 8-32 1 Hyperkalemia,
Worsening renal function Irbesartan 150-300 1
Losartan 25-100 1-2
Telmisartan 20-80 1
Valsartan
80-320 1-2
Direct rennin inhibitors
Aliskiren 150-300 1 Hyperkalemia (?)
Worsening renal function (?)
Arterial direct vasodilators
Hydralazine
MInoxidil
25-100
2.5-80
3-4
1-2
First-dose hypotension,
Orthostatic hypotension, Headache,
Dizziness, Tachycardia,
Peripheral edema,
Lupus-like syndrome (hydralazine),
Hirsutism (minoxidil)
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8 ()
()
Centrally-acting agents
Clonidine 0.1-0.8 2 Headache, Drowsiness, Rebound
hypertension upon sudden withdrawal
Methyldopa 250-1000 2 Headache, Sedation, Bradycardia,
Impotence, Hemolytic anemia,
Peripheral edema
Reserpine
0.1-0.25 1 Sedation, Depression,
Peptic ulcer disease
JNC7
6
(initial first-line
antihypertensive agents) 5 Thiazides, Beta-blockers (BBs), Calcium channel
blockers (CCBs), Angiotensin-converting-enzyme inhibitors (ACEIs) Angiotensin receptor blockers
(ARBs)
JNC7
( preferred initial antihypertensive agent) thiazide diuretics hydrochlorothiazide
stage 1 hypertension
thiazide diuretics
stage 2 hypertension 2 (
SBP 10 mm Hg)
1 thiazide diuretics (
ACEIs, ARBs, BBs CCBs thiazide diuretics) 1 2
1
thiazide ACEIs, ARBs, BBs CCBs ALLHAT 60
2 140/90 mm Hg 30
3
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1
(orthostatic hypotension)
autonomic dysfunction
1 1
2
JNC 7 thiazide diuretics (preferred initial
antihypertensive agent)
thiazides (ACEIs, ARBs, BBs, CCBs)
ALLHAT 40,000 thiazide-like diuretics
(chlorthalidone) ACEIs (lisinopril) CCBs
(amlodipine) thiazides ( 25 mg
hydrochlorothiazide)
hypokalemia impotence thiazide metabolic
adverse effects hyperglycemia, dyslipidemia hyperuricemia
thiazides
JNC 7 thiazide
European Society of Cardiology/European Society of Hypertension
(2007) ( preferred intial agent)
ACEIs, ARBs, BBs CCBs thiazide diuretics
thiazides beta-blocker
metabolic syndrome National Institute of Health and Clinical Excellence (NICE)
British Society of Hypertension
(.. 2011) ACEIs ARBs preferred initial agent
55 CCBs Thiazides preferred initial agent
55 2
( 9)
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9 NICE guideline
1
compelling indication
JNC 7 (heart failure)
(post-myocardial infarction) (high coronary
disease risk) (stroke transient ischemic attack)
BBs, ACEIs aldosterone receptor blockers
BBs ACEIs aldosterone antagonists
10 JNC 7
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1
stage 2
3 6 JNC 7 serum
creatinine serum potassium 1-2
10 JNC 7
Diuretics BBs ACEIs ARBs CCBs Aldo
ANT
Heart failure MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE,
ValHEFT, RALES, CHARM
Post-myocardial
infarction
BHAT, SAVE, CAPRICON, EPHESUS
High coronary disease
risk
ALLHAT, HOPE, ANBP2, LIFE, CONVINCE, EUROPA,
INVEST
Diabetes UKPDS, ALLHAT
Chronic kidney
disease
Captopril Trial, RENAAL, IDNT, REIN, AASK
Recurrent stroke
prevention
PROGRESS
BB = beta-blockers, ACEI = angiotensin-converting enzyme inhibitors, ARB = angiotensin receptor blockers, CCB = calcium channel
blockers, Aldo ANT = aldosterone receptor antagonists
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(HYPERTENSIVE PATIENTS WITH COMPELLING INDICATIONS)
stable coronary artery disease (CAD)
(angina) CAD
stable CAD
(1) (2)
stable CAD
BBs
BBs oxygen
demand heart rate cardiac contractility
CCBs 2 (1) CAD BBs
CCBs non-
dihydropyridines heart rate (2) CAD BBs
CCBs dihydropyridine CCBs BBs
negative inotropic negative chronotropic effects CCBs
CAD (long-acting) (short-acting)
sympathetic outflow reflex tachycardia
ACEIs
ventricular systolic dysfunction ( ejection fraction < 40%) ACEIs
ACEIs
ARBs
(post-myocardial infarction; post-MI)
(coronary artery)
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BBs
CCBs BBs
CCBs (long-acting)
(short-acting) sympathetic outflow BBs
CCBs non-dihydropyridines BBs
bradycardia negative inotropic effect 2 ( CCBs
10 post-MI
post-MI 2 )
ACEIs
ventricular systolic dysfunction ( ejection fraction 40%)
ACEIs
ACEIs ARBs
Aldosterone antagonists ventricular
systolic dysfunction (EF 40%)
eplerenone (EPHESUS trial)
(chronic heart failure)
(ventricular systolic dysfunction)
(
)
ACEIs, ARBs, BBs, diuretics, aldosterone antagonists.
