Hypertension Explained Clearly - Causes, Diagnosis, Medications, Treatment, Pathophysiology

welcome to another MedCram lecture we could talk about hypertension and

specifically we're going to talk about the definition why talking about

hypertension is important and then the treatments and I really want to dedicate

this first video to the treatments simple treatments of hypertension and

how you choose medications to treat hypertension so for number one what's

the definition of hypertension well the a and C seven actually defines this for

us and the definition is simply any blood pressure that is greater than 140

over 90 now there's different stages there's stage 1 hypertension and that

would take you from 140 to 159 and then the diastolic would similarly be 90 to

99 so this would be stage 1 stage 2 hypertension on the other hand would be

anything greater than or equal to 160 over anything greater than or equal to

100 this would be stage 2 hypertension it's just a way of telling you what the

different stages are obviously the higher the stage the worse the

hypertension is now why this is important is pretty obvious because we

know that just from studies that high blood pressure leads to a whole bunch of

things you know things like stroke

things like ischemic cardiomyopathy things like a hypertensive heart disease

coronary artery disease and these things are all associated with very bad

outcomes obviously and so if we can reduce blood pressure we can reduce

these things and studies have shown that if you reduce blood pressure by even 5

millimeters of mercury so if we just drop the blood pressure again by 5

millimeters of mercury we can see a reduction in stroke

by 34% that's 1/3 that's pretty dramatic ischemic heart disease can be reduced by

21% and so that's pretty good you could also see a decrease in

dementia heart failure mortality from cardiovascular disease and so forth so

these reductions here are actually pretty pretty good and doesn't take much

to drop your blood pressure by 5 millimeters of mercury so I really

haven't told you something that you haven't already known

what's the treatments let's talk about the treatment and I would be remiss if I

didn't tell you about lifestyle changes we've got to make sure that we include

lifestyle anytime you have a blood pressure that's elevated we have so much

evidence now that lifestyle actually helps with blood pressure we're talking

about dietary changes so diet a low sodium diet is instructive now we're

talking about physical exercise

there's other things called biofeedback relaxation meditation but again I think

dietary is key with low sodium they talked about a - diet you've heard of

the - diet so things that are rich in nuts whole

grains fruits and vegetables

okay so vegetarian diet is very good for reducing blood pressure but of course

the thing that we get tested on in addition to lifestyle is medications and

that's what I kind of want to dedicate the rest of the talk to because

medications have side effects

now nuts whole grains fruits and veggies don't have side effects so this

obviously is a very good thing to do whereas medications are sometimes you're

forced to use medications and medications have side effects and so

this is the real philosophy when it comes to starting medications on

patients with high blood pressure because really there are so many

different types of blood pressure medications out there and you don't

start blood pressure medications because you don't know whether or not it's good

to reduce blood pressure because you know that these medications are going to

reduce blood pressure that's what they're designed to do

so what makes you decide which blood pressure medication to start it's based

on two things number one what the underlying diagnosis is because certain

blood pressure medications help in certain diagnoses and number two what

are the comorbidities that your patient has because these medications have side

effects and you want to make sure you get the right side effect profile so

that's what we're going to talk about next is these medications and their side

effects and how to choose which one to have so there are many different types

of blood pressure medications the way I want to divide this

is in a way that's easy for you to remember obviously and so in this first

video we're going to talk about the four major types of blood-pressure

medications and I like to call this the a B C and D of blood pressure

medications so what is a stand for well a stands for ACE inhibitors and a are

B's B stands for beta blockers C stands for calcium channel blockers and D

stands for diuretics now I know that there's other types of medications for

instance like alpha blockers nitrates vasodilators alpha-2 agonist we're going

to talk about that in the next video but let's first talk about these major types

of medications okay so ACE inhibitors let's talk about

the diagnoses that make ace inhibitors useful so we like to use ace inhibitors

in patients with blood pressure elevation who are what well we know that

in diabetes this can help with kidney problems and it protects the kidneys we

also know that in congestive heart failure it can improve ejection fraction

so that's important to know we know that it helps in post MI it improves survival

