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Showing posts with label Hypertension. Show all posts
Showing posts with label Hypertension. Show all posts

What is the role of ACE inhibitors in hypertension ?

What is the role of ACE inhibitors in hypertension ?


• In the HOPE (Heart Outcomes Prevention Evaluation) study the use of ramipril was associated with reductions of stroke, coronary artery disease and heart failure in both hypertensive and non-hypertensive groups as compared to placebo (N Engl J Med 2000; 342: 145-53).

• In the Captopril Prevention Project (CAPPP) the risk of stroke was slightly greater with ACE inhibitor based therapy than with diuretic-based or beta-blocker based therapy but the higher baseline and follow-up blood pressure among patients assigned the ACE inhibitor regimen may largely or entirely account for the excess risk of stroke (Lancet 1998; 353:611-16).
What is the role of ACE inhibitors in hypertension ?


• In the HOPE (Heart Outcomes Prevention Evaluation) study the use of ramipril was associated with reductions of stroke, coronary artery disease and heart failure in both hypertensive and non-hypertensive groups as compared to placebo (N Engl J Med 2000; 342: 145-53).

• In the Captopril Prevention Project (CAPPP) the risk of stroke was slightly greater with ACE inhibitor based therapy than with diuretic-based or beta-blocker based therapy but the higher baseline and follow-up blood pressure among patients assigned the ACE inhibitor regimen may largely or entirely account for the excess risk of stroke (Lancet 1998; 353:611-16).

What is the role of calcium channel blockers in the treatment of hypertension ?

What is the role of calcium channel blockers in the treatment of hypertension ?
 

• In the SYST-EUR study nitrendipine showed a reduction in the risk of stroke
inisolated systolic hypertension when compared to diuretics (Lancet 1997; 350: 757-64).
 

• In the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) study, there was some evidence that the risks of myocardial infarction and of heart failure were greater with calcium antagonist based therapy than with ACE-inhibitor based therapy, but there were no clear differences between either of these regimens and a third based on diuretics and beta-blockers (Lancet 1999; 354: 1751-6). In this study 34-39% of patients withdrew from the three treatment regimens.
 

• The International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment
(INSIGHT) trial compared long-acting nifedipine with a diuretic (hydrochlorothiazide and amiloride combination) and found that the calcium channel antagonist was as effective as diuretics in preventing overall cardiovascular or cerebrovascular complications (Lancet 2000; 356: 366-72). There was a marginally significant excess of heart failure with nifedipine-based treatment. Fatal myocardial infarctions were more common in the nifedipine group. There was an 8% excess withdrawal of drug in the nifedipine group because of peripheral oedema whereas serious adverse events were more frequent in the diuretic group.
 

• In the Nordic Diltiazem Study (NORDIL) from Sweden diltiazem was compared with diuretics,
beta-blockers or both (Lancet 2000; 356: 359-65). This study found that diltiazem was as effective as treatment based on diuretics, beta-blockers or both in preventing the primary end point of all stroke, myocardial infarction and other cardiovascular deaths. There was a marginally significant lower risk of stroke in the diltiazem group despite a lesser reduction in blood pressure. In this study, 23% of the patients withdrew from the diltiazem-based group and 7% withdrew from diuretic-based and beta-blocker based therapy.
What is the role of calcium channel blockers in the treatment of hypertension ?
 

• In the SYST-EUR study nitrendipine showed a reduction in the risk of stroke
inisolated systolic hypertension when compared to diuretics (Lancet 1997; 350: 757-64).
 

• In the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) study, there was some evidence that the risks of myocardial infarction and of heart failure were greater with calcium antagonist based therapy than with ACE-inhibitor based therapy, but there were no clear differences between either of these regimens and a third based on diuretics and beta-blockers (Lancet 1999; 354: 1751-6). In this study 34-39% of patients withdrew from the three treatment regimens.
 

• The International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment
(INSIGHT) trial compared long-acting nifedipine with a diuretic (hydrochlorothiazide and amiloride combination) and found that the calcium channel antagonist was as effective as diuretics in preventing overall cardiovascular or cerebrovascular complications (Lancet 2000; 356: 366-72). There was a marginally significant excess of heart failure with nifedipine-based treatment. Fatal myocardial infarctions were more common in the nifedipine group. There was an 8% excess withdrawal of drug in the nifedipine group because of peripheral oedema whereas serious adverse events were more frequent in the diuretic group.
 

• In the Nordic Diltiazem Study (NORDIL) from Sweden diltiazem was compared with diuretics,
beta-blockers or both (Lancet 2000; 356: 359-65). This study found that diltiazem was as effective as treatment based on diuretics, beta-blockers or both in preventing the primary end point of all stroke, myocardial infarction and other cardiovascular deaths. There was a marginally significant lower risk of stroke in the diltiazem group despite a lesser reduction in blood pressure. In this study, 23% of the patients withdrew from the diltiazem-based group and 7% withdrew from diuretic-based and beta-blocker based therapy.

What is the role of alpha-blocker based regimens in the control of blood pressure ?

What is the role of alpha-blocker based regimens in the control of blood pressure ?
 

