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Case Presentation. King Faisal Specialist Hospital and Research Center (2007-1428). Presented by: Manar Lashkar Samah Al-shehri Pharm.D candidates. Supervised by: Dr. Seema. Outline. Hypertension JNC VII Guidelines Resistant hypertension Pheochromocytoma Case Scenario

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presented by manar lashkar samah al shehri pharm d candidates

Case Presentation

King Faisal Specialist Hospital and Research Center

(2007-1428)

Presented by:

Manar Lashkar

Samah Al-shehri

Pharm.D candidates

Supervised by:

Dr. Seema

Manar & Samah

outline
Outline
  • Hypertension
  • JNC VII Guidelines
  • Resistant hypertension
  • Pheochromocytoma
  • Case Scenario
  • Points of Discussion

Manar & Samah

slide4
Hypertension affects more than 20% of the adult Saudi population with expected increasing prevalence
  • It is an important modifiable risk factor for cardiovascular diseases
  • Despite overwhelming evidence that lowering BP reduces morbidity and mortality, its management remains frequently sub-optimal

Manar & Samah

hypertension
Hypertension
  • It is defined as persistent elevation of systolic blood pressure SBP ≥ 140 mm Hg and/or diastolic blood pressure DBP ≥ 90 mm Hg in adults not on anti-hypertensive medications
  • It can be classified as either essential(primary) or secondary
    • Essential hypertension indicates that no specific medical cause can be found to explain a patient\'s condition
    • Secondary hypertension indicates that the high blood pressure is a result of (i.e. secondary to) another condition

Manar & Samah

identifiable causes of hypertension
IdentifiableCausesofHypertension
  • Chronic kidney disease
  • Coarctation of the aorta
  • Cushing’s syndrome and other glucocorticoid excess states including chronic steroid therapy
  • Drug induced or drug related
  • Obstructive uropathy
  • Pheochromocytoma
  • Primary aldosteronism and other mineralocorticoid excess states
  • Renovascular hypertension
  • Sleep apnea
  • Thyroid or parathyroid disease

Manar & Samah

resistant hypertension
Resistant Hypertension

Resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic

Manar & Samah

causes of resistant hypertension

■ Nonadherence

■ Inadequate doses

■ Inappropriate combinations

■ Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors

■ Cocaine, amphetamines, other illicit drugs

■ Sympathomimetics (decongestants, anorectics)

■ Oral contraceptive hormones

■ Adrenal steroid hormones

■ Cyclosporine and tacrolimus

■ Erythropoietin

■ Licorice (including some chewing tobacco)

■ Selected over-the-counter dietary supplements and medicines

(e.g., ephedra, bitter orange)

■ Excess sodium intake

■ Volume retention from kidney disease

■ Inadequate diuretic therapy

■ Obesity

■ Excess alcohol intake

CausesofResistantHypertension

Volume overload

Drug-induced or other causes

Associated conditions

Manar & Samah

slide12

Drugs Used

in Hypertension

Manar & Samah

diuretics
Diuretics

Manar & Samah

slide14

Adrenergic Blockers

Manar & Samah

slide16

After age 50, high systolic blood pressure (> 140 mm Hg) is much more important than high diastolic pressure as a risk factor for cardiovascular events

People with a systolic blood pressure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg should be considered prehypertensive and should undertake health promoting lifestyle modifications to prevent cardiovascular disease.

Most patients with hypertension need two or more antihypertensive medications to achieve their goal pressure (<140/90 mm Hg or < 130/80 mm Hg for patients with diabetes or chronic kidney disease).

If blood pressure is more than 20/10 mm Hg above goal, one should consider starting therapy with two agents, one of which usually should be a thiazide-type diuretic

Thiazide-type diuretics should be used to treat most patients with uncomplicated hypertension, either alone or combined with drugs from other classes, but certain high risk conditions constitute compelling indications for the initial use of other types of antihypertensive drugs

People who are normotensive at age 55 still have a 90% lifetime risk for developing hypertension.