it also improves survival and CHF so make sure you know those things because

if you're patient happens to have diabetes or happens to have congestive

heart failure or how it happens to be post myocardial infarction these are

things that help we also like to use ace inhibitors

in patients with connective tissue disease like scleroderma okay and that

also protects the kidneys okay all right so those are the diagnoses that I would

concentrate on what about beta blockers so beta blockers we like to use beta

blockers in again patients with congestive heart failure if we know that

it improves survival we also like to use beta blockers in post MI again for the

same reason it improves survival data blockers arm can also be used in young

and I would also put young here in terms of ACE inhibitors young people who have

problems with blood pressure C's these typically work well in young

people I'd also put a white here as well Caucasian young white we find that it

seems to be more effective in that population in terms of congestive heart

failure the ones that you should know are the two special types of beta

blockers that should be used in congestive heart failure is carve a

Dalal and metoprolol if that's what you're using it for you need to use

those two medications because those are the only two beta blockers that have

been found to improve survival in the studies for CHF for post mi you can use

just about anything but generally speaking carve a delimit overall should

be used in those situations as well all right what about calcium channel

blockers calcium channel blockers really haven't been shown to improve survival

in any patients and so we don't really use calcium channel blockers to improve

survival and so they don't get much of an indication here but you should know

that in African American and in the elderly

they could be useful and that goes the same for diuretics

again diuretics really haven't been shown to improve survival in any

condition and so I would recommend that you know that african-americans seem to

actually respond well to them and also the elderly okay so those are diagnoses

where you'd want to use those medications in those particular patients

what about side effects let's talk about side effects okay so we'll just put a

line here and we'll go over the side effects so you'd want to know the side

effects of these to avoid these problems so what are the side effects of ACE

inhibitors and ARVs the first thing I want to talk about is

angioedema so that's where the tongue swells the next swells this could really

be a problem so you make sure you know that the patient knows that if this

happens they can go to the emergency room and we see it both in ACE

inhibitors and AR B's both cough we see in patients 30% of the time on the Aces

and of course if we see that we switch them to an ARB because we usually don't

see that as much but some of the cut more common side effects would be

hyperkalemia hyponatremia also we see problems with the creatinine especially

in renal artery stenosis so if you have bilateral renal artery stenosis that's

contraindicated you shouldn't use it in those situations obviously you can have

increases in creatinine and that can cause renal failure which is kind of

paradoxical because these are medications that are used especially in

problems with the kidneys to protect from protein area especially in diabetes

so be aware that you know what those side effects are for the ACE inhibitors

okay what about side effects for beta blockers now of course you know that

beta blockers can cause the heart rate to go down that's almost not even a

that's almost a known response obviously they're going to drop blood pressure as

well but some of the other things you may not know is that it could increase

your lipids and cholesterol it can increase depression if they've got

asthma it can increase asthma and COPD with bronchospasm so depression

hyperlipidemia decreased heart rate increased asthma bronchospasm these are

all side effects of beta blockers it could also increase potassium as well so

that's something to keep in mind especially if someone has a hyperkalemia

to begin with beta blockers can can do that calcium channel blockers you really

should divide these up into two different categories there are the

dihydropyridine and there are the non the hydro pyridine x' okay so what are

the dihydropyridine let's switch to a different color to highlight what what

it is that I'm talking about so the dihydropyridine x' or anything that ends

in a beam like nifedipine the feta peen em low to peen and also full-load opine

so no feta P&M low doping and falow to peen these are all dihydropyridine x'

what's the reason why you should know about this it's because they cause

peripheral vasodilation whereas the non dihydropyridine for instance diltiazem

and verapamil cause reduction in inotrope what does that mean that means

it reduces contractility of the heart

as a result we typically see the heart rate go down in this non de hydro

pyridine x' and we see the heart rate go up or stay the same in the

dihydropyridine x' now there is an exception to that and that is m low to

peen that's kind of like the black sheep of the family

and low to peen tends to make the heart rate go down which is which is good

because this is very good in ischemic heart disease so if you want to use a

dihydropyridine and don't want to cause the heart rate to go fast you can

actually use a amlodipine which is still a dihydropyridine but it doesn't make

the heart rate go as fast so that's a favorite one to use in ischemic heart

disease so what are the other side effects that you could see from these

calcium channel blockers well you could see edema in the lower extremities you

could also see constipation and you could see heart failure why again

because of this negative ion at ro- contractility this is a really good

medicine to use in atrial fibrillation with rapid ventricular response these

non dihydropyridine because they reduce the response through the AV node and

aren't going to transmit the electrical conduction of atrial fibrillation which

is going so rapidly that the ventricle can't keep up and it will block that

transmission alright so those are calcium channel blockers what about

diuretics well diuretics is such a broad term I think what we ought to do is

break it down into the two major diuretics and those are the thighs IDEs

so I'll just abbreviate that as hydrochlorothiazide and of course lasix

now of course the the differences between these two can be major there are

a number of side effects of hydrochlorothiazide first of all

hydrochlorothiazide is an a sending limb diuretic whereas lasix or furosemide is

a loop diuretic okay so what there are four things that you should know that

hydrochlorothiazide increases we know that diuretics is a general rule

decrease potassium so we'll put that on both sides but what are four things that

hydrochlorothiazide will increase number one it will increase calcium levels

whereas lasix decreases calcium levels in the blood the second thing that

hydrochlorothiazide increases is uric acid and so that can make gout worse the

next thing that it could increase is lipids and then the last thing that

hydrochlorothiazide can increase is glucose which you have to sometimes

worry about in diabetes so the four things I'll ask you about is calcium

uric acid lipids and glucose of course hydrochlorothiazide reduces potassium

and because it's a diuretic it can also increase your cratan and put you into

renal failure it can also reduce your sodium concentration and it's sometimes

the cause for a hypotonic hyponatremia which is hypovolemic if you want more

information on that look at our med creme lecture on hyponatremia is as a

result lasix gets rid of calcium gets rid of potassium it could also cause

hyponatremia and it can also increase the creatinine and cause renal failure

so these are the four basic food groups if you will of medicines that you can

treat patients with hypertension so let's just go over these a few just in

your mind here if you had a patient with gout you would not want to put them on

hydrochlorothiazide because it could increase the uric acid level if you had

a patient with kidney stones you would not want to put them on something that's

going to put a lot of calcium into the urine like lasix because it drops

the serum calcium level by dumping calcium into the urine whereas a

thiazide diuretic would be ideal since it reduces the amount of calcium that is

excreted into the urine and thereby increases the serum calcium

concentration now in the next video I'm going to talk a little bit more about

some of these other antihypertensive medications like alpha blockers alpha-2

agonist s' nitrates etc so please join me for that