Pediatric Hypertension

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Pediatric Hypertension , Causes , Diagnosis , management : www. pedheartsat. org

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Presentation Transcript

GREETINGS FROM THIRUVANANTHAPURAM : 

GREETINGS FROM THIRUVANANTHAPURAM

PEDIATRIC HYPERTENSIONNot so Uncommon ? : 

PEDIATRIC HYPERTENSIONNot so Uncommon ? M.Zulfikar Ahamed Thiruvananthapuram, Kerala

Slide 3: 

Major causes of Deaths In India (2005) Source : WHO

MORBIDITY IN INDIA : 

MORBIDITY IN INDIA

Slide 5: 

The Deadly Quartet DIABETES HYPERTENSION DYSLIPIDEMIA OBESITY SMOKING

HYPERTENSION : 

HYPERTENSION 50 % of Stroke EYES P VESSEL KIDNEY 25 % of AMI

Slide 7: 

What is Hypertension ? “ level of BP at which there is a doubling of long term CVD risk ” Only an arbitrary answer !

Slide 8: 

140 mmHg SBP CVD risk _ _ _ _ _ 5 4 3 2 1

Slide 9: 

85 – 90 mmHg DBP CVD risk _ _ _ _ _ 5 4 3 2 1

Slide 10: 

DOUBLING OF RISK occurs at - Adult SBP : 130 – 139 140 mm Hg DBP : 85 – 89 90 mm Hg

Slide 11: 

STAGING of BPJNC 7 Stage SBP DBP Action Optimal < 120 < 80 no Pre hypertension 120 –139 80- 89 recheck . LSM Hypertension Stage 1. 140 –159 90 –99 Confirm + Evaluate 2. 160 –179 100- 109 Evaluate . Refer 3. > 180 > 110 Evaluate – immediate refer

Slide 12: 

Adult hypertension has antecedence in childhood Childhood HTN can track to adult and cause CVD WHY PEDIATRIC HTN Is important ?

Slide 13: 

CUPS study - 21 % Bombay 2004 - > 40 % Gupta - 30 % Kerala - 47 % HAP (Kerala) - 41 % ADULT HTN Prevalence

ADULT HTN India Over The Years : 

ADULT HTN India Over The Years 5% 15% 30% 35% 40% 1960 1990 1995 2000 2005

Slide 15: 

Urban : 25 – 30 % Rural : 10 – 15 % INDIA HTN Burden Pooled values May be

Slide 16: 

1989 USA 1 - 3 % 2004 USA 5 % HYPERTENSION Prevalence in Children “ Average BP may be increasing across pediatric Population over time ” ? Secular trend Increasing BMI

Slide 17: 

11 - 17 years No : 6790 HTN PREVALENCE J Ped 2007 Hypertension : 9 % Pre hypertension : 9 % 3rd Reading : PH 15 . 0 % H 3.0 %

Slide 18: 

PREVALENCEChildhood HypertensionJ of Pediatrics 20076790 children11 – 17 years 9% 9% 3% 15% INITIAL 3RD PRE HTN PRE HTN HTN HTN

Slide 19: 

Name year AGE Prevalence % PEDIATRIC HTN Over the years (India & Abroad) Gupta Verma Anand Moudo Sorof 0.34 0. 40 (13 .7) 3.5 5.2 4.5 5-15 5-15 5-17 5-18 5-17 1990 1994 1996 1996 2002

Slide 20: 

1990 1994 1996 1996 2002 PEDIATRIC HTNOver the Years 3.5 5.2 4.5 Prevalence 0.34 0.40

Slide 21: 

>95th <5th Centile BMI centile c HBP; BMI in CHILDRENSorof etal 2004 2 11 Prevalence of HTN

Slide 22: 

No : 503 Age : 10 - 16 Prevalence : 6 - 16 % PEDIATRIC HTN Mysore, India

PREVALENCE AND RISK FACTORS OF HYPERTENSION AMONG SCHOOL CHILDREN AGED 9-12 YEARS IN TRIVANDRUM CITY : 

PREVALENCE AND RISK FACTORS OF HYPERTENSION AMONG SCHOOL CHILDREN AGED 9-12 YEARS IN TRIVANDRUM CITY P.M Abdul Saleem, Dr. Susan Uthup Dr. Lalitha Kailas SAT Hospital , GMC , Tvpm The prevalence of hypertension among school children in the age group 9-12 yrs Study was conducted in 2043 school children (both boys and girls) in various schools of Trivandrum City from January 2005 to December 2006..

