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Date: 25-04-2013 Hypertension Encyclopedia - 1

Moderators : Dr. C. Venkata S. Ram and Dr. Siddharth N. Shah

Hypertension Encyclopedia - 1


Dr. C. Venkata S. Ram:  The whole idea of this interaction that we will have is to have a robust exchange of comments, by comments I don’t mean agreements, you can always say what you feel is appropriate for the subject and myself and Dr. Siddharth Shah have always considered that these kind of interactive sessions probably are the most crucial foundation of anything, more than the structured lectures.  So, what we will do is we have a group of panelist and we will select somebody random, unprepared, and then we will go from there.  From the audience, use either the microphone or if you want to write, there are cards, and we will select and go over this section of the program.


Dr. Siddharth Shah:  We have found this to be very, very important and more of interaction because you have lot of questions.  As a student when I used to attend all these lectures, we never had an opportunity to ask our own problems.  You are clinicians you must be facing, some of the questions have already been answered by the speakers after a lecture, but there must be definitely more questions.  You should not take it for granted what is given over here. You might be having more experience with your patients and you might be having questions which you may feel it is foolish, but it may be very relevant. I was going through a few journals recently and in one of them I found that it was mentioned about salt and hypertension.  So, I would like to ask Dr. Rau to start the ball rolling.  By reducing the quantum of salt in a multicentric trial in USA and the portions of meals that are being served, reducing the potassium content and salt content it is claimed that the blood pressure does come down.  What do you feel about our country where the intake of salt is different in various part of the country and whether the salt does make any difference and when you prescribe in a hypertensive what type of salt restriction would you like to give?  This question is also open to other panelist if they want to answer from their own experience.


Dr. N.R. Rau:   Thank you chairpersons, Dr. Shah and Dr. Venkata S. Ram.  The first treatment for hypertension was substitution of sodium for potassium and hence early in the treatment of hypertension, potassium salts were given as a substitute, but in our clinical practice if the hypertension is mild, with lifestyle modification we advise salt restriction.  It is easy to advice.  I personally feel that, especially the South Indian diet, pickles and papad are two very important components and these two if they keep away to a great extent it helps in reducing the mild hypertension along with lifestyle modification like decrease in weight, decrease in obesity with good 30-45 minutes of exercise everyday.


Dr. M.S. Hiremath:  Like all us of Dr. Rau went around the question of eating salt or no, but it is not one line answer that he gave, I mean we as Indians eat too much salt that’s what you mean?


Dr. Kunal Kothari:  One important thing, which I find with the salt, it is easy to say that don’t eat the salt or use less salt, it is very difficult to manage in life that how to reduce amount of salt. The one practical example which has been given by Dr. Rau is that to avoid salty things and it is easy to manage in life.


Dr. A N Rai:  I think we all know that the first thing in the management of hypertension is lifestyle modification and in that the DASH diet comes as low-salt and high potassium, which I already said.  The amount we should take, though in USA it is said less than 3 gram, but in India less than 6 gram should be the amount per day.


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. Santanu Guha:  I fully agree with what Dr. Ravi has said that one should be very strict in salt restriction, particularly in the elderly population in our country that too during summer.  Chance of hyponatremia really increases and in this respect, I want to just tell about one study, very important study which was ICMR sponsored, it was done in Assam, and a very close friend of mine Dr. Kalita, he was a principal investigator.  There what happened in the tea-garden area, the tea-garden workers had a very high incidence or prevalence of hypertension.  The prevalence went up to more than around 90%, to that extent.  On trying to analyze the cause it was found that from the British era itself one common habit was they used to add salt to everything, to water, to milk, to rice to everything whatever they eat or drink they add salt.  They tried to dissuade them from doing so, particularly they picked up some young children going to school, they found that they could not control the hypertension, because the children they also had hypertension.  Then they analyzed that the water they are getting from home that is mixed with salt, so addition of salt to everything really increase the prevalence of hypertension in that particular community and some selective study trying to reduce the salt intake could control hypertension to certain extent.