The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) trial showed that an alpha-blocker based regimen is less efi'ective than a diuretic-based regimen in preventing heart failure (JAMA 2000: 283: 1967-75). Additionally, there was a marginally significant excess of stroke in the alpha-blocker group. Although poorer blood pressure control might account for the higher risk of stroke, it does not entirely explain the two-fold greater risk of heart failure.
What is the role of alpha-blocker based regimens in the control of blood pressure ?
 

The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) trial showed that an alpha-blocker based regimen is less efi'ective than a diuretic-based regimen in preventing heart failure (JAMA 2000: 283: 1967-75). Additionally, there was a marginally significant excess of stroke in the alpha-blocker group. Although poorer blood pressure control might account for the higher risk of stroke, it does not entirely explain the two-fold greater risk of heart failure.

Why are diuretics and beta-blockers recommended as first-line agents in the management of hypertension?

Why are diuretics and beta-blockers recommended as first-line agents in the management of hypertension?
 

Until recently, evidence about the effects of blood pressure lowering agents on the risks of cardiovascular complications came exclusively from trials of diuretic-based or beta-blocker based regimens in the hypertensive population. Those trials collectively showed reductions in risk of stroke and coronary heart disease of about 38% and 16% respectively (Br Med Bull 1994; 50: 272-98) and reductions in the risk of heart failure of about 40% (Hypertension 1989; 13 (5 suppl): 174-9: JAMA 1997; 278: 212-16).
Why are diuretics and beta-blockers recommended as first-line agents in the management of hypertension?
 

Until recently, evidence about the effects of blood pressure lowering agents on the risks of cardiovascular complications came exclusively from trials of diuretic-based or beta-blocker based regimens in the hypertensive population. Those trials collectively showed reductions in risk of stroke and coronary heart disease of about 38% and 16% respectively (Br Med Bull 1994; 50: 272-98) and reductions in the risk of heart failure of about 40% (Hypertension 1989; 13 (5 suppl): 174-9: JAMA 1997; 278: 212-16).

How would you manage a patient with mild hypertension ?

How would you manage a patient with mild hypertension ?
 

General measures
 

• Diet: weight reduction in obese patients, low-cholesterol diets for associated hyperlipidaemia, salt
restriction. Increased consumption of fruit and vegetables.
 

• Regular physical exercise that should be predominantly dynamic (for example brisk walking) rather
than isometric (weight lifting).
 

• Limit alcohol consumption (<14 units per week for women and <21 units/week for men).
 

• Stop smoking.
 

Antihypertensives
 

Beta-blockers or low-dose thiazides.
 

Other drugs
 

Aspirin, statins.
How would you manage a patient with mild hypertension ?
 

General measures
 

• Diet: weight reduction in obese patients, low-cholesterol diets for associated hyperlipidaemia, salt
restriction. Increased consumption of fruit and vegetables.
 

• Regular physical exercise that should be predominantly dynamic (for example brisk walking) rather
than isometric (weight lifting).
 

• Limit alcohol consumption (<14 units per week for women and <21 units/week for men).
 

• Stop smoking.
 

Antihypertensives
 

Beta-blockers or low-dose thiazides.
 

Other drugs
 

Aspirin, statins.

What is the purpose of treatment in hypertension ?

What is the purpose of treatment in hypertension ?
 

The purpose is to reduce the risk of devastating hypertensive complications such as myocardial infarction, stroke and heart failure.
What is the purpose of treatment in hypertension ?
 

The purpose is to reduce the risk of devastating hypertensive complications such as myocardial infarction, stroke and heart failure.

What are causes of hypertension ?



What are causes of hypertension ?

· Unknown or idiopathic (in 90% of cases).

· Renal: glomemlonephritis, diabetic nephropathy, renal artery stenosis, pyelonephritis. 


· Endocrine:Cushing's syndrome, steroid therapy, phaeochromocytoma.

· Others: coarctation of aorta, contraceptives, toxaemia of pregnancy.



What are causes of hypertension ?

· Unknown or idiopathic (in 90% of cases).

· Renal: glomemlonephritis, diabetic nephropathy, renal artery stenosis, pyelonephritis. 


· Endocrine:Cushing's syndrome, steroid therapy, phaeochromocytoma.

· Others: coarctation of aorta, contraceptives, toxaemia of pregnancy.

How would you investigate a patient with hypertension in outpatients ?

How would you investigate a patient with hypertension in outpatients ?
 

• Full blood count (FBC).
• Urine for sugar, albumin and specific gravity.
• Urea, electrolytes and serum creatinine.
• Fasting lipids, fasting blood sugar, serum uric acid.
• Serum total:HDL cholesterol ratio.
• ECG.
• Chest radiograph.
• 24-hour urine collection to measure vanillylmandelic acid.
How would you investigate a patient with hypertension in outpatients ?
 

• Full blood count (FBC).
• Urine for sugar, albumin and specific gravity.
• Urea, electrolytes and serum creatinine.
• Fasting lipids, fasting blood sugar, serum uric acid.
• Serum total:HDL cholesterol ratio.
• ECG.
• Chest radiograph.
• 24-hour urine collection to measure vanillylmandelic acid.

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