Slide 24: 

PREVALENCE OF HYPERTENSION

BMI and Hypertension : 

BMI and Hypertension Both systolic and diastolic BP shows significant correlation with height ,weight and Body mass index. 37% of the obese children are found to be hypertensive

CONCLUSIONS : 

CONCLUSIONS The blood pressure percentiles for the study group ie, 50th , 90th , 95th and 99th centiles were obtained Overall prevalence of hypertension is 2.84% Prevalence of hypertension is high in male children As age increases , blood pressure increases. Mean systolic BP ranges from 97.07 to 101.88 Mean diastolic BP ranges from 62.74 to 67.90

Slide 28: 

EPIDEMIOLOGY of HTN Infant / Preschooler - Almost always secondary < 6 years - Renal PD .RVH. CoA 6-12 years - RPD. RVH. > 12 years - Primary

Slide 29: 

HTN & OBESITY Prevalence : 1 - 3 % In BMI > 5th centile : 30 %

Slide 30: 

METABOLIC SYNDROME Reaven 1988 Definitions: WHO NCEP IDF

Slide 31: 

METABOLIC SYNDROMEA Road To Perdition OBESITY INSULIN RESISTANCE CVD TG HTN TG HDL HTN HG

Slide 32: 

METABOLIC SYNDROME IN CHILDREN 3 / 5 of Obesity ( BMI / WC) Hypertension IGT / HG HDL- low TG - high

Slide 33: 

Hyperglycemia Hypertension Obesity Low HDL High TG MS IN CHILDREN Components 1.5% 4.9% 9.8% 23.3% 23.4%

Slide 34: 

HYPERTENSION Concept of Pre hypertension Philip T Dick Pre crime JNC VII 2003

HYPERTENSION Child onset ? : 

HYPERTENSION Child onset ? TRACKING : Adolescents who have high centiles of BP continue to have higher centiles in adulthood and are likely to develop hypertension

Slide 36: 

TRACKING in HTN Child Adol Young Ad Adult BP Centile HTN 90th 50th 25th

Slide 37: 

TRACKING in HTN Child Adol Young Ad Adult BP Centile HTN 90th 50th 25th

Slide 38: 

Risk of CVD BP C B A

Slide 39: 

Population Primary Secondary HYPERTENSION Causes 95 % 85-90 % 5% 5 % 10-15 % 95 % Adult Child. Adolescence Young child. Infant

Slide 40: 

causes HYPERTENSION Adult Child Infant Adol Child % 90 % 90 % 10 % 5 % 95% 10 % secondary primary

Slide 41: 

HTN- Causes & age Newborn : Renal Arterial Thrombosis .RAS CoA. Renal anomaly < 6 years : RPD. RAS. CoA 6-12 yr : RAS. RPD . 10 HTN > 12 yrs : 10 HTN . RPD. RAS.

Slide 42: 

RENOVASCULAR HTN Uncommon; but prospect of Cure 5-10% Fibromuscular dysplasia Vasculitis External compression Others Causes: > 10 % Familial

Slide 43: 

HTN Renal Endocrine Tumors CNS causes Drugs. Toxins Miscellaneous CVS 1. Primary 2. Secondary Renal Parenchymal Renal Vascular

Renal Hypertension - SAT Experience : 

Renal Hypertension - SAT Experience Renal parenchymal disease 68 Reflux Nephropathy - 17 FSGS 16 Posterior urethal valve & renal failure - 13 Lupus Nephritis 7 D- HUS 5 Cystic Renal disease 4 Hypoplastic Kidneys 3 IgA Nephropathy 3 Renal artery stenosis 2

Slide 45: 

Family history 86% Obesity 52% PRIMARY HTN

Slide 46: 

Sphygmomanometer Oscillometry Doppler ‘Intraarterial’ BP RECORDING Mercury Aneroid

Slide 47: 

Routine : > 3 years BP RECORDING < 3.0 years Preterm baby LBW Child with CHD Child with CKD Child with F /H kidney disease Systemic diseases Certain drugs

Slide 48: 

