CARDIOLOGY
HYPERTENSION
- Most common long-term drug use disease
- Common complications on target organs: CV disease (stroke), CHD, LVH, heart failure, AF, renal disease:
FSGE (renal insufficiency), HT retinopathy, peripheral vascular disease (aortic aneurysm, aortic dissection)
- Cause: Primary (Essential) or Secondary
- Main causes of deaths associated to HT: Stroke (45%), Heart Failure, Renal Failure
- Classification:
• Essential HT—90-95%; persistent HT in absence of underlying disease
• Secondary HT—5-10%; due to underlying disease
Causes: Renal Disease; Endocrine Disease; Coarctation of the Aorta (newborns);
Polyarteritis Nodosa; Pregnancy
*Refer ASAP if diagnosis is clear
• Malignant HT—diastolic pressure > 120 mmHg and exudative vasculopathy in retinal and renal
circulation; HT EMERGENCY or URGENCY
• Refractory HT—BP > 140/90 mmHg after maximum doses of 2 drugs x 3-4 months
- Most common presentation in secondary severe HT is hypertensive retinopathy
In young patient with acute HT, initial assessment are in-office tests that suggest or confirm a secondary
cause; Older patients can present with chronic progressive changes in fundoscopy —common cause is
chronically untreated elevated BP in essential HT
Fundoscopy Changes
Cotton wool spot
Arteriovenous nipping
, Affects insulin and could worsen
DM control → IMPROVE DM
CONTROL/ MONITORING 1st line for CAD and HF with reduced EF—extends diastolic period
( myocardial O2 demand)
In angina: BB + NTG + Statins
Contraindicated in Bronchial Asthma
> 65 years old,
non-complicated HT
/ Ischemic
heart
disease
< 65 years old, ALWAYS
complicated HT FIRST LINE
not used with BB → heart block
- Affects AV node
- Extends diastolic period
If with side effects to
ACEI/ARB, shift to CCB Have negative cardiac inotropic and
chronotropic effect with modest
vasodilatory effect
May be useful in patients with stable
angina; contraindicated with left
ventricular failure or left ventricular
ejection fraction < 40%--worsen
myocardial function
,4-6 week trial for optimal
effect of the drug
If ineffective→
increase gradually to
maximum dose
recommended or add a
drug from another
compatible class
Add 1 drug at a time
and wait for 4 weeks
between dosage
adjustments
Usually 1 drug from
any class at the same
time
**The main objective of drug therapy is to prevent long-term complications of elevated blood pressure:
cardiovascular disease (CVD), heart failure, kidney disease
**The decision to start BP-lowering treatment should be primarily determined by patient’s absolute VCD risk
**Before starting drug therapy, confirm that elevated BP is not secondary to a treatable cause
AMBULATORY 24-HOUR MONITORING INDICATIONS:
▪ Fluctuating HT
▪ Borderline levels
▪ Refractory HT
▪ Timing in drug therapy
▪ Resistance to drug therapy
▪ Suspected sleep apnoea
HYPERTENSIVE URGENCY
- Severe and persistent elevation of BP > 180/110 mmHg associated with significant symptoms such as
headache or dizziness, mild to moderate nonacute end-organ damage or dysfunction
- Should be referred to hospital for investigations
- Management with oral therapy is usually appropriate; aiming for relief of symptoms and a slow,
nonprecipitous reduction of BP to a safe level
- Medications:
NIFEDIPINE 10 mg immediate-release, orally
Captopril 12.5mg orally
, Clonidine 100 mcg orally
Prazosin 2 mg orally
*If patient is unable to take oral therapy, give IV Hydralazine
HYPERTENSIVE EMERGENCY
- Severe elevation in BP, usually above > 220/140 mmHg, that is associated with acute end-organ damage
or dysfunction, such as acute pulmonary oedema, acute kidney failure, hypertensive encephalopathy,
papilledema or cerebrovascular haemorrhage
- Life-threatening
- Arrange immediate transport to hospital by ambulance for treatment in an emergency department, ICU
or CCU
- Medications:
IV Hydralazine bolus
IV Metoprolol tartrate bolus
Esmolol-Glyceryl trinitrate by IV infusion
Furosemide
Na nitroprusside IV infusion—begins to lower BP in minutes; requires blood testing and ICU monitoring;
contraindicated in pregnancy and severe kidney or liver impairment
WHEN TO REFER:
▪ Refractory HT
▪ HT Urgency/Emergency
▪ Ongoing target organ impairment
▪ Kidney Failure (GFR < 60 ml/min)
▪ If a secondary treatable cause is found