Dr. C. Venkata S. Ram:  Okay then we will conclude, Dr. Satyavan you want to add?


Dr. M.S. Hiremath:  Actually, honestly, I want to ask this question.  The patient is in front of you, we have so many smart medicines these days which can control the blood pressure, so we really need to talk to them about salt, I mean that is my concern, I mean as a fan of salty things, I am asking you this question.


Dr. C. Venkata S. Ram:  If Dr. Satyavan has no comment then we can close this part with some take home messages.


Dr. C. Venkata S. Ram:  Remember, abundant salt causes abundant blood pressure, but on the other hand the salt restriction in many individuals has to be individualized.  As Dr. Hiremath has suggested due to the availability of a wide variety of antihypertensive drugs that lower the blood pressure, the enthusiasm or the need for vigorous salt restriction has somewhat abated, but I am not suggesting you should not.  One thing we must always do as doctors, you must always tell the patients about nonpharmacological treatment because if you do not tell them, nobody else will tell them, that is very important.  Doctors have to tell their patients about importance of nonpharmacological treatment.  What aspects of it you want to stress has to be strictly individualized, so the salt story will go on, it will never end.  The only thing which never happens is extremely low-salt diet can be decremental from a hemodynamic point of view and there are some observational studies that vigorous sodium restriction if it is followed is associated with increased risk of cardiovascular events because of activation of renin angiotensin system.  Having said that, very few individuals in the society ever restrict the salt so much.  I think, the take home message would be, I think the salt intake in moderation, namely, I think somebody use the word not using salty foods, no added salt, etc. it is going to be very very simple, nothing very, very dramatic at all.


Question from Audience: Sir, one of the speakers mentioned potassium supplementation in his slide and one of the panelist also said salt restriction and potassium supplementation.  We really talk about potassium supplementation to our patients.  I want to ask whether it is really safe to give potassium supplementation now with the era of combination antihypertensives where we are using ARBs plus ACE inhibitors.  Can you please detail on this.


Dr. A N Rai:  We are just saying fruits, take plenty of fruits that will have potassium, not supplementation.


Question from Audience:  What you are saying is absolutely right, but potassium supplementation whether it is pure potassium or fruits or bananas, it is still potassium, body absorbs potassium.  Is it safe to talk about potassium fruits in the presence of these antihypertensives?


Dr. Siddharth Shah:  I think as it has been pointed out, it has to be individualized.  We will have to take care of many other things like renal involvement, cardiac involvement.  We have to be careful when we talk about this, but I think the message that has been given to you is to be moderate, individualize the therapy, and wherever it is necessary you might have to.  If you are using diuretics like thiazide diuretics some patients may ask you, I am using so much, so whether potassium has to be replaced or not, so all these things has to be considered when treating with diuretics.


Question from Audience:  My observation over the last two decades, you tell patients reduce your salt intake, they say we do not take salt at all that is one thing.  Second thing, which I have come to conclusion, I tell my patients eat as many items you want to have, but in your dish only one item should have salt and third I have a suggestion to Dr. Kothari, I think he belongs to Jaipur he must be coming in contact with lot of jains and they observe a particular period, some duration of time when they do not take at all any salt.  I would request him to study those guys, when they take normal salt and when they do not take salt at all and see the effects.


Question from Audience:  Sir, during the diuretic therapy, do you advise salt restriction?


Dr. C. Venkata S. Ram :  Actually, somebody might comment on it, then I will have one more final comment, will conclude whoever talked on drug treatment, when somebody is on diuretic, is it needed for salt restrictions.  Shall we start from Dr. Satyavan and go that way?


Dr. Satyavan Sharma:  Actually, those patients who are not volume overloaded and if you are giving them diuretic, I do not think we should be really too strict about stopping their salt intake during that point, but if a person is having a sort of volume overloading, edema, that time certainly you have to tell not to have salt.