Ease of use Easy in newborn ,ICU No inter observer bias OSCILLOMETRY Needs calibration ‘ Standards ’ Good Bad

Slide 49: 

CUFF SIZE Breadth Length in cms New born 4 8 Infant 6 12 Child 9 18 Adol –Adult 10 Adult 13

Slide 50: 

BP MEASUREMENT Practices in UK Only 2/3 Pediatricians took BP at OPD Only 50 % had appropriate cuff Unclear regarding definitions

Slide 51: 

BP VALUES < 1.0 yr - SBP only 1-17 yrs - SBP . DBP 95th -99th centile - 8mmHg

Slide 52: 

Normal : Both SBP < 90th centile Prehypertension : SBP/ DBP 90 - 95th centile Hypertension : SBP/ DBP > 95th centile Stage I 95th to 99th + 5 m Hg Stage II > 99th + 5 mm Hg DEFINITIONS

Slide 53: 

1. While Coat hypertension (WCH) High BP in office recordings; Normal ABP monitoring 2. Masked hypertension Normal BP in office recordings Abnormal values in ABP Monitoring 3. BP Load duration (%) of abnormal reading in ABPM DEFINITIONS

Slide 54: 

NEONATAL HTN < 7 days SBP > 96 mmHg . 28 days SBP > 104 mmHg

Slide 55: 

DOES THIS CHILD HAVE HBP ? Significant Newborn < 1wk 1-4 wk Infant (< 2yr ) 2 - 5 yrs 5 - 12 yrs > 12 yrs Severe 96 104 112 / 72 116 / 76 124 / 80 140 / 90 110 112 124 / 84 124 / 84 132 / 86 150 / 98

Slide 56: 

A 10 yr old boy has a BP of 136/94 Is he hypertensive ? YES Is it serious ? YES It is stage II HTN

Slide 57: 

WHITE COAT HYPERTENSION in Children In 15-20 % Linked to LV Mass ? Long term risk of CVD Mgt: LS Modification Monitoring – ABPM Look for risk factors

Slide 58: 

Genetic ; Familial Sensitivity to salt intake d RAA System d Sympathetic System OBESITY LBW ? PRIMARY HTN IN CHILDREN FACTORS

Slide 59: 

Genetic . Familial Obesity . Hormonal LBW . Renal anomaly Sodium intake . Formula ? PRIMARY HTN Causes

Slide 60: 

Pediatric HTN & Genetics > 10 polygenes control BP BP variation 30- 60 % gene Monogenetic HTN eg. Liddle Gordon BRIGHT study

Slide 61: 

HYPERTENSION Prenatal origin ? Environment IUGR Genetic LBW Post natal Hypertension

Slide 62: 

Pediatric Hypertension Symptomatic : 2/3 Head ache : 40 % Sleep dist : 30 % Tired : 25 %

Slide 63: 

SEC .HTN BMI OBESITY & CAUSES OF HTN 100%

Slide 64: 

WHY OBESITY CAUSES HTN ? in Cardiac Output in Blood volume Na+ intake Steroid production Cell receptor alteration Insulin resistance SVR

Slide 65: 

HTN & MetS Part of Meta bolic Syndrome ( 10% ) in Children Childhood HTN Adult Met Syndrome ( FELS study)

Slide 66: 

SECONDARY HYPERTENSION More common in children Very young children , Stage II hypertension & children with systemic findings are likely to have secondary Htn Lower limb BP measurement must

Slide 67: 

PRIMARY HYPERTENSION Co Morbidity Over weight; Obesity Sleep apnea Insulin Resistance Met Syndrome LOW HDL High TG IR Uric acid ? Clustering Phenomenon

Slide 68: 

CONFIRMED HTN (> 95 centile ) Basic Investigations Diagnostic Clue IMAGING BIOCHEMICAL

Slide 69: 

HTN Basal Investigations Urine RE. Urine C&S CBC RFT CXR Electrolytes ECG USS Abdomen Echo + S. glucose. Lipid profile. Insulin ADVANCED TESTING Clinical Exam. BMI. TOD ? Markers

Slide 70: 

EVALUATION in Overweight + BP > 90th centile All > 95 th centile ? FH of CVD / HTN CKD Lipid Profile Plasma Glucose ;Insulin Micro albuminuria