Manar & Samah

pheochrmocytoma
Pheochrmocytoma
  • Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells (medulla)
  • Because of excessive catecholamine secretion, pheochromocytomas may precipitate life-threateninghypertension or cardiac arrhythmias

Manar & Samah

symptoms and signs
SymptomsandSigns
  • Clinicalsigns
  • Hypertension(50% paroxysmal)
  • Postural hypotension
  • Hypertensive retinopathy
  • Pallor
  • Fever
  • Tachyarrhythmias
  • Pulmonary edema

Symptoms

  • Headache
  • Diaphoresis
  • Palpitations
  • Tremor
  • Nausea
  • Weakness
  • Anxiety

Manar & Samah

risk factors
RiskFactors
  • Precipitants of a hypertensive crisis
    • Anesthesia induction
    • Opiates
    • Dopamine antagonists
    • Cold medications
    • Radiographic contrast media
    • Drugs that inhibit catecholamine reuptake, such as tricyclic antidepressants and cocaine
    • Childbirth

Manar & Samah

slide20

Case Scenario

Manar & Samah

a 75 year old female with a history of
A 75-year-oldfemale with a history of:

Past Medical History:

Hypertension

Left Bundle Branch Block

Diabetes Mellitus

Chronic renal impairment (Serum Cr = 127umol/L)

Bronchial Asthma

Osteoporosis

Interventions:

CAD CABG (2002, KFMH)

PCI LCX (5/2006)

PCI RCA (12/2006)

Labs: (7/2007)

Ejection Fraction= 40-45%

Negative Thallium

Social History:

Quit smoking 3 years ago

Manar & Samah

past medication history
Past Medication History
  • Aspirin 81 mg PO OD
  • Clopidogrel 75 mg PO OD
  • Carvedilol 12.5 mg PO BID
  • Atorvastatin 40 mg PO OD
  • Amlodipine 10 mg PO OD
  • Irbesartan 300 mg PO OD
  • Furosemide 60 mg PO BID
  • Isosorbide dinitrate retard 40 mg PO OD

Manar & Samah

on 10 12 2007
On 10/12/2007
  • Came to arrhythmia clinic complaining of recurrence syncope and blood pressure of 206/100 mm Hg
  • Admitted to N2 (cardiology ward)

Manar & Samah

during whole admission period she was on
During whole admission period she was on
  • Aspirin 81 mg PO OD
  • Gabapentin 400 mg PO BID
  • Clopidogrel 75 mg PO OD
  • Atorvastatin 40 mg PO OD
  • Insulin regular SC (Sliding Scale) Q6h
  • <8.3 ------------- none
  • 8.4-11.1 --------2 units
  • 11.2-13.9-------4 units
  • 14-16.7----------6 units
  • 16.8-19.4-------8 units
  • 19.5-22.2------10 units
  • >22.3-----------notify MD and do STAT blood sugar, urine ketone

