INTEGRATED APPROACH

“Man talks about of killing time, while time quietly

kills them”

-Dion Boucicault (1820-90)

London - Assurance.

This fact is true in case of all chronic non-communicable diseases. These all
diseases kill the men with passage of time. They cause silent damage to our
body & give us unwanted gift of impairing morbidity and slow but sure
mortality.

Hypertension is a modern devil which is immortal up till now. i.e.

Hypertension once developed can’t be cured. It can only be controlled &
prevented.

Hypertension is one of the most important risk factor of many cardiovascular

diseases which are number one killer of world. So control & prevention is
necessary.

It is achieved by integrated approach in hypertension. Integrated approach

means bringing together the presenting, promotive & Preventive concept of
medicine.

AIMS OF INTEGRATED PRACTICE:

 Easily detection of cases
 Management of condition & its complication
 Prevention of condition in other family members

DETECTION OF CASES:

 Diagnosis of hypertension can be done clinically by following symptoms:

1. Morning occipital headache
2. Giddiness, Blurring of vision
3. Polyuria
4. Recurrent backaches
5. Easy fatigability
6. Palpitation
7. Epistaxis, Hematuria
 8. Weight gain, Muscle weakness
 Patient may have family history of hypertension prevalent in any
relatives. (Blood relative)
 If patient has secondary hypertension then he may have diabetes
mellitus, Pheochromocytoma, renal artery stenosis or any other condition
causing hypertension.
 Some times patient is presented with complication of hypertension that
he/she may have paresis, pedal edema, proteinuria, repeated attack of
convulsion or any other condition.
 On general examination patient have shows high blood pressure level
persistently. They also show some time round faces which are due to
Cushing syndrome (secondary hypertension).
 On systemic examination patient shows sign of complications like carotid
stenosis, renal artery bruits, engorged neck veins, HepatoJugular reflex
+ve, louder 3rd heart sound, bulge of precordium due to hypertrophy etc.
 Sometimes signs of secondary hypertension are also seen.
 Diagnosis is confirmed by blood pressure measurement.

MANAGEMENT OF HYPERTENSIVE PATIENTS:

 The sole objective of antihypertensive therapy is to reduce the incidence

of adverse cardiovascular events particularly CHD, Stroke & Heart
failure.
 The relative benefit of antihypertensive therapy is approximate 30%
reduction in the risk of stroke & 20% reduction in risk of CHD.
 Investigations:-
1. serum cholesterol & total cholesterol profile
For diagnosis of hyperlipidemia
2. Blood glucose level (FBS & PP2BS)
For diagnosis of diabetes mellitus & diabetic nephropathy. It is
also helpful to rule out Cushing syndrome, Pheochromocytoma
etc.
3. Urine analysis for blood, sugar or
protein
To assess status of kidney
4. Blood urea, creatinine & electrolytes
To provide base line before diuretic
therapy, assess renal function & rule
out mineralocorticoid induced
hypertension
5. ECG, Chest X-ray & Echocardiogram
For assessment of any cardiac
anomaly so management will be
guided. [Cardiac hypertrophy,
coarctation of aorta etc]
6. Renal ultrasound & Angiography
For rule out renal artery stenosis
7. For thyroid related hypertension TSH
is required.
8. Specific investigations for secondary hypertension are:
- ACEI radionuclide renal scan, renal duplex Doppler flow
studies (Reno vascular status)
 - 24-hour urine assay for creatinine, metanephrines &
catecholamines [Pheochromocytoma]
- Overnight dexamethasone suppression test or 24-hour urine
cortisone & creatinine [Cushing’s syndrome]
- Plasma aldosterone: renin activity ratio [Primary aldosteronism]

INDICATION OF THERAPY:
 Patients with a diastolic pressure repeatedly >90 mmHg or systolic
pressure >140 mmHg should be treated unless specific
contraindication exist.
 Isolated systolic hypertension should also be treated if patient’s age
is >65 year.
 Patients with atherosclerotic vascular disease or diabetes mellitus
and diastolic blood pressures between 85 and 90 mmHg should also
receive antihypertensive therapy.
TREATMENT TARGETS:
 Optimal target to lower blood pressure during therapy is Systolic
blood pressure <140 mm Hg & Diastolic is <80 mm Hg.
 For diabetic person goal is <130/85 mm Hg.

TREATMENT OF HYPERTENSIVE PATIENT HAS 2 MODALITIES:

1. pharmacological treatment
2. Non pharmacological treatment
 Non pharmacological treatment:
1. Correcting obesity
2. Regular Physical Exercise
3. Adopt diet that have law saturated fat
4. Restriction of salt intake
5. Increase consumption of fruits & green
leafy vegetables
6. Reduction in alcohol & smoking
 Pharmacological therapy includes drugs of
various group

Initiation of treatment
 Assess BP and other risk
with target organ damage

SBP<180/DBP<110mmHg SBP≥180/DBP≥110mmHg

Stratify about risk & Begin drug therapy +

Initiate lifestyle measures Life style measures

Medium/low

High

Start combination Drugthearpy

Stratified risk is medium/low

SBP130-139 or SBP 140-179or

DBP 85-89 on several occasions DBP 90-190 on several occasions

No treatments
only monitor BP and other risk factors
Begin drug treatment

APPROACH TO PATIENT AFTER INITIATING DRUG THERAPY

- After initiating therapy if high risk patients

have achieved the goal of blood pressure then
every 3 months BP checkup must be there.
Same procedure is done with low risk patient
every 6 month.