Slide 71: 

ADVANCED TESTING IMAGING BIOCHEMICAL MCU IVU Renal Scan MRI. MRA CT Scan DSA MIBG Scan TFT Urine Catecholamines Urine steroids PRA Micro albuminuria

Slide 72: 

Picks up LVH sens : 35 % spec : 90 % Electrolyte abnormalities ? ECG in HTN

Slide 73: 

LV Mass: 0.80 [ 1.04 ( IVS Thickness + LVID + LVPW thickness ) 3 - LVIOD 3] + 0.6 Abnormal > 51.0 gm/ M 2.7 ECHO

Slide 74: 

LVH ( LV Mass) LV Function Diastolic dysfunction [ 30-40 % ] Secondary causes eg: CoA Takayasu Arteritis Carotid IMT ? ECHOCARDIOGRAPHY In HTN

Slide 75: 

USS 80 55 Scintigraphy 70-90 70- 90 CT Angio 80-90 80- 90 MRA 90-98 70 - 100 EVAL: IMAGING Sens Spec NON INVASIVE INVASIVE DSA gold standard Renal vein sampling

Slide 76: 

Secondary HTN ? USS >95 th RVH RVH Likely less likely DSA MRA . CT Scan Treat with drugs Not controlled Pre & post Captopril scan

Slide 77: 

Low value : Mineralocorticoid related disease High value : RAS PRA screens

Slide 78: 

IMAGING in RVH Doppler Ultrasound Abdomen Intra arterial DSA IV DSA ? Captopril – Renal Scintigraphy MR Angio 3D CT reconstruction

Slide 79: 

PEDIATRIC HYPERTENSION TOD Severe Elevation : Chronic Elevation : CVA Encephalopathy CHF Death Accelerated atheroscleosis LV Mass Carotid IMT

Slide 80: 

MANAGEMENT OPTIONS Pre hypertension Recheck in 6 mo LSM 0 Drug Stage I Hypertension Recheck in 1-2wk LSM + Drug Evaluate Stage II Evaluate LSM + Drug Hypertension compelling indications CKD DM HF LVH * * *

Slide 81: 

LSM Exercise 30-60 mt / day TV watching < 2 hrs / day Salt 1.2- 1.5 gm Na+ DASH diet ?

Slide 82: 

LSM Benefits ( Fall in BP) Aerobic Exercise DASH diet Wt. Reduction (3-9%) Salt reduction Decrease Alcohol Stop smocking - 5 - 11 -3 - 5 - 4 ? - 4 - 6 - 3 - 3 - 2 ? SBP DBP

Slide 83: 

DASH RCT Proven benefit in Audit Ongoing trial in Children DASH diet + Sodium restriction ( < 1.6 gm) Mono drug treatment 1.6 gm Na = 4 gm salt

Slide 84: 

PRE HYPERTENSION 90 -95th centile LSM 90 - 95th < 90 th centile - OK OW N Wt Redn Monitor Rpt BP Consider Diagnostic Workup

Slide 85: 

Stage I HYPERTENSION Rpt BP 95th LSM Diagnostic workup I0 II0 LSM R + cause Drug Drug

Slide 86: 

STAGE I HTN LSM x 3-6 mo Not responsive Drugs Follow up 2 weekly Normal for 6 mo Step down Stop ?

Slide 87: 

STAGE II HTN Diagnostic Workup I0 II0 R cause Drugs

Slide 88: 

TREATMENT Secondary HTN Stage : I II LSM drugs + Drugs LSM Non remediable Remediable drugs + LSM Primary HTN surgical catheter Emergencies IV Drugs

Slide 89: 

Drug TRT In Children Patho physiological approach Stepped Care approach Cafeteria approach

Slide 90: 

INITIAL DRUGS Stage 2 HTN Symptomatic Secondary HTN TOD Diabetes No response to LSM

Slide 91: 

INDICATION FOR DRUG Symptomatic Hypertension Stage II Hypertension Secondary Hypertension Diabetes Mellitus Persistent Hypertension despite LSM

Slide 92: 

ACEI Popular . Any age Specially for Trials have shown Benefit Drugs: Diabetes Microalbuminuria Mild CKD Enalapril Lisinopril Ramipril Fosinopril

Slide 93: 