HYPERTENSION
- Most common long-term drug use disease
- Common complications on target organs: CV disease (stroke), CHD, LVH, heart failure, AF, renal disease:
FSGE (renal insufficiency), HT retinopathy, peripheral vascular disease (aortic aneurysm, aortic dissection)
- Cause: Primary (Essential) or Secondary
- Main causes of deaths associated to HT: Stroke (45%), Heart Failure, Renal Failure
- Classification:
• Essential HT—90-95%; persistent HT in absence of underlying disease
• Secondary HT—5-10%; due to underlying disease
Causes: Renal Disease; Endocrine Disease; Coarctation of the Aorta (newborns);
Polyarteritis Nodosa; Pregnancy
*Refer ASAP if diagnosis is clear
• Malignant HT—diastolic pressure > 120 mmHg and exudative vasculopathy in retinal and renal
circulation; HT EMERGENCY or URGENCY
• Refractory HT—BP > 140/90 mmHg after maximum doses of 2 drugs x 3-4 months
- Most common presentation in secondary severe HT is hypertensive retinopathy
In young patient with acute HT, initial assessment are in-office tests that suggest or confirm a secondary
cause; Older patients can present with chronic progressive changes in fundoscopy —common cause is
chronically untreated elevated BP in essential HT
Fundoscopy Changes
Cotton wool spot
Arteriovenous nipping
, Affects insulin and could worsen
DM control → IMPROVE DM
CONTROL/ MONITORING 1st line for CAD and HF with reduced EF—extends diastolic period
( myocardial O2 demand)
In angina: BB + NTG + Statins
Contraindicated in Bronchial Asthma
> 65 years old,
non-complicated HT
/ Ischemic
heart
disease
< 65 years old, ALWAYS
complicated HT FIRST LINE
not used with BB → heart block
- Affects AV node
- Extends diastolic period
If with side effects to
ACEI/ARB, shift to CCB Have negative cardiac inotropic and
chronotropic effect with modest
vasodilatory effect
May be useful in patients with stable
angina; contraindicated with left
ventricular failure or left ventricular
ejection fraction < 40%--worsen
myocardial function
,4-6 week trial for optimal
effect of the drug
If ineffective→
increase gradually to
maximum dose
recommended or add a
drug from another
compatible class
Add 1 drug at a time
and wait for 4 weeks
between dosage
adjustments
Usually 1 drug from
any class at the same
time
**The main objective of drug therapy is to prevent long-term complications of elevated blood pressure:
cardiovascular disease (CVD), heart failure, kidney disease
**The decision to start BP-lowering treatment should be primarily determined by patient’s absolute VCD risk
**Before starting drug therapy, confirm that elevated BP is not secondary to a treatable cause
AMBULATORY 24-HOUR MONITORING INDICATIONS:
▪ Fluctuating HT
▪ Borderline levels
▪ Refractory HT
▪ Timing in drug therapy
▪ Resistance to drug therapy
▪ Suspected sleep apnoea
HYPERTENSIVE URGENCY
- Severe and persistent elevation of BP > 180/110 mmHg associated with significant symptoms such as
headache or dizziness, mild to moderate nonacute end-organ damage or dysfunction
- Should be referred to hospital for investigations
- Management with oral therapy is usually appropriate; aiming for relief of symptoms and a slow,
nonprecipitous reduction of BP to a safe level
- Medications:
NIFEDIPINE 10 mg immediate-release, orally
Captopril 12.5mg orally
, Clonidine 100 mcg orally
Prazosin 2 mg orally
*If patient is unable to take oral therapy, give IV Hydralazine
HYPERTENSIVE EMERGENCY
- Severe elevation in BP, usually above > 220/140 mmHg, that is associated with acute end-organ damage
or dysfunction, such as acute pulmonary oedema, acute kidney failure, hypertensive encephalopathy,
papilledema or cerebrovascular haemorrhage
- Life-threatening
- Arrange immediate transport to hospital by ambulance for treatment in an emergency department, ICU
or CCU
- Medications:
IV Hydralazine bolus
IV Metoprolol tartrate bolus
Esmolol-Glyceryl trinitrate by IV infusion
Furosemide
Na nitroprusside IV infusion—begins to lower BP in minutes; requires blood testing and ICU monitoring;
contraindicated in pregnancy and severe kidney or liver impairment
WHEN TO REFER:
▪ Refractory HT
▪ HT Urgency/Emergency
▪ Ongoing target organ impairment
▪ Kidney Failure (GFR < 60 ml/min)
▪ If a secondary treatable cause is found