Dr. C. Venkata S. Ram:  Efficiency of the diuretics is only when there is moderate salt restriction, because what happens is I think somebody commented on diuretic induced side effects such as hypokalemia.  If you eat more salt when you are taking a diuretic you are exchanging sodium for potassium in the kidney and you are more prone to hypokalemia.  So, one way to attenuate diuretic induced hypokalemia is to reduce the amount of salt not to the extent to eliminate it, but you reduce it.  The more salt you take, more hypokalemia you develop.


If Dr. Siddharth Shah has no comment any questions from the audience either from the right side or the left side, front or back, men or women, young or old, we have a mixture of people here, people with lot of hair, people who have difficulty with combing.  This is a forum.  This is a not a lecture hall.


Question from Audience:  The sodium component of sodium chloride is what you call the main contributive factor to raise the BP as I know, so is there any role of salt substitute likes the KCl, which does not contain sodium, but provides salty taste, like say in diabetics saccharine is used.


Dr A N Rai:  It can be added, but it cannot be substituted.


Dr. C. Venkata S. Ram:   Potassium has a vasorelaxing property.  Actually, the studies have shown it is not just sodium restriction, but sodium-to-potassium molar ratio.  Less sodium, more potassium, the molar ratio is responsible for vasorelaxation and the best way for the potassium is not through potassium by prescription, but potassium through food.  That is the best way and hyperkalemia from potassium intake should not happen in people who have normal kidney function, very unusual, almost unheard of to develop hyperkalemia when you have normal kidney function, because the moment you have potassium that is accumulating, you stimulate aldosterone and the potassium goes out.  So, I think potassium supplementation as a drug is not that much needed unless somebody has protracted hypokalemia from diuretic use, heart failure, etc.


Question from Audience:  Role of salt in pregnancy-induced hypertension and elderly, actually most of time they land with hyponatremia and altered sensorium in ICU.


Dr. N.R. Rau:  See the commonest cause of altered consciousness we see in our critical area is hyponatremia.  So personally, in people above 65, I use calcium-channel blocker as it has been told here rather than diuretic, because I am very, very sensitive to diuretics and the west coast as well as the North India in summer we sweat so much.  I fully agree that too much of salt restriction may be counterproductive.  As our chairpersons have clearly told we have to strike a balance and individualize.


Dr. C. Venkata S. Ram:  I want Dr. Amaresan to comment, Dr Rau has mentioned the risk of hyponatremia in the elderly not so much from sodium restriction, but from diuretics, the reason for that, maybe Dr. Amaresan can correct it, for a given level of volume deficit, there is a greater ADH release in the elderly. The ADH release in the elderly is very, very brisk and that is the reason why they develop more hyponatremia at a given dose of a diuretic.  Dr. Amaresan, you have a question and comment.


Dr. Amaresan:  I think the comment is that it is pertinent particularly in hypertension in elderly individual.  Actually if you go into the epidemiology of chronic kidney disease, the chronic kidney disease is increasing due to various risks, but one of the important thing is the increase in the elderly population, where there is a declining GFR and so there is a retention of salt and so leave alone the pregnancy and elderly, even in old, old or young old you got to reduce the salt, because there is a reduction in GFR and so that is one thing.  The second comment is, it is not only the potassium supplementation in the food, the calcium supplementation in the food; magnesium supplementation in the food is also antihypertensive besides reducing. The salt reduction in hypertension potentiate the action of ACEI and ARB and also reduces the proteinuria when you use ACEI and ARB in a case of hypertensive, so it is important, and you go through the excess salt, it produces endothelial dysfunction.  What a human being requires is only about 2 gram of salt, but maybe, as Dr. Siddharth Shah say that we may have a little more than the 2 grams, but then not 12 grams or 13 grams, which we consume everyday that is very important.  It can give rise to cardiovascular problem with an excess of salt leaving alone the volume overload and rise in the blood pressure.