ARB Trials in children still progress Used beyond 6 yrs 2 drugs Losartan 0.7 – 1.4 / kg / D Irbesartan 75 – 150 mg / kg / D

Slide 94: 

B Blockers 2nd choice only Drugs: Bisoprolol Metoprolol Atenolol Bisoprolol + HCZ

Slide 95: 

CCB Primary choice in children I0 generation : Nifedipine II0 “ : Esradipine III0 “ : Amlodipine

Slide 96: 

AMLODIPINE 2.5 - 5 mg / day SBP irrespective of cause Dose dependent Benefit > 7-9 mm Hg fall AE < 5 % in childhood Hypertension RCT J Ped 2004

Slide 97: 

STEPPED CARE TRT STEP I Start one recommended drug II Increase the dose to maximum III Add a complementary drug IV ? Add a third drug GOAL : Bring < 95th centile

Slide 98: 

GOOD DRUGS For Childhood Hypertension Calcium Channel Blockers ACE Inhibitors ARB ( > 6 yrs) Bisoprolol + HCTZ

Slide 99: 

HTN Preferred Drugs ACE CCB 2nd line B Blockers ARB Diuretics All Ages ]

Slide 100: 

FIXED DOSE DRUG Beneficial ? ACE I + CCB ACE I + Diuretic ARB + Diuretic ACE I + ARB

Slide 101: 

PEDIATRIC HYPERTENSIVE Emergencies TYPE 1st Line 2nd Line Encephalopathy Ac LVF Cerebral Hge Ac Renal Failure NTP Labetalol Diuretics NTP Nimodipine Diuretics Nicardipine Esmolol Metoprolol NTG Enalaprilat NTG Nicardipine NTP

Slide 102: 

HYPERTENSIVE EMERGENCY IV Drugs 25 % reduction in 8 hours Gradual reduction to 95th centile in 24-48 hours

Slide 103: 

SECONDARY HYPERTENSION Specific R 1. RVH : Rercutaneous Transluminal Renal Angioplasty + stenting ? : Segmental Ethanol ablation : Revascularisation – Surgical : Nephrectomy

Slide 104: 

SECONDARY HYPERTENSION Specific R Tumor resection Nephrectomy : Unilateral NF Kidney Coarctation repair

CHILD ONSET ADULT HYPERTENSION : 

CHILD ONSET ADULT HYPERTENSION A Road map Fetal origin Adolescent Hypertension Tracking Adult Hypertension CVD Environment Co-morbid Conditions

Slide 106: 

< 5 yrs - BP > 110 / 70 mmHg 5 - 10 yrs - BP > 120 / 80 mmHg 15- 10 yrs - BP > 130 / 80 mmHg BP IN CHILDREN Evaluation Indicated if

Slide 107: 

ADOLESCENT HYPERTENSION 10 - 15 yrs SBP > 130 DBP > 80 mm hg 15 - 20 yrs SBP > 135 DBP > 85 mm hg

Slide 108: 

HTN - LSM Reduction in weight of 1 kg will SBP by 2- 3 mmHg DBP by 1- 2 mmHg

Slide 109: 

LSM - Impact Modification SBP reduction Weight reduction 5 - 20 mm Hg Sodium restriction 2 - 8 mm Hg Exercise 4 - 10 mm Hg Alcohol redn 2 - 4 mm Hg DASH eating plan 8 - 14 mm Hg

HYPERTENSION PREAMBLE : 

HYPERTENSION PREAMBLE One of the major risk factors for CVD Modifiable Asymptomatic disease in adults Advent of newer drugs. New drug combinations.

Slide 111: 

BP RECORDING Methods Sphygmomanometry Flush Oscillometry Doppler Cauterization Mercury Aneroid

Slide 112: 

How is the BP to be taken ? Near optimal surroundings Take it in the beginning and at end SBP K1 DBP K5

Slide 113: 

BP RECORDING SBP : K 1 DBP K 5 CUFFS : Newborn - 3 / 5 cms Infant - 5 cms Young child - 8 cms Older child - 12 cms

Slide 114: 

HYPERTENSION Evaluation Confirm high blood Pressure [ Age . Gender . Height ] 2.Clinical signs ; co morbid conditions; BMI 3.TOD - clinical assessment 4. LAB EVALUATION

Patient Evaluation : 