Manar & Samah

slide25

13\12

13\12

13\12

11\12

11\12

11\12

18\12

18\12

18\12

12\12

12\12

12\12

14\12

14\12

14\12

15\12

15\12

15\12

16\12

16\12

16\12

17\12

17\12

17\12

Recurrence Syncope

She started to have tremor

Hypertension

Surgery for single chamber pacemaker implantation

Asthma

Others

Manar & Samah

slide26

13\12

13\12

13\12

13\12

11\12

11\12

11\12

11\12

18\12

18\12

18\12

18\12

12\12

12\12

12\12

12\12

14\12

14\12

14\12

14\12

15\12

15\12

15\12

15\12

16\12

16\12

16\12

16\12

17\12

17\12

17\12

17\12

SrCr

160 umol/L

Hypertension

Irbesartan

300 mg PO OD

Isosorbide dinitrate retard

20 mg PO BID

Amlodipine

PO OD

carvedilol

12.5 mg PO BID

Furosemide

40 mg IV

40 mg PO OD

10 mg

5 mg

COPD/ Asthma

Others

Manar & Samah

slide27

13\12

13\12

13\12

11\12

11\12

11\12

18\12

18\12

18\12

12\12

12\12

12\12

14\12

14\12

14\12

15\12

15\12

15\12

16\12

16\12

16\12

17\12

17\12

17\12

Asthma

Attack

Irbesartan

300 mg PO OD

Isosorbide dinitrate retard

20 mg PO BID

Amlodipine

PO OD

carvedilol

12.5 mg PO BID

Furosemide

40 mg IV

40 mg PO OD

10 mg

5 mg

Hypertension

Fluticasone/salmeterol

250/25 mcg/ puff BID

Budesonide nebulizer

500 mcg TID

Ipratropium nebulizer

500 mcg TID

Asthma

Others

Manar & Samah

slide28

SrCr

107 umol/L

19/12

19/12

2/1

2/1

20/12

20/12

3/1

3/1

21/12

21/12

22/12

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29/12

30/12

30/12

31/12

31/12

1/1

1/1

4/1

4/1

20 mg

40 mg

40 mg

60 mg

40 mg

Hypertension

?

Irbesartan

300 mg PO OD

Isosorbide dinitrate retard

PO BID

Amlodipine

10 mg PO OD

Nifedipine LA

60 mg PO STAT

Captopril

6.25 mg PO TID

carvedilol

12.5 mg PO BID

Metoprolol

12.5 mg PO BID

Clonidine

100 mcg PO OD

Furosemide

IV BID

20 mg PO

40 mg PO

Manar & Samah

slide29

19/12

19/12

19/12

2/1

2/1

2/1

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20/12

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3/1

3/1

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1/1

1/1

1/1

4/1

4/1

4/1

40 mg

30 mg

20 mg

50 mg

15 mg

10 mg

5 mg

60 mg

Hypertension

Methylprednisolone

60 mg IV OD

Prednisolone

PO OD

Magnesium Sulphate

2 g IV

Different inh/neb

COPD

Asthma

K 5.5 mmol/L

K 5.4 mmol/L

K 5.3 mmol/L

Ca polystyrene Sulphonate

30 g PO OD

Heparin Sodium

5000 U S.C BID

Others

Manar & Samah

slide30

Patient was distress, tachypnic, wheezing, complaining of shortness of breath, orthopnea, bilateral chest crepitation

Manar & Samah

transferred to icu

Transferred to ICU

Manar & Samah

slide32

7\1

7\1

7\1

5\1

5\1

5\1

6\1

6\1

6\1

8\1

8\1

8\1

9\1

9\1

9\1

10\1

10\1

10\1

Hypertension

COPD/ Asthma

Others

Manar & Samah

slide33

7\1

7\1

5\1

5\1

6\1

6\1

8\1

8\1

9\1

9\1

10\1

10\1

Hypertension

Irbesartan

300 mg PO OD

Amlodipine

10 mg PO OD

Nitroglycerin

5 mg SLstat

200 mcg/ml INF

Clonidine

100 mcg PO OD

Enalapril

5 mg PO OD

Furosemide

IV BID

60 mg

40 mg

40 mg

80 mg

80 mg

40 mg

Manar & Samah

slide34

7\1

7\1

7\1

5\1

5\1

5\1

6\1

6\1

6\1

8\1

8\1

8\1

9\1

9\1

9\1

10\1

10\1

10\1

Irbesartan

300 mg PO OD

Amlodipine

10 mg PO OD

Nitroglycerin

5 mg SLstat

200 mcg/ml INF

Clonidine

100 mcg PO OD

Enalapril

5 mg PO OD

Furosemide

IV BID

Hypertension

60 mg

40 mg

40 mg

80 mg

80 mg

40 mg

Hydrocortisone

IV stat

IV TID

Different Neb/Inh

Aminophylline

IV 250 mg stat

40 mg

80 mg

COPD

Hospital Acquired

Pneumonia

K 3.5 mmol/L

K 2.9 mmol/L

Piperacillin/Tazobactam

2.25 mg IV Q6h

Potassium Chloride

IV over 2h

40 mEq PO

Heparin (PROTECT study)

