Let's move on to
in blood pressure
And I'm going to talk to you about
mixing drugs now.
Okay, let's start out
with taking a look
at the different types of
medications we use
for hypertension control.
When you look at most guidelines for
most countries all over the world,
the first line agent
is one of a choice
of four different drug groups.
It doesn't matter which of these
four you choose,
in the absence of other diseases.
You could choose one of the
you could choose one of the ARBs,
you could have choose
chosen one of the
calcium channel blockers,
or you could choose
a thiazide diuretic.
Any one of these four is correct.
Now, the second-line agents could
include other types of diuretics,
including the loop diuretics,
Or you could use the
such as spironolactone
or you could use a beta-blocker.
So those are second-line agents.
And then the other agents
that we have talked about
in other lectures
would be third-line agents.
So to be clear,
these are special drug mixtures
or special drug choices
in certain types of diseases.
This first slide
refers to those patients
who have high blood pressure
in the absence of other diseases.
And this should fall in line
with most countries guidelines
on hypertension management.
Let's move on to other diseases.
wherever you are in the world
do not choose a first-line agent.
a first-line set of choices
based on the disease state.
So let's take diabetes,
In general, diabetics,
we like to use ACEs or a ARBs
as a first-line agent,
and then go on to a
calcium channel blocker,
and then to a diuretic,
and then to spironolactone,
and then to a beta-blocker.
we try to avoid in diabetes,
because it can mask
the symptoms of hypoglycemia.
The reason why ACEs and ARBs
are first-line therapy choices
is because they also have
vascular protection effects
in the eye, in the brain,
in the kidney,
and we believe also in
the peripheral vasculature.
That's why they are
first-line in this class.
ACEs or ARBs?
The next class of drugs
that we would like to use in this disease state
are the non-dihydropyridine
calcium channel blockers.
I won't get into the details
or the argument as to,
whether or not adding it to an
ARB or an ACE inhibitor is better.
There are several medications that
can be used to treat hypertension
in the setting of acute heart failure.
We often start with a combination therapy agent.
Either an ARB or ACE inhibitor with a diuretic.
Next, we would reach for direct vasodilators,
such as, hydralazine or nitrates.
Another option would be spironolactone, which is,
particularly helpful in treating
hypertension in the setting of heart failure.
Use this with caution though,
as combining an ACE inhibitor with spironolactone,
can cause high potassium levels.
The next choice for controlling
hypertension and heart failure
are beta blockers, but use these with caution.
As adding a beta blocker
during an acute exacerbation
of heart failure, can further
decrease the cardiac output.
It is safe to continue beta
blockers during acute exacerbations,
but do not initiate therapy with a beta blocker,
until the patient has been stabilized.
Lastly, you can consider calcium channel blockers
for controlling blood pressure.
But be sure to use dihydropyridine
calcium channel blockers
to avoid the negative inotropic
effects of non-dihydropyridines.
In terms of the chronic heart failure patient,
you can see how the order is changed a little bit.
ARB or ACE inhibitor, diuretic,
spironolactone, beta blockers
and then others such as neprilysin inhibitors.
In isolated systolic hypertension or “ISH”,
our preferred agents are calcium channel blockers
and thiazide diuretics.
These have been shown to be the most effective
at reducing blood pressure.
The next best choice is to reach for an ARB.
Notice that ACE inhibitors are not listed here,
as isolated systolic hypertension,
has a clear study showing that ARB’s
are more useful than ACE inhibitors.
After exhausting these options,
consider other medications such as, beta blockers.
In terms of post-MI patients,
it's absolutely essential
that we get these people on beta blockers.
We're not using the beta blocker for hypertension,
but I put this list here to reiterate
the importance of using a beta blocker post-MI.
After that we'll use either an ACE or an ARB.
Now, on your exam both ACE’s
and ARB’s are a correct answer.
In a cardiologist's office the
correct answer is ACE inhibitor.
That's because ACE inhibitors have a
lot of evidence to support its use.
The ARB’s also have a lot of
evidence to support their use,
but they're later drugs and could only be compared
against ACE inhibitors and they were never shown
to be truly superior in class 1 trials.
There is another trial that
suggested that ARB’s are better,
but it was an observational study,
it looked at a large group of patients
in the province of Ontario and Canada
and it showed that the ARB’s did
quite well in those patients,
but still you'll often find clinically
people are favoring ACE inhibitors.
On your exam we should treat them equally.
Pulmonary Edema is something we commonly see
in both the intensive care
unit and coronary care unit.
Oral diuretics will not be
potent enough to achieve
the rapid diuresis that is
needed for these patients.
Give intravenous furosemide,
starting with a 40-milligram dose,
track the patient's intake and output closely
to ensure an adequate response.
If not responding to the intravenous furosemide,
patients can be given a dose of oral metolazone,
30 minutes before the next dose of furosemide.
This essentially primes the pump
and allows for massive diuresis.
When using this combination be aware
that there is a high risk of hypokalemia,
so be sure to monitor this closely.
Despite the risk of electrolyte abnormalities,
this is a very effective therapy for
a person with fluoride heart failure
that is not responding to furosemide alone.
Let's talk about the ascites special.
So sometimes you'll have patients
who either have liver cancer
or liver failure or abdominal
ascites for some other reason.
Giving spironolactone 100
milligrams in combination
with furosemide 40 milligrams
is quite an effective
combination medication drug regimen.
Keep that ratio the same so,
for every 100 milligrams of spironolactone,
you give 40 of furosemide,
so, you can give 100/40, 200/80, 300/120,
400/160 is a mega dose,
so, you really need to know what you're doing
if you're going to use that dose.
But definitely it works quite well
with patients who have ascites.
If you're wondering where the source of this is,
is, if you look at a New England
journal of medicine article
on the treatment of ascites.
It's an old article but it's a good one,
you can look at it and see how
the mechanism actually works.