hypertension- Management in special situation

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Hypertension, Heart failure,Refractory hypertension, renal hypertension

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Hypertension –Management in special situation:

Hypertension –Management in special situation Dr. Md.Toufiqur Rahman MBBS, FCPS , MD, FACC , FESC, FRCPE , FSCAI, FAPSC, FAPSIC , FAHA, FCCP, FRCPG Associate Professor of Cardiology National Institute of Cardiovascular Diseases, Sher -e- Bangla Nagar, Dhaka-1207 Consultant, Medinova , Malibagh branch Honorary Consultant, Apollo Hospitals, Dhaka and STS Life Care Centre, Dhanmondi drtoufiq19711@yahoo.com

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Summary :

Summary "Hypertensive urgency" is the situation in which a patient's DBP is >120 mm Hg. If there is acute or rapidly worsening  target­organ  damage, then the term used is "hypertensive emergency." Hypertensive urgency can be managed as an outpatient, but hypertensive emergency requires admission to a unit with cardiovascular monitoring facilities, for  parenteral  antihypertensive therapy. There are many causes of secondary hypertension, including primary  aldosteronism  and RAS. Primary aldosteronism  may be caused by an  aldosterone­producing  adenoma of the adrenal gland, or by bilateral adrenal hyperplasia. There is suppressed PRA, increased urinary potassium loss, often but not always with  hypokalemia,and   hypertension. Screening for primary  aldosteronism  is appropriate in patients with hypertension  andspontaneous   hypokalemia , or in any patient with  treatment­resistant  hypertension. The screening test of choice  isthe  morning PAC to PRA ratio, which if >20 (with a PAC of ≥12  ng /dl) is suggestive of primary   hyperaldosteronism,and  if >70 with a PAC of ≥15  ng /dl and a PRA of ≤1  ng /ml/h is virtually diagnostic.  High­resolution  CT of the adrenal glands completes the workup. . drtoufiq19711@yahoo.com

Summary :

Summary RAS may result in hypertension and/or ischemic  nephropathy. Most cases are due to atherosclerosis, but about10% are due to  fibromuscular  dysplasia, which affects younger persons, particularly  women.  The most powerful predictors of the presence of RAS are:  age,  atherosclerotic cardiovascular disease elsewhere,  the presence of an abdominal bruit,  recent onset of hypertension or recent loss of BP control,  unilateral small kidney,  a  largeincrease  in serum  creatinine  after an ACE inhibitor or ARB,  hypercholesterolemia,  cigarette smoking, and absence of a family history of hypertension drtoufiq19711@yahoo.com

Summary :

Summary A workup for atherosclerotic RAS should be done only if there is resistant hypertension or if there is  worseningrenal  function, and if there is no contraindication to an invasive procedure (renal angioplasty or  revascularizationsurgery ), and if the patient is willing to accept revascularization. Otherwise, only medical management is advised. Measurement of peripheral venous PRA at rest or following stimulation with ACE inhibitors lacks the  sensitivityand  specificity to be useful in screening for RAS.  Useful tests for RAS include radioisotope scanning with  ACEinhibition  ( captopril   scintigraphy ), Doppler ultrasound, MRA, CTA, and renal  arteriography . In atherosclerotic  renovascular  hypertension, BP control may be achieved in >90% of cases with  medical  therapyalone , usually with a combination of antihypertensive drugs, but more invasive management is indicated if  thehypertension  is refractory to medical therapy with multiple antihypertensive agents at maximum dose, or if there  isprogressive  deterioration of renal function.  By contrast, in  fibromuscular  hyperplasia, renal artery angioplasty  isthe  treatment of choice. OSA is characterized by repetitive interruption of ventilation for 10 seconds or more during sleep caused  bycollapse  of the pharyngeal airway, and with associated respiratory effort. Persons with  hypertension and  theclinical  features/predisposing factors for OSA, particularly loud snoring,  daytime sleepiness, or  witnessedapneas , should undergo formal overnight sleep testing (" polysomnography ") to make the diagnosis.  Therapy is behavioral, medical, and surgical. drtoufiq19711@yahoo.com

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