Dr. C. Venkata S. Ram:  One thing about the nephrologist is they always make us believe that kidneys are the heart of the matter.  Somehow, they lead us to conclude the kidneys are heart of the matter.  Regarding pregnancy, one would avoid sodium restriction in pregnancy because in hypertensive disorders in pregnancy on an average there is a deficit of 500 mL to 1 L deficit.  Unless there is a compelling indication such as congestive cardiac failure or chronic kidney disease one would avoid salt restriction, one would avoid diuretics in hypertensive disorders in pregnancy, because they are already volume depleted due to the underlying pathophysiology.


Question from Audience:  Normally, daily requirement of salt is about 10 to 12 gram and the normal diet contains around 5 to 6 gram of the salt, so requirement is not more than 4 gram, so daily requirements of extra salt is 4 gram, that is sufficient.  So if you take more than 4 gram extra salt and that will lead to the hypertensive patient and that is difficult to control.


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.


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. C. Venkata S. Ram:  There is question, are we doing a lot of injustice to beta-blocker, I presume for hypertension.  We can start quickly from here, brief comments, if we are taking criticism on beta-blockers too much or is there a middle ground.


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.


Question from Audience:  Sir, from the morning, we have heard lectures on the basics of hypertension and also the panelist have talked about it, but nobody has talked especially about stress and it is effect on hypertension or coronary artery disease and the interaction.  Is it that we talk about it only when we have episodes or events in cardiologist or physicians who have these cardiovascular events.  I mean that is one issue.  The second thing is, Dr. Hiremath very rightly said in the secondary prevention beta-blockers with ACE inhibitors or ARBs should be the drugs of choice.  If that is so, suppose we get a big amount of patients in the age group of around 30 with a very strong family history of coronary artery disease who were only hypertensive and dyslipidemic.


Dr. Siddharth Shah:  In Mumbai, every one has got stress, but acute stress does cause problems and that acute stress has to be managed, it does cause problem.


I think Dr. Kasliwal is known for his lifestyle modification, what do you think about the stress and hypertension.


Dr. R. R. Kasliwal:  Absolutely correct, what you said acute stress can to the extent cause dissection of aorta because of huge rises in pressure, but truly in the environment that we all are, whether it is Mumbai or Delhi or wherever, there is huge chronic stress and that actually adds to the other co-existing risk factors of the psychosocial stress with cigarette smoking or obesity or metabolic syndrome.  I think that is what we are talking about and why no body talked about individually because it was clumped as lifestyle measures, so I think that chronic stress has definitely contributed towards increase of blood pressure and its aftermath.


Dr. Satyavan Sharma:  Let me define your question, the question which you asked.  There are two aspects of stress; one is the role of stress in causation of chronic diseases.  Right, I do not think any one of us was allowed to speak on that, so nobody touched it.  What you are trying to ask is the role of stress as a trigger in some short of acute coronary syndromes or in short of some acute situations.  Now, these are completely two different things.  Stress plays a role in triggering many acute coronary syndromes, sudden cardiac death, acute hypertensive episodes, but that is different than the role of stress and causation of hypertension, causation of diabetes, and causation of coronary artery disease, so these are two different areas.


Dr. C. Venkata S. Ram:  I think we talked about heart rate, the role of ivabradine and outcomes.


Dr. Ravi Kasliwal:  If there is hypertension and increased heart rate, there is no role of ivabradine, beta-blocker should be given, nebivolol, bisoprolol what ever your choice is.


Dr. M.S. Hiremath:  Suppose it is hypertension with bronchial asthma and tachycardia?


Dr. Ravi Kasliwal:   If it is hypertension with bronchial asthma, still bisoprolol is a better choice than to give ivabradine.


Dr. C. Venkata S. Ram:  There are no comparative studies between chlorthalidone and indapamide, but there are comparable outcomes studies with the drugs.  With indapamide, I think somebody has mentioned the HYVET, PROGRESS, EUROPA.  With chlorthalidone SHEP, SHEP extension, so they are separate, nobody has compared chlorthalidone with indapamide.  Anybody wants to differ?


Dr Kunal Kothari:  One comment, I would like to know what happens say continued use of diuretic particularly in elderly has been advocated.  Is there are any role of giving twice a week or once a week or twice a week giving diuretic and taking care.