Patient Evaluation Assess the risk for CVD in a given patient. Assess target organ damage (TOD) Assess concomitant medical conditions Rule out secondary causes

CVD RISK STRATIFICATION TARGET ORGAN DAMAGE : 

CVD RISK STRATIFICATION TARGET ORGAN DAMAGE Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Slide 117: 

CHILD HOOD HYPERTENSIONLab Evaluation STEP I Basic Evaluation Urine RE C&S Renal Function ; Electrolytes Chest X ray . ECG. Echocardiography (?) Ultrasound Abdomen with Doppler Common Blood Counts Lipid profile Blood Glucose

Slide 118: 

CHILDHOOD HYPERTENSIONLab Evaluation STEP II Pause & Contemplate ? Which way to Go ? STEP III Advanced Evaluation

Slide 119: 

STEP II : Advanced Evaluation choose from 1. Urinary Catecholamines 1. Renal isotope scan 2. Urinary steroids 2. Aortography 3. Serum Cortisol etc 3. CT scan / MRI . MRA 4. TFTests 4. MIBG scan 5. Hormonal assays 6. PRA activity BIOCHEMICAL IMAGING

Slide 120: 

TREATING CHILDHOODHYPERTENSIONDRUGS ? Hypertensive emergency / urgency Severe HTN TOD Symptom / sign of hypertension Aim - to Bring down BP o < 90 th centile Always indicated in

Slide 121: 

TREATMENT

Slide 122: 

Why Should We Treat High BP ? Reduce CVD mortality and morbidity Reduce / Abolish Symptoms

Slide 123: 

TREATING HTN ACUTE CHRONIC

Slide 124: 

NON PHARMACOLOGIC MANAGEMENT 1. Diet Sodium restriction ( < 6 gm /day) Fall in SBP/ DBP 2. Dietary supplementation of Potassium 3. Weight reduction

Slide 125: 

NONPHARMACOLOGIC MANAGEMENT 4. Exercise 5. Reduce Alcohol consumption 6. Stress management 7. Vegetarian diet 8. Fiber intake +

Slide 126: 

HTN - LSM Reduction in weight of 1 kg will SBP by 2- 3 mmHg DBP by 1- 2 mmHg

Slide 127: 

LSM Impact Modification SBP reduction Weight reduction 5 - 20 mm Hg / kg Sodium restriction 2 - 8 mm Hg Exercise 4 - 10 mm Hg Alcohol redn 2 - 4 mm Hg DASH eating plan 8 - 14 mm Hg

Slide 128: 

Treating HBP ‘Lower the Better’ No J curve in action Concept of “ Pre hypertension”

Hypertension – goals of therapy : 

Hypertension – goals of therapy Effective control of BP Reduction in mortality Prevent morbidity – complications Cardioprotection Vasculoprotection Renoprotection

Slide 130: 

Inspite of 96 antihypertensives, the search is still on for the BEST antihypertensive…

Slide 131: 

DRUGS IN HYPERTENSION Diuretics b. Blockers ACE inhibitors Calcium Channel blockers Angiotension Receptor Blockers Vasodilators / a blockers

Slide 132: 

MAJOR ANTIHYPERTENSIVE DRUGS Diuretics b- blockers ACE inhibitors AR Blockers Calcium Channel Blockers and also … Vasodilators Centrally Acting Drugs

MANAGEMENT STRATEGY : 

MANAGEMENT STRATEGY Risk stratification Level of BP Presence of RF Presence of TOD Presence of ACC Non - pharmacologic measures Life style modifications Drug Therapy

Slide 134: 

Decrease in every mm of Hg counts… 1. Every 2mm decrease in DBP reduces the risk of CVD by 6%. 2. 2 mmHg reduction in SBP offers 7% reduction in death from ischemic heart disease 10% reduction in death from stroke

Slide 135: 

ANTIHYPERTENSIVES ‘First line’ ‘Front line’ ‘Preferred’

Slide 136: 

HTN - DRUGSWhich Drugs To Chose ? ACE Inhibitors Calcium Channel Blockers b-Blockers + Diuretics ?

