ESSENTIAL HYPERTENSION , COMBINATION OF CCB AND ARB, CHOICE AGENTS BY Dr. BAMBANG SN, Sp. PD DEPARTMENT OF INTERNAL MEDICINE GENERAL HOSPITAL OF Dr. SOEDARSO PONTIANAK Presented on Round Table Discussion of Hypertension April, 07 th 2013, Pontianak, West Kalimantan
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Essenstial Hypertention, What the Rationale Option Treatment
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ESSENTIAL HYPERTENSION , COMBINATION OF CCB AND ARB,
CHOICE AGENTS
BYDr. BAMBANG SN, Sp. PD
DEPARTMENT OF INTERNAL MEDICINEGENERAL HOSPITAL OF Dr. SOEDARSO
PONTIANAK
Presented on Round Table Discussion of Hypertension
April, 07th 2013, Pontianak, West Kalimantan
I. INTRODUCTIONHypertension is still an important problem in the world time by time, because of highly prevalence and its serious complication esspecially cardio vascular disease (CVD).
More than 95% cases is essential hypertension, the rest is secondary.Associated with modern style, the risk factors such as sedantary life, physical inactivity, hyperlipidemie, obesity, distress, and tobacco smoking have important role on pathogenesis essential hypertension.
Life style modification is a basic way in management of hypertension before or together medication treatment.
Provider must recognize profile of anti-hypertensive agent that will be given to hypertensive patient for safety and better result.
Blood pressure can be controlled by medication besides life style modification to avoid or delay acute or chronic complication esspecially CVD.
II. PATHOGENESIS II. PATHOGENESIS There are many factors contribute to controle blood There are many factors contribute to controle blood
pressure, such as genetic, obesity, stress, sodium pressure, such as genetic, obesity, stress, sodium intake, nephron number and endothelium derived intake, nephron number and endothelium derived factors.factors.
Renin angiotensin aldosteron system is the most Renin angiotensin aldosteron system is the most important system, that regulate blood important system, that regulate blood pressurepressure
When thWhen thisis system does uncontrole, blood pressure will system does uncontrole, blood pressure will go up persistanly and hypertension will accure. go up persistanly and hypertension will accure.
To control and lower blood pressure, we have to stop To control and lower blood pressure, we have to stop production of angiotensinproduction of angiotensin II II or eliminate its effect on or eliminate its effect on the receptor.the receptor.
All conditions as risk factors of All conditions as risk factors of hypertension produce oxidatif stress, that hypertension produce oxidatif stress, that affect endothelial dysfuction and smooth affect endothelial dysfuction and smooth muscle activation.muscle activation.
Treatment of hypertension must be started Treatment of hypertension must be started by lifestyle modification and then followed by lifestyle modification and then followed drug medication.drug medication.
Lifestyle modification incluLifestyle modification includede weight weight reduction, eating plan, sodium reduction reduction, eating plan, sodium reduction intake, phisycal activity and moderation intake, phisycal activity and moderation alcohol consumption and so on.alcohol consumption and so on.
Some of Factors Involved in Controlling Blood Pressure
• How serious and dangerous of hypertension because it has many complications, acute and chronic esspecially cardiovascular events.
• It is our task and responsibility to socialize and inform about hypertension and its implication to all people, esspecially those at risk.
• Unfortunetelly not all people know about their blood pressure, also hypertension patients do not understand well and not allert to seek medical acces.
IV. Prevalence of Hypertension
• In fact, prevalence of hypertension is increased time by time.
• It is influenced by several condition and risk factors. The older people the higher blood pressure.
Elevated systolic BP interacts with diabetes to increase CVD risk
MRFIT: men with diabetes and elevated systolic BP are at greater risk of CVD than those without
diabetes
0
50
100
150
200
250
300
<120 120-139 140-159 160-179 180-199 ≥200
CVD
dea
ths
per 1
0,00
0 pe
rson
-ye
ars
Systolic BP (mm Hg)
Patients with diabetesPatients without diabetes
Stamler et al, Diabetes Care, 1993.
VI. Treatment of Hypertension• Trials and experiences indicate that decreasing blood
pressure decreasing prevalence all complication.• Every lowering systolic blood pressure of 23 mmHg, lower
incidens of stroke, heart failure and myocardial infartion.• Doctors have to initiate treatment as soon as possible for
patients with hypertension, to ovoid and eliminate acute or chronic complication.
• There are 2 ways approachs, the 1st is nonfarmacologic and the 2nd is farmacologic. Don’t wait to treat hypertension, more earlier more better result.
In every 23 mmHg reduction in Systolic Blood In every 23 mmHg reduction in Systolic Blood Pressure, Pressure, lowers incidence of........lowers incidence of........
-42%
-26%-29% -30% -31%
-45%
-30%
-15%
0%
Per
cent
Red
uctio
n
*Fatal and nonfatal heart failure and nonfatal myocardial infarction and sudden death **Fatal and nonfatal heart failure and nonfatal myocardial infarction, sudden death and stroke
* **Stroke All cardiac
end pointsMIHeart
Failure
All fatal/ nonfatal cardiovascular
end points
Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99
mmHg) Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
http://www.nice.org.uk/download.aspx?o=CG034fullguideline.Accessed June 2006
UK NICE Guidelines: Treatment for Recent Diagnosis of Hypertention
Possible combination of different classes of anti hypertension drugs
Most rationalcombination
Proven bene-ficial in trialsJournal. Of Hypertension 2003
Current Guidelines Recommend Initiating Combination Therapy Early in Patients with Stage 2 Hypertension or High Cardiovascular Risk
• JNC 7 guidelines state1:“When BP is more than 20 mmHg above systolic goal or 10 mmHg above diastolic goal, consideration should be given to initiate therapy with 2 drugs...”
• ESH/ESC guidelines state2:“A combination of two drugs at low doses should be preferred as first step treatment when initial BP is in the grade 2 or 3 range or total cardiovascular risk is high or very high.”
1Chobanian et al. Hypertension 2003;42:1206–52 2Mancia et al. J Hypertens 2007:25:110587
ESH = European Society of HypertensionESC = European Society of CardiologyJNC = Joint National Committee
Angiotensin II Effects
– Vasoconstriction– Aldosteron secretion– Sodium reabsorption– Symphatic activation– Vasopressin release– Hypertrophy and proliferation of
myocardium and vascular cells
ARB
AT Receptors:•Heart•Vascular•Lung•Liver•Kidneys•Adrenal, Prostate•Placenta, Brain
Angiotensin Receptor Blocker
• Angiotensin Receptor– Mostly on heart and vascular– Another organs : lungs, liver, kidneys,