Dr. C. Venkata S. Ram:  Let me tell you one comment I have and then we will go to the goal pulse pressure, what happens with the diuretics is the volume reduction that happens, it only happens initially.  With long-term diuretic therapy, the volume comes back to baseline, so the continued use of a diuretic does not mean you cause continued volume depletion because if you cause continued volume depletion, there is a consequence, known as death, people die with continued volume depletion, so what happens is volume goes down, but it comes back again, so other mechanism that is coming into play.  Now, Ravi, are there any guidelines for goal pulse pressure.


Dr. R. R. Kasliwal:  I do not think so.  The only thing they have eluded to is in the European Society Guidelines, but not to that extent, I think systolic and diastolic.


Dr. C. Venkata S. Ram:  I will ask one question, where you can also comment, for Dr. Shah.  Hypotension, I do not know how one defines this is hypotension.  Do you want to treat it with sodium intake.


Dr. Siddharth Shah:  First of all comment is that hypotension is not a known entity.  It has been conjured up to and I do not think hypotension is a relative term and if it is due to drug, then it has to be treated; otherwise, hypotension per se does not exist.


Dr. C. Venkata S. Ram:  Sodium treatment for hypotension is only for people who have adrenal insufficiency.  People who have adrenal insufficiency, if you do not give sodium supplements, they are going to very, very ill.


Dr. M.S. Hiremath:  Incidentally, there is something like tablet Mephentine, which is available in the market.


Dr A N Rai:  I think one should treat the underlying cause of hypotension, not the sodium supplementation.


Dr. N.R. Rau:  I think best way hypotension be seen in clinical practice, now that summer is coming, acute gastroenteritis, then we start with treatment.


Dr A N Rai:  Treat the underlying cause.


Dr. C. Venkata S. Ram:  Multiple medicines, the blood pressure is not controlled, the next option?  Let us presume the patient is compliant, let us not question patient's compliance, because then there is no discussion.


Dr A N Rai:  Sympathic renal denervation is the one for resistant hypertension.


Dr. C. Venkata S. Ram:  And proper use of aldosterone antagonist.


Dr. Santanu Guha:  It is mentioned that if the patient has not received the aldosterone antagonist whether he has resistant hypertension it is a question.


Dr. M.S. Hiremath:  I think we should go further to eplerenone also.


Dr. C. Venkata S. Ram:  In fact, some other renal denervation studies have been criticized that the patients were inducted into RDN trial without sufficient exposure to spironolactone.  Dr. Hiremath mentioned the renal denervation does reduce heart rate, but Dr. Kasliwal will be pleased to know that it also has been shown to decrease pulse wave velocity, so multiple things happen.


Dr. M.S. Hiremath:  I think sleep apnea, which correlates so much with hypertension that also is expected to benefit with RDN therapy.


Dr. C. Venkata S. Ram:   What is this, nobody asking from the right side, this is like Lok Sabha or something, only one section is voiceless, what happened right side.  We want some balance.


Question from Audience:  This question is for Dr. Hiremath, he spoke so well on combining various antihypertensives and starting with combinations.  He also mentioned combining first and then stepping up, maybe even the combination stepping up, the STITCH study.  He also mentioned a point where he suggested stepping up diuretic, so how good is to consider stepping up a dose of diuretic or combining two diuretics, especially when treating a resistant hypertension.


Dr. M.S. Hiremath:  No, I do not think I mentioned anything about stepping up diuretics, but it is in STITCH study.  They started with half tablet and some of the combinations could have a diuretic, so what you are saying is going from half tablet of H or chlorthalidone to a regular full dose, which is still acceptable.


Question from Audience:  Is it rationale to step up?


Dr. M.S. Hiremath:  I think all these we know what is the upper limit, like say we would not go more than 25 mg of hydrochlorothiazide.


Question from Audience:  Within that limit, is it rationale to step up the dose?


Dr. M.S. Hiremath:  Yes sure.