Slide 137: 

ACE INHIBITORS Particularly helpful in Diabetic Nephropathy Effective in reducing CVD risks Very useful in CHF / Post MI patients Protects against ‘recurrent stroke’ Adverse effects - cough

Slide 138: 

ACEI - Overview Special Advantages : in Diabetes Nephropathy Coronary ischemia / Post MI LV Dysfunction

Slide 139: 

CALCIUM CHANNEL BLOCKERS Most popular Nifedipine Amlodipine Diltiazem Verapamil All ages; All race ! Reduce CVD events – esp : Stroke Use in a. Diabetes Mellitus ? b. Nephropathy ?

Slide 140: 

CALCIUM CHANEL BLOCKERS - Overview Very useful in Elderly Useful in prevention of Stroke Very good in co existing angina cyclosporine or NSAID use Preferable to have 2nd gen DHP – Amlodipine ( 24 hr action)

Slide 141: 

AR Blockers 6 recommended ARBS - comparable effect All are potentiated by a diuretic Used in ACEI induced cough also in Diabetes Nephropathy Most have a ‘24 hr effect’

Slide 142: 

Preferred initial choice Thiazides or Indapamide + K+ sparer Alone In combination Most useful in ‘Salt sensitive’ Adverse effects - ‘ low dose Diuretic’ Has Cardiovascular protective effect – ‘ ALLHAT’ DIURETICS

DIURETICS – SIDE EFFECTS : 

DIURETICS – SIDE EFFECTS Hypokalemia Effects on lipids Insulin resistance Hyperuricemia Hypercalcemia Sexual dysfunction

Diuretic therapy - options : 

Diuretic therapy - options Thiazide diuretics Loop diuretics Potassium sparing diuretics Aldosterone antagonists Combination diuretics Indapamide

Slide 145: 

DIURETICS - Overview Initial choice in most hypertension Least expensive drug Very important second choice ( Add on ) Useful in osteoporosis Lipid unfriendly – Impaired GTT

Slide 146: 

Atenolol : 1 mgm / kg / day Losartan : 0.5 - 1.0 mgm / kg /day once daily ( 25-50mg) HTN - DRUG DOSAGE

Slide 147: 

HTN - Drugs . Dosage Captopril : 2- 4 mg / kg / day 3 divided doses Enalapril : 0.1 mgm/ kg / dose 2 doses Nifedipine : 0.5 - 1.0 mgm / kg /day 3 divided doses

Slide 148: 

CHOSING ANTIHYPERTENSIVE DRUGS ? Patient profile 24 hour protection Combination therapy

Slide 149: 

HBPLSM Without Compelling Indications Compelling indic sp: Drugs Stage I Stage II Single drug 2 drug combination > 140 / 90 or > 130 / 80 Initial drug choice

Slide 150: 

2nd choice Appropriate a blockers b blockers ACEI / ARB CCB BPH CAD D Mellitus Elderly Arrhythmia CHF S HTN CHF ? CAD PVD 1st choice Diuretic

Slide 151: 

DRUGS Usage Nifedipine 0.5-1.0 mgm/kg/day TID SL - 0.25 – 0.5 mgm/kg Prazogin 5-30 mcg/kg/day QID

Slide 152: 

DRUGS Dosage DIURETIC Frusimide 2-3 mgm/ kg /day PO 1 mg /kg/ day IV Spironolactone 2-3 mgm/ kg/day PO Torsemide

Slide 153: 

DRUGS Dosage ACE Inhibitors Captopril 2-6 mgm/ kg/ day PO Enalapril 0- 1 mgm / kg/ day PO Ramipril

Slide 154: 

DRUGS Dosage Propranolol 2-6 mg /kg/ day P.O QID Atenolol 1-2 mg/kg/day P.O QD Metoprolol 0.5 –2 mgm/ kg/day P.O BID b-Blockers

Slide 155: 

DRUGS Usage IV Enalaprilat 5-10 mcg/kg over 5 mts IV bolus Nicardipine 0.5 – 5mcg/kg/mt infusion

Slide 156: 

DRUGS Dosage IV b-BLOCKERS Esmolol 500 mgm/kg IV bolus 50-300 mcg/kg /mt infusion Metoprolol 0-1 0.3 mgm/kg/ over 60mts Others NTP 0.5 – 8mcg/kg/mt infusion usual - 2-3 mcg /kg

CONGESTIVE CARDIAC FAILURE : 