20 mEq

40 mEq

Others

Manar & Samah

slide36

11/1

11/1

12/1

12/1

13/1

13/1

14/1

14/1

15/1

15/1

16/1

16/1

17/1

17/1

18/1

18/1

19/1

19/1

20/1

20/1

21/1

21/1

22/1

22/1

Hypertension

Irbesartan

300 mg PO OD

Amlodipine

10 mg PO OD

Nifedipine LA

60 mg PO OD

Nitroglycerin

200 mcg/ml INF

Isosorbide dinitrate

40 mg PO BID

Spironolactone

25 mg PO OD

Hydralazine

25 mg PO BID

Enalapril

PO

Furosemide

40 mg IV BID

40 mg PO OD

10 mg QD

10 mg BID

Manar & Samah

slide37

11/1

11/1

11/1

12/1

12/1

12/1

13/1

13/1

13/1

14/1

14/1

14/1

15/1

15/1

15/1

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17/1

17/1

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18/1

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19/1

20/1

20/1

20/1

21/1

21/1

21/1

22/1

22/1

22/1

5 mg

20 mg

10mg

Irbesartan

300 mg PO OD

Isosorbide dinitrate

40 mg PO BID

Amlodipine

10 mg PO OD

Nifedipine LA

60 mg PO OD

Spironolactone

25 mg PO OD

Hydralazine

25 mg PO BID

Enalapril

PO

Nitroglycerin

200 mcg/ml INF

Furosemide

40 mg IV BID

40 mg PO OD

Hypertension

Hypertension

10 mg QD

10 mg BID

Prednisolone

PO QD

Different Neb/Inh

COPD

K 2.8

mmol/L

K 3.2

mmol/L

Heparin Sodium

5000 U S.C BID

Potassium Chloride

40 mEq IV

40 mEa PO OD

Others

Manar & Samah

slide38

Was not

managed before

Same Medications

Was not

managed before

carvedilol 12.5 mg PO BID

Irbesartan 300 mg PO OD

Furosemide 60 mg PO BID

Isosorbide dinitrate retard 40 mg PO OD

Aspirin 81 mg PO OD

Clopidogrel 75 mg PO OD

Atorvastatin 40 mg PO OD

Amlodipine 10 mg PO OD

was on

was on

  • Insulin NPH SC 32 Units BID
  • Gabapentin 400 mg PO BID
  • Alfacalcidol 0.5 mcg PO OD
  • Calcium carbonate 500 mg PO BID

Daibetes/

Complications

Osteoporosis

Discharge

Medications

Problems List/

Medications

  • Prednisolone 5 mg PO OD (for 15 days)
  • Fluticasone/ Salmetrol inhaler 2 puffs TID
  • Albuterol 2 puffs inhaler PRN

Hypertension/

CV Problems

carvedilol 12.5 mg PO BID

Spironolactone 25 mg PO OD

Irbesartan 300 mg PO OD

Furosemide 40 mg PO BID

Nifedipine LA 60 mg PO BID

Enalapril 10 mg PO BID

Hydralazine 25 mg PO BID

Isosorbide dinitrate retard 20 mg PO BID

Aspirin 81 mg PO OD

Clopidogrel 75 mg PO OD

Atorvastatin 40 mg PO OD

COPD

Manar & Samah

corticosteroids side effects
CorticosteroidsSide Effects
  • Adverse reactions:
  • Dose and duration related side effects include fluid and electrolyte disturbance (e.g. hypokalemia with possible edema and hypertension), hyperglycemia, peptic ulcer disease, osteoporosis, euphoria, psychosis, myopathy, and infections