Question from Audience:  Like in thiazide, can we go from 25 to 50?


Dr. M.S. Hiremath :  No, no,  I wouldn't go more than 25.  You can go to 50, but I think 25 is my upper limit for hydrochlorothiazide.


Dr. C. Venkata S. Ram:  Just a comment on guidelines, don’t get yourself too much uptight on guidelines.  We are all endowed with a wonderful faculty known as clinical judgment and it is not a bad idea to apply clinical judgment at all.  Do not worry sometimes about the dosage and how much, how soon you want to increase.  All of us come with sufficient level of intelligence that you should be able to manage the doses and frequencies, etc.


Dr Muralidhar Rao:  We are talking about hypotension.  Lot of patients suffer from postural hypotension and chronic diabetics with long-term diabetics also suffer from postural hypotension.  We used to have a drug called fludrohydrocortisone, fludrocortisone in the past.  Sometimes used it in hypotension.  You know, suddenly falling, feeling syncopal and all that.  Do you think there is anything that can be done for it.


Dr. Siddharth Shah:  I do not think that that would help, but definitely you have to go to the bottom of the pathophysiology of the low blood pressure, we can consider that, then I think you can treat any of this hypotension.


Dr. C. Venkata S. Ram:   You know sometimes postural hypotension is such a headache, so difficult to treat, you can talk and talk and talk, talk, some people try indomethacin, nonsteroidal anti-inflammatory drugs, sodium restriction, etc.  It is very, very hard to treat true postural hypotension.


Dr. Santanu Guha:  Just a little while before, we were discussing about the beta-blockers and I want comment from both of you on two aspects, one is the UKPDS study, 20 years result, which has come up.  It has got atenolol with or without diuretic has not faired inferior to captopril, plus and minus diuretics, rather on the 7-end point counts, it was marginally superior with all, that is number one.  Secondly, I am a little more confused about the metaanalysis which was published in BMJ perhaps in 2009 by Law et al.  One of the largest metaanalysis involving 148 studies.  The conclusion was it is the reduction of the blood pressure, which gives a benefit and there is no special benefit of any special drug.  Third conclusion was only two drugs had some minor advantage over others.  One of them was beta-blockers given within 2 years of an acute coronary event and second was calcium blockers are slightly more neuroprotective than others, but at the same time with the incidence of heart failure it is less protective on heart failure accounts.  So, these studies were done with the beta-blockers, majority of the studies were done with atenolol.  It is a fashion now that we go on bashing atenolol, so is it really true that this should be discarded or this should be pushed down to the fourth line as per NICE guideline.


Dr. Siddharth Shah:  Let me tell you that UKPDS has set what Dr. Guha is saying, that what is important is to bring down the blood pressure, whether you use one drug, two drug, three drug or ABC drugs that has been already pointed out by UKPDS and has been well accepted.  What is important is to bring down the blood pressure.  As far as the use of atenolol, newer studies have come and I am sure JNC-8 is going to look in to this and definitely atenolol has been shown to have adverse effects, which are still coming in. We are not bashing out atenolol.  Let me tell you, atenolol is one drug, which is very important and we use it on a day-to-day basis, but we are not trying to bring it down, what is important that we are having newer drugs, which are having less side effects and that is why the future is going to be, that is the recommendation, and that is also going to be the JNC-8 recommendation that if you have newer drugs with fewer side effects, then atenolol use will definitely come down.


Dr. Satyavan Sharma:  There are two questions; one question is what next additional antihypertensive in resistant systolic hypertension with reading of 200/80 on 4 drugs amlodipine, metoprolol, spironolactone, furosemide, olmesartan, prazosin.  Now, this is definitely a case of resistant hypertension.  In such cases, the approach should be:

1.  We try and see whether we have missed out any secondary cause and it is not unusual in patients of systolic hypertension, elderly, sometimes to develop a renal artery stenosis subsequently.  So you should check these patients thoroughly for any evidence of renal artery stenosis.  Suppose, we do not find any cause, now this actually sounds like a really excellent case to be evaluated for renal denervation therapy.  Now, what we can do practically at this moment, I think this is a case, where sometimes we have to fall back on the drugs, which we have forgotten like centrally-acting drugs and the drugs, which our nephrology colleagues still use or what we use in sometimes in pregnancy, alpha methyldopa, use of centrally acting drug like clonidine, moxinidine, so these are the drugs, which should be tried in this patient, so this is first question.