- If goal is not achieved in 1-2 month then

combination therapy/increase dose or
substitution of drug should be done.

PHARMACOLOGICAL TREATMENT:-
A. Thiazides & other diuretics:-
- Hydrochlorthiazide 12.5-25 mg daily orally
- Furosemide 20-80 mg 2-3 times a day orally
- Spiranolactone 25 mg 2-4 times a day orally
M/A prevent reabsorption of sodium & water.
Adverse effects are hyperglycemia, hypokalemia(not with spiranolactone),
hyperuricemia etc.

B. β1 blocker:-
- Metoprolol 25-150 mg twice daily
- Atenolol 25-100 mg daily
M/A These all are cardio selective β blocker so act on β1 receptor in
heart & decrease heart rate & cardiac output so decrease tension to
blood vessel.
Adverse effects can’t withdraw suddenly, suppress symptom of
hypoglycemia,bradycardia.

C. ACE inhibitors:-
Enalapril 2.5-40 mg daily orally
Ramipril 1.25-20 mg daily orally
Lisinopril 5-40 mg daily orally
M/A These Angiotensin converting enzyme inhibitors acts on the enzyme
then prevent conversion of Angiotensin 1 into 2 & therefore prevent
vasoconstriction, reduce vessel resistance & also reduce sodium
reabsorption so decrease blood pressure.
Adverse effects are dry cough, angioedema, postural hypotension, mental
retardation of growing fetus etc.

D. Angiotensin receptor antagonist:-

Losartan 25-50 mg once/twice in a day orally
Valsartan 40-160 mg daily orally
M/A They act by similar mechanism like ACEI but they directly act on
Angiotensin receptors as antagonists.
Adverse effects are less than ACEI especially cough & angioedema other
may occur

E. Calcium channel blocker:-

Amlodipine 5-10 mg daily orally
Nifedipine 30 -90 mg daily orally
M/A These two are calcium channel blockers of dihydropyridine group
use for hypertensive emergency & chronic treatment both. It acts on
smooth muscle of vessel & relax them so vessel tone reduce & pressure
falls. Other drugs like verapamil diltiazem are also used but have
tendency to block sinus rhythm.
Adverse effects are reflex tachycardia (Dihydropyrimide only), postural
hypotension

F.  + β blocker
Labetalol 100-600 mg twice a day orally
Carvedilol 6.25-25mg 12hourly
M/A They are adrenergic blockers which block both  & β receptors. They
are used in infusion form in malignant phase of hypertension
Adverse effects are more postural hypotension, sexual dysfunction etc.
 G.  blocker
Prazosin 0.5-20 mg daily in divided dose
Doxazosin 1-16 mg daily
Adverse effects are substantial hypotension on first dose.

H. Drugs directly acting on blood vessel

Hydralazine 25-100 mg every 12 hourly
Minoxidil 10-50 mg daily
Adverse effects are headache, tachycardia, postural hypotension, 1st dose
effect etc.

I. Centrally acting drug

Methyldopa 250 mg 8 hourly
Clonidine 0.05-0.1 8 hourly
Adverse effect is rebound hypertension with clonidine,

APPROACH TO DRUG THERAPY:-

Ideally one would choose a therapeutic program that specifically
corrects the underlying defect but it is only possible in secondary
hypertension. Essential hypertension is idiopathic so it is only controllable.
The US joint national Committee (JNC) & the European society of
Hypertension have given treatment guidelines which recommended following
5 groups of main drug as line of treatment.

INDICATION OF DRUGS

Possible
Class of drug Compelling indication
indication
Diuretics Heart failure Diabetes
Elder patient
β- blocker Angina Heart failure
After MI Pregnancy
Tachyarrhythmias Diabetes
ACEI Heart failure PVD
Left ventricular dysfunction
After MI
Diabetic nephropathy
Calcium channel Angina PVD
blocker Elder patient
Angiotensin 2 Same as ACEI Heart failre
antagonist ACEI cough

CONTRAINDICATION OF DRUGS

Compelling Possible
Class of drug
contraindication contraindication
Diuretics Gout Sexually active Male
Dyslipidemia
β- blocker Asthma & COPD PVD
Heart block Athlete & Physically
 active person
ACEI Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis
Calcium channel Heart block CHF
blocker
Angiotensin 2 Same as ACEI
antagonist

MANAGEMENT OF ACCELERATED PHASE OF MALIGNANT

HYPERTENSION:
- Here it is unwise to reduce blood pressure too quickly
- Reduction to about 150/90 mmHg over 24-48 hours is ideal
- Drugs & doses
- IV or IM labetolol 2 mg/min max 200 mg
- IV Glyceryl trinitrate 0.6-1.2 mg /hour
- IM hydralazine 5- 10 mg repeated at half hour interval
- IV sodium nitroprusside 0.3-1.0 microgram/kg/min
Thus in this way hypertension can be managed.
In our patient Ratilalbhai has started treatment according to advice of Dr.
J.D.Lakhani . He is trying to reduce his weight by help of controlling Diet &
exercise and take –mg mmmm & --- mg kkkkk Daily.