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Hypertension–Pharmacological Treatment
Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of CardiologyNational Institute of Cardiovascular Diseases,
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branchHonorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi [email protected]
SummaryOnce hypertension develops, pharmacologic treatment is needed to reduce BP and prevent CVD outcomes.
Clinical trial data indicate that lowering BP with antihypertensive drugs effectively reduces CVD outcomes,including stroke, CHD, CHF, and CV death, as well as total mortality.
Outcome benefits have been seen particularly with antihypertensive regimens based on ACEIs, ARBs, CCBs, anddiuretics (such as chlorthalidone). Meta analyses of data from randomized controlled trials have not shownsignificant differences in total major CV
events between regimens based on ACEIs, ARBs, or CCBs, and diuretics,with traditional beta blockers being less effective.
For outcomes other than CHF, differences in achieved SBP reduction have been shown in some analyses to berelated to the extent of risk reduction, independent of treatment assignment. Therefore, some would argue that, forhypertensive patients as a whole, reduction of BP (especially SBP) is possibly more important than choice ofantihypertensive drug(s) for reducing CVD risk. However, this remains controversial.
Clinical trials have shown that in most patients, two or more antihypertensive medications are required to achievegoal BP, namely <140/90 mm Hg in most; <130/80 mm Hg in those with diabetes, CKD, CAD, CAD equivalents,and high risk patients, i.e., those with a Framingham risk score of ≥10%. Accordingly, initiation of therapy with twoagents (in individual tablets or fixed dose combination) should be started in those with BP >20/10 mm Hg abovegoal.
SummaryJNC 7 guidelines recommend using thiazide type diuretics as first line treatment in most hypertensives,
and incombination with other drug classes where multiple drugs are required. This differs from European guidelines, in
which antihypertensive drug choices are left up to the health care provider.The American Heart Association (AHA) Scientific Statement on hypertension and CAD has emphasized ACEIs,ARBs, and CCBs as the most appropriate agents, with a diuretic. The rationale for the preferred status of the
diuretics such as chlorthalidone includes: 1) the favorable outcome trial data delineating their benefits, 2) theirability to enhance the antihypertensive efficacy of most other drug classes, and 3) their low cost. Their biochemical
adverse effects (i.e., hypokalemia, reduced insulin sensitivity) and diabetes are a concern, and may in the longer
term negate the shortt erm benefit seen in the clinical trials.A hypertensive patient may also have a high risk condition (e.g., CAD, diabetes, CKD) that constitutes acompelling indication for use of other antihypertensive drug classes. In that case, initial treatment should bedictated by the compelling indication, bearing in mind that BP control is paramount. Treatment guidelines
from JNC 7, as well as the AHA, American College of Cardiology, ADA, and the NKF concur on the drug class choices for each compelling indication.
RAS agents have been shown to be beneficial in patients with CAD, diabetes, or CKD. In addition, beta blockers
are indicated in established CAD, and CCBs can be used in patients with high CHD risk or diabetes based onoutcomes data.Meta analyses have shown that treatment regimens based on ACEIs, ARBs, and CCBs are superior to
thosebased on thiazide diuretics or traditional beta blockers. The caveat is that most of these studies usedhydrochlorothiazide as the diuretic and atenolol as the beta blocker. Chlorthalidone, which is not a
thiazide per se,has been shown to be effective, and is likely to supplant hydrochlorothiazide as the diuretic of choice.Newer beta blockers (carvedilol, metoprolol, bucindolol, nebivolol), lower BP and are also effective in
improvingoutcomes in patients with impaired LV function.CVD is the leading cause of morbidity and mortality in developed countries, and aggressive risk factormodification is needed to control this burgeoning public health problem. Tight BP control is
fundamental forprimary and secondary prevention of CVD
Summary
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