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ACEIs ACEIs
angioneurotic edema ARBs
Diuretics
loop diuretics
BBs
ACEIs diuretics
Aldosterone antagonists spironolactone
(NYHA class III-IV )
CCBs
( non-dihydropyridines verapamil, diltiazem)
systolic BP 110-130 mm Hg
2 insulin resistance
ACEIs, ARBs, BBs, CCBs,
diuretics
ACEIs ARBs
(renoprotective effects) ACEIs
ARBs
CCBs ACEIs ARBs
BBs hyperglycemia dyslipidemia
BBs
1 BBs 2 BBs
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(precaution)
BBs
Diuretics ALLHAT thiazide diuretics
ACEIs
CCBs
thiazides thiazide diuretics
hyperglycemia thiazides
American Diabetes Association
.. 2013 140/80 mm Hg ( 130/80 mm Hg ADA
130/80 mm Hg
)
(chronic kidney disease)
JNC 7
(1) 60 ml/min/1.73 m2
(2) albumin (albuminuria) 300
albumin creatinine (urinary albumin-to-creatinine ratio) 200
creatinine
(1) (2) National Kidney Foundation (NKF)
guideline (kidney damage) , renal imaging
study, urine protein urine sediment 3
GFR
(end-stage renal disease)
ACEIs ARBs
(diabetic nephropathy)
(proteinuria) ACEIs ARBs
diuretics loop diuretics (GFR 30 ml/min/1.73 m2)
CCBs BBs
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11
NKF
130/80 mm Hg
(cerebrovascular disease)
(ischemic stroke transient ischemic attack; TIA)
(hemorrhagic stroke)
35-40
(stroke TIA) JNC 7
thiazide diuretics ACEIs (PROGRESS trial)
American Stroke Association thiazides thiazides ACEIs
2
1. 35
PMH: asthma since childhood
SH: cigarette 1 pack per day, (-) EtOH
FH: 50
All: NKDA
11 NKF
(
)
Diabetic kidney disease ACEIs ARBs diuretics BBs CCBs
Nondiabetic kidney disease
spot urine
protein-to-creatinine 200 mg/g
ACEIs ARBs diuretics BBs CCBs
Nondiabetic kidney disease
spot urine
protein-to-creatinine
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143 98 12
4.7 23 1.090
143 98 12
4.7 23 1.090
Meds: paracetamol PRN for headache, ENO 2
PE: Weight 75 kg Height 1.75 m, BP 145/95 mm Hg, RR 18, P 75 bpm, T 37.6 C
ROS are all non-contributory
Labs:
TC 190 mg/dL, TG 160 mg/dL, HDL 40 mg/dL
2. 45 (BP 150/100 mmHg)
HPI:
PMH: hypertension x 1 month
SH: (-) cigarette, (-) EtOH,
FH: non-contributory
All: NKDA
Meds: hydrochlorothiazide 12.5 mg PO AM
1-2
PE: Weight 75 kg Height 1.65 m, BP 144/94 mm Hg, RR 16, P 70 bpm
ROS are all non-contributory
Labs: all are within normal limit
3. 50 1
HPI:
PMH: hypertension x 5 , dyslipidemia x 5 , mild COPD x 2
SH: 1 , (-) EtOH,
FH: non-contributory
All: NKDA
Meds: Aspirin 80 mg PO AM, Atorvastatin 10 mg PO PM, Berodual Q6H PRN dyspnea
PE: BP 140/90 mm Hg, P 70 bpm
Labs: BUN 12 mg/dL, Scr 1.2 mg/dL
4. 58
(MI) 2
HPI: 2
PMH: hypertension, dyslipidemia, s/p MI
SH: (-) cigarette, (-) EtOH,
FH: non-contributory
All: NKDA
Meds: Aspirin 80 mg PO AM, Simvastatin 20 mg PO PM, Clopidogrel 75 mg PO AM, isosorbide mononitrate 60 mg PO
AM , Metoprolol 100 mg PO BID, Isosorbide dinitrate 5 mg SL PRN
PE: BP 146/90 mm Hg, P 70 bpm
Labs: BUN 14 mg/dL, Scr 1.1 mg/dL, ECHO (2 ):80%
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143 98 16
4.5 23 1.3130
143 98 16
4.5 23 1.3130
143 98 14
4.5 23 1.1130
143 98 14
4.5 23 1.1130
143 98 20
4.7 23 1.4128
143 98 20
4.7 23 1.4128
143 98 20
4.7 23 1.4128
143 98 20
4.7 23 1.4128
5. 45 DM, hypertension, dyslipidemia
PMH: DM, hypertension, dyslipidemia
SH: (-) cigarette, (-) EtOH,
FH: non-contributory
All: NKDA
Meds: Aspirin 80 mg PO AM, Simvastatin 20 mg PO PM, HCTZ 25 mg PO AM, glipizide 5 mg PO BID