CONGESTIVE CARDIAC FAILURE ACEI ARB Beta blockers / Carvedilol Diuretics Aldosterone antagonists

Slide 158: 

A. Calcium Channel Blockers ADOL. GIRL DRUG THERAPY ACE inhibitors b-blockers DiureticsARB

DIABETES : 

DIABETES ACEI ARB Low dose diuretics Beta blockers CCB Alpha blockers Combination therapy for most

Slide 160: 

Treating HBP - Disease & Drug Diabetes Mellitus ACE Inhibitors AR Blockers Diuretics Calcium Channel Blockers b- blockers

Hypertension and Renal failure : 

Hypertension and Renal failure Can ACEI be used? Caution: If serum creatinine > 3 mg / dl Progressive or persistent rise in creatinine Role of Fosinopril Loop diuretics preferred Thiazides ineffective if creatinine > 3mg / dl Careful with K+ sparing diuretics Majority require multiple drugs

Slide 162: 

Treating HBP - Disease & Drug Nephropathy ACE Inhibitors AR Blockers b- Blockers ? Calcium Channel Blockers Diuretics

Slide 163: 

CHILDHOOD HYPERTENSION – Disease & Drug Captopril Nifedipine Diuretic NTP b-Blocker ACE inhibitor Calcium M- dopa Diuretic channel Blockers Situation Preferred Second line Not / Contra Neonate Coaretation

Slide 164: 

CHILDHOOD HYPERTENSION – Disease & Drug Calcium blockers Metroprolol ACEI Diuretics Prazocin ARB Nifedipine Metroprolol Captopril Diuretic Situation Preferred Second line Not / Contra Ac Nephritis Nephrotic Syndrome

Slide 165: 

CHILDHOOD HYPERTENSION – Disease & Drug ACE inhibitor Nifedipine Diuretics ARB b-Blockers ACE inhibitors Nifedipine Diuretics a Blockers b- Blockers ARB Situation Preferred Second line Not / Contra Diabetes Dyslipidemia

Slide 166: 

CHILDHOOD HYPERTENSION – Disease & Drug ACE inhibitors ARB Diuretics Calcium Blockers b- Blockers Calcium Blockers a Blockers ACE inhibitors Diuretics ARB Metroprolol Atenolol Situation Preferred Second line Not / Contra Mild CRF CRF

Slide 167: 

CHILDHOOD HYPERTENSION – Disease & Drug ACE inhibitor Carvedilol b- blockers ? Diuretics Calcium blockers Calcium ACE Inhibitors b- blockers blockers ARB Diuretic Situation Preferred Second line Not / Contra CHF Asthma

Slide 168: 

CHILDHOOD HYPERTENSION – Disease & Drug ACE Inhibitors b-Blockers CCB Labetolol Carredilol b-blockers a+b blockers Diuretics Situation Preferred Second line Not / Contra Unilateral Pheochromo- cytoma ?

Slide 169: 

HYPERTENSIVE EMERGENCYDRUGS Oral SL Nifedipine 0.5 mgm/ kg /dose SL Captopril 0.5 mgm / kg/ dose IV NTP 0.5 - 5 mcgm / kg/ ml infusion IV Labetalol IV Esmolol 500 mgm/ kg/ IV load /2 IV Enalaprilat 50 mcg /kg/mt

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HYPERTENSIVE Emergency & Urgency Hypertensive Encephalopathy ,, SAH ,, LVF Plus . Eclampsia . ACS. Dissection

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DRUGS IN Hypertensive EmergenciesIV Drugs available Nitroprusside *** Labetalol *** Esmololol ** Enalaprilat * Nitroglycerin *

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HYPERTENSIVE EMERGENCYDRUGS PREFERRED Situation First option others H. Encephalopathy Nitroprosside Esmolol Labetalol H. CHF Nitroprosside Nitroglycerin IV Diuretic infusion H. Stroke Calcium Channel Diuretic Blockers

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www.pedheartsat.org Please visit our Website !

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MAJOR REFERENCES 1. The Fourth report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004: 114. 555-576 2. Hypertension in Children and Adolescents PCNA 53 (20060 493- 512 3. Renovascular Hypertension in Children Lancet vol. 371 April 26, 2008 4. Pharmacological treatment of Hypertension in Children & Adolescents J of pediatrics 2006 : 149 : 746 - 54

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