Question from Audience:  Sir, time and again we keep getting referrals from our ENT colleagues.  Patients present to them with epistaxis with the reference that there is nothing seen in the ENT examination and it is because of hypertension.  Those patients quite often have hypertension, whether that was situational or is it really hypertension causing epistaxis, because most of them do not have any tell tale evidence of hypertension, so is it really the cause.


Dr A N Rai:  I think epistaxis, one of the manifestation, first presentation of the hypertension, so if you have grade 2 hypertension, it is to be treated.  If it is a borderline hypertension, you can wait and watch, but epistaxis is one of the presentations of hypertension.


Question from Audience : Without any ECG change or any target organ damage?


Dr. Satyavan Sharma:  Is systolic hypertension treated differently as diastolic one, if yes, how?  Actually, I did answer this question.  By and large the principal of treating systolic hypertension and the combined hypertension is the same, but as I mentioned in systolic hypertension is more common in elderly persons, so our approach should be little more cautious because of postural hypotension and other issues are there.  So again, the drugs the same way.


Dr. Siddharth Shah:  I think the last question and the last comment will be from the senior most nephrologist of the country, I think your comments will be very welcome.


Dr. Amaresan:  I don't know why Dr. Venkata S Ram is very diplomatic about atenolol.  Because atenolol has only reduced the blood pressure.  It has got only 17 hours of duration of action.  It does not produce any results like bisoprolol or extended metoprolol carvedilol study in diastolic heart failure.  They are cardioprotective and carvedilol and nebivolol as Dr. Hiremath said, carvedilol is an antioxidant.  Carvedilol reduces the proteinuria, carvedilol anti-inflammatory, carvedilol is lipid neutral, so that is why we try to use carvedilol and nebivolol.  Nebivolol is actually a nitric oxide donor and it appears to be almost equivalent to carvedilol except that slight raise of glucose may be there, so I think that is the one comment.  Second comment is in a resistant hypertension as already alluded too, the aldosterone antagonist particularly eplerenone will be a ideal drug, because Aldactone has got side effects.  If you doesn't reduce in spite of 3 drugs with diuretic, aldosterone antagonist doesn’t reduce, you can use minoxidine or you can use clonidine, where there is always increased sympathetic surge even in an essential hypertension leave alone CKD, so clonidine will be a very good drug in resistant hypertension.  This is what I wanted to comment.


Dr. C. Venkata S. Ram:  American College of Cardiology, they asked me to address next month on the preferred choices of beta-blockers in modern treatment of hypertension.  I do not know what I am going to say, but I still have time to prepare.  Now, I think the entire panel agrees and this is a comment, Dr. Shah that when we treat hypertension, you treat it as a syndrome, because it comes with package of other risk factors, not in isolation.  You can have hypertension today, but day after tomorrow you can develop diabetes, so I think we all consider this as a part of the syndrome.


Dr. Siddharth Shah:  I think we have had real good encyclopedia of questions and we have tried to solve as far as possible with the learned speakers over here and this is not over yet.  Tomorrow, we are going to have another session of encyclopedia when we are going to have another set of panelists who are going to enlighten us on various aspects of hypertension.  We reserve a few questions that you have given us today, which we are not addressed to.  We will continue it tomorrow and I think we must acknowledge the good work of this panel.  We must give them a clap for their good work !!

Management of Hypertension in Diabetes

By Dr.Siddharth Shah, Mumbai

Hypertension Encyclopedia - 2

Moderators : Dr. C. Venkata S. Ram and Dr. Siddharth N. Shah