Question from Audience: I just like to emphasise one thing regarding all these debate, acute or chronic situation, whenever using ACE inhibitor, you have to judge the circulating volume, filling pressure properly. If filling pressure is low, you are not going to use and how to judge it clinically is by postural fall, that is one thing, and if you are not sure, you can use your echocardiography, many of you are doing and filling pressure, and then if you find it is low, then do not use ACE inhibitor, it would be dangerous.
Dr. R. R. Kasliwal: There is a middle ground, certainly.
Dr A N Rai: I think we are biased about the beta-blocker. Beta-blocker, no doubt we are using in compelling indication, but in certain other conditions we can use if there is no acute contraindication. It can be used.
Dr Kunal Kothari: If there is no contraindication and if it is a young person with a lot of tachycardia and with the mild hypertension, we might use a beta-blocker and otherwise not.
Dr. N.R. Rau: I agree with them, it becomes the drug of first choice in hypertension with coronary artery disease. It recedes to the background if there is a hypertension with diabetes.
Dr. M.S. Hiremath: I think they are all not the same, I mean we have to make a difference between atenolol one side and something like bisoprolol on the other side, like your question with some degree of bronchospasm, bisoprolol is still okay. I mean unless it's overt asthma. I guess we have enough data for bisoprolol to be continued under this setting. Correct, so nebivolol/bisoprolol what we can call as a new generation beta-blockers, I think they are quite helpful.
Dr A N Rai: Most of the studies are with atenolol that is why all beta-blocker, but all beta-blockers are not the same.
Dr. M.S. Hiremath: But you know having used atenolol for so many years, I think the drop in blood pressure, which I think is the key, which is very strong with atenolol. You cannot go away from the fact that atenolol can give you the drop, which metoprolol cannot give in so many cases.
Dr A N Rai: Especially for a stroke, I think beta-blockers should be the second choice.
Dr. C. Venkata S. Ram: As Dr. Hiremath mentioned, I can tell you JNC is likely to make a distinction between older beta-blockers exemplified by atenolol and they will comment on not really newer, but nebivolol and carvedilol because of their metabolic effects and because effects on glucose insulin resistance and also pulse wave velocity, there a lot of advantages to it and there is a comment here, control of heart rate, there is a lot of data looking at a epidemiologically the heart rate and the prognosis, but generally you do not treat the heart rate, usually not, you treat the underlying cause, so it is correct that studies have shown that inverse correlation between heart rate and survival, but I think heart rate is like a sedimentation rate, it is marker of something.
Dr. Siddharth Shah: Yes, the latest guideline on hypertension has already commented on this that atenolol is going down worldwide as far the usage is concerned and newer beta-blockers are recommended for control of hypertension. Atenolol has come down in the use as a recommendation for control of blood pressure.
Dr. M.S. Hiremath: I think going back on the issue of heart rate, I think it tells me a lot of things, you know if you have somebody in front of you who has high blood pressure, which is in the moderate range and heart rate of 100 or 90 on one side and same kind of pressure with heart rate of 60 in front of you, I think the drug choice is clearly different and beta-blockers would certainly be very, very crucial. The RDN therapy, which we use for uncontrolled blood pressure, where you need more than 3 medications that has also shown to bring down the heart rate, so heart rate to me is something like excessive sympathetic activity, MSNA (muscle sympathetic nerve activity), and this has to be controlled and I guess the beta-blocker would be a very strong option.
Dr. Satyavan Sharma: The question is, is it necessary to control severe isolated hypertension vigorously? Practically not possible without side effects. Let me answer this way, I do not think we should control any patient of blood pressure vigorously. We should control the patient of hypertension meticulously with a systematic approach. It is the important to control the patient, where there is isolated systolic hypertension and if the hypertension is severe. This is also true that sometime side effects do develop and as I was mentioning and as Dr. Hiremath also pointed out, we have to use most of the times even in systolic hypertension a combination of drugs, so maybe by using judicious combinations, trying to avoid the side effects, we control the blood pressure, not that our aim should be to bring down the blood pressure vigorously on day one, but our aim should be as possible in a due course of time, in a safe time, minimizing the side effect to control the blood pressure.
Dr. M.S. Hiremath: Dr. Satyavan what is your treatment plan, which is your first drug, which is your next when you have isolated systolic hypertension.
Dr. Satyavan Sharma: I did mention in my presentation that one can begin depending on the overall profile of the person.
Dr. M.S. Hiremath: I give you 180/80 is the pressure and no other disease.
Dr. Satyavan Sharma: Actually, most of the time the choice will be a calcium channel blocker and next can be addition.
Dr. M.S. Hiremath: It is not easy to get isolated systolic hypertension down, so many times we struggle, so amlodipine is the first drug, then we go for chlorthalidone.
Dr. Satyavan Sharma: ACE inhibitor or ARB.
Dr. M.S. Hiremath: Not the diuretic?
Dr. Satyavan Sharma: You can go to diuretic also.
Dr. M.S. Hiremath: It is so easy I mean?
Dr. Satyavan Sharma: Yeah, you can go to diuretic.
Dr. M.S. Hiremath: I thought my second drug would be a chlorthalidone kind of diuretic and then I go to ARB. ARB again would probably be more effective in elderly compared to ACE inhibitors.
Dr. Satyavan Sharma: Actually, I have seen our Indian patients, particularly elderly patients, particularly in Mumbai heat, and I am sure Pune weather is almost the same, the diuretics are not well tolerated by our Indian patients. In a hospital where we have a lot of cross referrals, lot of patients get problems with diuretics.
Dr. Siddharth Shah: Especially when there is dehydration, you will have to very careful with ACE inhibitors and ARBs, because that can create problems.
Dr. B R Bansode: Sometimes I am reading the literature after literature and volumes of literature on hypertension, what has happened today? If you see 4 or 5 decade previously, half reserpine was controlling everything about the hypertension. Today, whether the pathology has gone wrong because of the lifestyle or the disease has gone differently, why we are getting 4-5 drugs to control the hypertension, still today the blood pressure is uncontrolled. Was it the same true 50 years or 60 years back, where we are wrong?
Dr. Satyavan Sharma: Actually, let me answer part of the question. Dr. Bansode, I do not think during those days the blood pressure used to be ever controlled. I was a resident when you know we have used lot of reserpine. I and Ravi used to be batchmates in Jaipur. We have used lot of reserpine and the amount of side effects, which reserpine, blood pressure hardly used to be controlled. The patient used to move with 180, 190 on reserpine and then Adolphine came, so I do not think blood pressure was well controlled those days, may be our aims to control and then we are now not only looking at blood pressure, we are looking at organ protection with that, so our aims have certainly changed that is why we are trying to achieve better control.
Dr. N.R. Rau: Sir, may I add one thing, even the definition of hypertension 160/95 when I was in PG.
Dr. C. Venkata S. Ram: Let us also in all fairness, there are also questions written, so we will manage floor versus written questions. I will just comment on it unless somebody differs. Beta-blockers and central aortic pressure, I think the older beta-blocker CAFÉ trial Dr. Kasliwal shown does not lower the central aortic blood pressure. There is one non-outcome trial with nebivolol showing that it lowers the central aortic pressure. Anybody differs from this.
No comments:
Post a Comment