Management Of Co-Morbid Hypertension

Management of co-Morbid hypertension / Management of secondary hypertension:

Hypertension can be present with co-morbid conditions. The drug selection is based on the co-morbid conditions. The aim of selecting proper drug is to manage two or greater diseases with a single drug that drug should be chosen which benefices both diseases. Some common co-morbid conditions are

• Coronary heart disease (CHD)
• Diabetes mellitus (DM)
• Asthma
• Post myocardial infarction (PMI)
• Dyslipidaemia
• Pregnancy
• Chronic kidney disease (CKD)
• Coronary obstructive pulmonary disease (COPD)

Coronary heart disease:

• Angina
• Myocardial infarction

The patient suffering from coronary heart disease the targets should be

Goal blood pressure in coronary heart disease with hypertension:

For young goal blood pressure in coronary heart disease is less than 130 / 80 .

For elder goal blood pressure in coronary heart disease is less than 140 / 80.

Goal heart rate in coronary heart disease with hypertension:

Heart rate should be less than 60 beats / minute.

Goal LDL-C in coronary heart disease with hypertension:

LDL-C should be less than 55 mg / dL.

Treatment of coronary heart disease with hypertension:

ACEIs / ARBs + BB + CCB (DHP) + Aspirin / clopidogrel  + statins

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers

BB = beta blockers

CCB = calcium channel blockers

DHP = dihydophyridine

Why BB is not use with non dihydophyridine calcium channel blockers?

Can’t give BB with non dihydophyridine calcium channel blockers. If patient is contraindicated to beta blockers then alternate is non dihydophyridine calcium channel blockers.

Beta blocker cannot be used with non dihydophyridine calcium channel blockers like verapamil and diltazim because the effect is same .

The patient must receive aspirin or clopidogrel and statins.

Best order for statins is Rosuvastatin then atorvastatin then pravastatin . Rosuvastatin has least drug drug interaction and long acting life style modifications. In addition to these life style modifications in all patients.

Post stroke with hypertension:

Goal LDL-C in post stroke with hypertension:

LDL-C should be less than 70 mg / dL.

Treatment of post stroke with hypertension:

ACEIs / ARBs + CCB (NDHP) + Diuretic (thiazide) + statins + Antiplatelet (if patient suffering from ischemic stroke).

Restrict Antiplatelet in case of hemorrhage stroke. Care should be taken.

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers 

CCB = calcium channel blockers

NDHP = non dihydophyridine

Heart failure with hypertension:

Goal blood pressure is heart failure with hypertension:

Blood should be less than or equal to 130 / 80 and must be equal to or more than 120 / 70.

Treatment of heart failure with hypertension:

ACEIs / ARBs + BB + spironolactone + loop diuretics + CCB (DHP).

Loop diuretics is good in symptomatic management. And add CCB (DHP) if blood pressure is not control.

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers

BB = beta blockers

Chronic kidney disease with hypertension:

Goal blood pressure in chronic kidney disease with hypertension:

For young goal blood pressure in chronic kidney disease is less than 130 / 80 .

For elder goal blood pressure in chronic kidney disease is less than 140 / 80.

Treatment of chronic kidney disease with hypertension:

ACEIs / ARBs + CCB + thiazide diuretics

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers 

CCB = calcium channel blockers

If the eGFR is less than 30 then loop diuretics is replaced with thiazide diuretics.

Role of ACEIs and ARBs:

Anti protein uric

Anti hyperlipidaemic

Anti inflammatory

Renal protective

Cardio protective

Start ACEIs and ARBs with maximum doses because ADRs are not dose dependent. Start CCB with minimum doses because ADRs are dose dependent.

Treatment of Diabetes mellitus with hypertension:

ACEIs / ARBs + CCB + diuretics

Care should be taken that BB not prescribed with diuretics because can cause hypoglycemia/ hyperglycemia.

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers 

CCB = calcium channel blockers

Treatment of Dyslipidemia with hypertension:

ACEIs / ARBS + CCB + statins / fibrates

And other lipid lowering agents if needed.

ACEIs = angiotensin converting enzyme inhibitors

ARBs = angiotensin receptor blockers 

CCB = calcium channel blockers

Treatment of coronary obstructive pulmonary disease with hypertension:

ARBS + CCB + diuretics  + BB (if needed)

BB should be cardio selective.

ACEIs can not use in coronary obstructive pulmonary disease because increase bradykinin and can cause dry cough.

ARBs = angiotensin receptor blockers 

CCB = calcium channel blockers

BB = beta blockers

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Why BB is not used with non dihydophyridine calcium channel blockers?

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Goal heart rate in coronary heart disease with hypertension

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