Prolonged therapy can lead to suppression of pituitary-adrenal function

Too rapid withdrawal of long-term therapy can cause acute adrenal insufficiency (e.g. fever, myalgia, arthralgia and malaise)

  • In our case the patient suffered from:
  • Myopathy
  • Uncontrolled hypertension
  • Hypokalemia
  • Hospital acquired pneumonia
  • The patient is predisposed to osteoporosis

Manar & Samah

corticosteroids tapering off
Corticosteroids Tapering Off

There are many regimens for tapering off corticosteroids.

Example of prednisone tapering schedule:

However, corticosteroids can be rapidly tapered and discontinued abruptly if used for less than 2 to 3 weeks

Manar & Samah

slide43

19/12

19/12

19/12

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2/1

2/1

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3/1

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1/1

1/1

1/1

4/1

4/1

4/1

40 mg

30 mg

20 mg

50 mg

15 mg

10 mg

5 mg

60 mg

This is not a prednisolone tapering off. The goal of decreasing the dose was to seek for the lowest effective and tolerated dose that can manage her COPD with minimum myopathy and fluid retention

Hypertension

myopathy

Methylprednisolone

60 mg IV OD

Prednisolone

PO OD

Magnesium Sulphate

2 g IV

Different inh/neb

COPD

Asthma

Ca polystyrene Sulphonate

30 g PO OD

Heparin Sodium

5000 U S.C BID

Guaifenesin/ Dextromethorphan

10 ml PO BID

Others

Manar & Samah

b blocker withdrawal
b-Blocker Withdrawal

Withdrawing b-blockers may produce b-adrenergic supersensitivity. Both abrupt cessation and gradual withdrawal over 4 to 8 days have caused overshoot hypertension and cardiovascular complications within within 48 to 72 hours after the last b-blocker dose

To prevent b-adrenergic supersensitivity, the b-blocker dosage should be reduced over 7 to 10 days to the equivalent of 30 mg/day of propranolol and then maintained at this low dosage for 2 additional weeks

b-blocker Withdrawal in patient who are free of CHD resulted in fourfold increase in onset of CHD

Manar & Samah

slide46

19/12

19/12

2/1

2/1

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30/12

30/12

31/12

31/12

1/1

1/1

4/1

4/1

20 mg

40 mg

40 mg

60 mg

40 mg

Hypertension

Irbesartan

300 mg PO OD

Isosorbide dinitrate retard

PO BID

Amlodipine

10 mg PO OD

Nifedipine LA

60 mg PO STAT

Captopril

6.25 mg PO TID

carvedilol

12.5 mg PO BID

Metoprolol

12.5 mg PO BID

Clonidine

100 mcg PO OD

Furosemide

IV BID

20 mg PO

40 mg PO

Titration of the cavedilol 12.5 mg to metoprolol 12.5 mg

Then D/C b-blocker after 8 days

Manar & Samah

slide47

Thank you

Manar & Samah

references
References
  • Chobanian AV, Bakris GL, Black HR, et al and the National High Blood Pressure Education Program Coordinating Committee.The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA 2003; 289:2560–2572.
  • Vidit D, Borazanian R. Treat high blood pressure sooner: Tougher, simpler JNC 7 guidelines. Cleveland Clinic Journal of Medicine 2003; 70(8):721-728
  • Saudi Hypertension Management Society. Saudi hypertension guidelines. 2007; 1-46
  • Helms R, Quan D, Herfindal E eds. Textbook of therapeutics. Drug and disease management. Eighth Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2006: 451-471
  • Herfindal E and Gourley D. Textbook of therapeutics. Drug and disease management. Seventh Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2000: 795-823
  • http://www.emedicine.com/MED/topic1106.htm

Manar & Samah

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