Hypertension Encyclopedia – 1 Seminar(Organized By Hypertention Society of India)
Attended By: Dr Ravi R Kasliwal | Dr. C. Venkata S. Ram | Dr. Siddharth Shah | Dr. N.R. Rau | Dr. M.S. Hiremath | Dr. Kunal Kothari | Dr. A N Rai | Dr. Santanu Guha | Dr. C. Venkata S. Ram
Dr. R. R. Kasliwal: I was just saying that I agree, what I tell my patients is do a couple of things, one is APC, you know avoid achar, papad and chutney. It is easy to remember APC, but then there is an important thing that many of the patients come from regions where temperatures go up to 45 degrees and they are exposed to the sun, they are exposed to the summer, so do not be so categorical in saying, shut off all salt. It will not work. The patient will fall, so generally in these people I say don’t sprinkle salt, do not take it excessively all these salty things that we have. The other thing that we have to see is that in many families in Rajasthan particularly they still add salt to the roti, that pointedly you should tell, that look this should be without salt. So, management of hypertension on a long-term basis is very practical, very, very practical and you have to go down to that level.
Dr Sandhya Kamath: One last comment on salt in pregnancy, already a pregnant woman tends to develop postural drop in blood pressure and if you do not give her salt or ask her to take less salt or a salt-free diet that will further aggravate the situation.
Dr. C. Venkata S. Ram: Any comments or questions for the panelist here from any section, please raise your hand.
Dr. Siddharth Shah: Can we go beyond salt.
Dr. M.S. Hiremath: Imagine somebody who had blood pressure of 150 and he is on antihypertensive, whichever he choose, comes with LVEF, has some kind of LV dysfunction, ACS kind of scenario, blood pressure comes to about 100, may be 90. So, we have scene where we have LV dysfunction and the patient is previously hypertensive and we have to come down on his antihypertensives, so in long-term we are trying to push something like ramipril, because that is very a strong indication, so how do we keep adjusting between ramipril, something like carvedilol or metoprolol and diuretic under this setting.
Dr. Satyavan Sharma: I think, how we go in this patient is if the patient is at that particular time when the patient has come with ACS and patient is having LV dysfunction, if there is congestion, certainly we use diuretic at that time, let the congestion go away. If the patient is having lot of tachycardia, which many of them have, we start adding carvedilol and we get the carvedilol up in these patients to the tolerable dose and on a chronic basis then we have judicious balance between ACE and beta-blocker and both are going to be important for our patients and we try to get them you know as good dose of both as possible.
Dr Kunal Kothari: But the question is whether you can give ARB or ACE inhibitor in such situation or not.
Dr. M.S. Hiremath: I agree that they have to be given, the issue is how to build it up because only systolic pressure is very, very borderline, something like 90.
Dr Kunal Kothari: The only guidelines will come in due course of time with looking at the renal function and renal perfusion and that will determine what amount of dose and you have to give that while keeping a watch on this.
Dr. Satyavan Sharma: The patients in ICCU, when we treat the ACS patients with LV dysfunction even when their blood pressures are 100 or 110, we start with starting a small dose of ACE inhibitor because there was a time when we used to give them captopril and start with the small dose of captopril.
Dr. N.R. Rau: Sir, sometimes these patients of LVF, we may be able to give ACE inhibitors, but to start carvedilol, some of them have got severe bronchospasm?
Dr. Satyavan Sharma: If a person is having a bronchospasm, certainly you know we will have to avoid.
Dr. N.R. Rau: No, not bronchial asthma, bronchospasm coming along with LVF, non asthmatic.
Dr. R. R. Kasliwal: In a situation of acute coronary syndrome when the pressures are 90, there is tachycardia and may be there is a situation to put the patient on intraaortic balloon pump rather than to think of ACE inhibitors or because till the patient is euvolemic, ACE inhibitors will bring the patient down again. So, I think that in an acute situation, a chronic therapy is not advised.
Dr. Satyavan Sharma: I do not want to raise a debate here, but I think we do it everyday.
Dr. R. R. Kasliwal: Do it everyday, but if the pressures are low.
Dr. Satyavan Sharma: That every cardiologist knows.
Dr. Kunal Kothari: Renal profusion is alright and urine output is about 30 to 40 mL/hour, then there is no need to worry about it.
Dr. A N Rai: Intraaortic balloon pump is not available everywhere. The majority of hypertensives will not reach such place.
Dr. R. R. Kasliwal: We are not talking about hypertension here, we are about acute patients, a patient who has got acute coronary syndrome, LV dysfunction.
Dr. M.S. Hiremath: I am sorry, I started the whole issue. All that I meant was the patient was hypertensive, now he is leaving the hospital with a blood pressure of 90-100. He has finished the acute phase and he is leaving the hospital with a pressure.
Dr A N Rai: I think all the three combination; diuretics, beta-blocker, ACE inhibitor or ARB this should be used once the patient is leaving the hospital especially.
Dr. Santanu Guha: The other issue is even aldosterone antagonist is very much indicated and beneficial in this scenario.
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