PE: Wt 76 kg, Ht 174 cm, P 70 bpm, BP 138/84 mm Hg ( 140/90 136/86 mm Hg)
Labs:
6. 60 chronic heart failure
HPI:
PMH: DM, hypertension, dyslipidemia, CHF (ECHO 35%)
SH: (-) cigarette, (-) EtOH,
FH: non-contributory
All: NKDA
Meds: Aspirin 80 mg PO AM, Simvastatin 40 mg PO PM, HCTZ 25 mg PO AM, Enalapril 10 mg PO BID,
Glimepiride 4 mg PO AM, pioglitazone 15 mg PO AM
PE: Wt 76 kg, Ht 172 cm, BP 138/86 mm Hg, P 75 bpm
Labs:
7. 50 chronic stable CAD
HPI:
PMH: DM, hypertension, dyslipidemia, stable angina
Meds: Aspirin 80 mg PO AM, Simvastatin 20 mg PO PM, Atenolol 100 mg PO AM,
Glipizide 5 mg PO AM, Metformin 850 mg PO BID, Isosorbide mononitrate 60 mg PO AM,
Isosorbide dinitrate 5 mg SL PRN,
PE: Wt 72 kg, Ht 172 cm, BP 142/90 mm Hg, P 65 bpm
Labs:
8. 60 chronic heart failure, chronic stable angina
HPI:
PMH: DM, hypertension, CHF (ECHO 30%), stable CAD
All: NKDA
Meds: Aspirin 80 mg PO AM, Furosemide 20 mg PO AM, Enalapril 10 mg PO BID, atenolol 100 mg PO AM,
Glimepiride 4 mg PO AM
PE: Wt 76 kg, Ht 174 cm, BP 140/86 mm Hg, P 70 bpm Labs:
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(OTHER SPECIAL SITUATIONS)
(pregnancy)
12
methyldopa BBs ACEIs ARBS
( stage 1
hypertension) target organ damage
preeclampsia
target organ damage
150 mm Hg systolic BP 100 mm Hg
diastolic BP (drug of first choice) methyldopa
BBs atenolol
(pregnancy category D) labetalol
()
methyldopa diuretics CCBs ACEIs
ARBs 2 3
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12
Chronic hypertension BP 140 mm Hg systolic 90 mm Hg diastolic 20
12
Preeclampsia BP 140 mm Hg systolic 90 mm Hg diastolic (proteinuria)
300 24 20
preeclampsia eclampsia eclampsia
4
preeclampsia
Chronic hypertension
with superimposed
preeclampsia
20
()
20
- 2-3
-
- (thrombocytopenia)
- AST ALT
Gestational
hypertension
20 proteinuria
temporary diagnosis preeclampsia
Transient hypertension BP 12
(hypertensive crises)
1. (hypertensive emergency)
(BP > 180/120 mm Hg) target organ damage
hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left
ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm,
eclampsia
(mean arterial pressure) 25
1
160/100-110 mm Hg 2-6
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160/100 mm Hg
24-48
rebound hypertension
13
2. (hypertensive urgency)
( DBP > 120
mm Hg) target organ damage
, , (epistaxis)
(non-compliance) (inadequate
therapy)
24-48
captopril, labetalol clonidine
( 1-2 )
DBP < 120 mm Hg
1-2 JNC 7
shorting-acting nifedipine
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13
3 1. 52 Dyslipidemia, HTN, DM
EKG ST-depression acute coronary syndromes
BP 220/130 mmHg, RR 20, P 86, Temp 37.6 amlodipine 10 mg
AM, HCTZ 25 mg AM, glipizide 10 mg/day, aspirin 80 mg/day, atorvastatin 10 mg HS
2. 45 Dyslipidemia, HTN amlodipine 10 mg AM
BP
220/120 mmHg, RR 20, P 86, Temp 37.6
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Guidelines & Review Articles
Chobanian AV, Bakris GL, Black HR. et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. Hypertension. 2003; 42: 1206-52.
The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). 2007 Guidelines for the Management of Arterial Hypertension. Journal of Hypertension 2007, 25:
11051187.
National Institute for Health and Clinical Excellence. NICE clinical guideline 127 Hypertension: clinical management of primary
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