Annexure 9 A MODULE: 07 HYPERTENSION

1. Learning Objectives
End of the training the participants are able to Define and classify hypertension Record B.P and categorize the patient according to Joint National Committee (JNC) VII classification Identify risk factors Understand the pathophysiology involved in the elevation of blood pressure. Understand the pharmacological and non pharmacological approaches to manage hypertension Identify potential drug drug interactions in prescription containing antihypertensive drugs Give important counseling points for specific antihypertensive agent.

2. Introduction
Hypertension is a clinical condition where there is elevation of blood pressure and it is an important risk factor for cardiovascular and cerebrovascular complications. The pharmacological management and non-pharmacological approaches plays major role in controlling and in preventing the complications of hypertension. Patients with hypertension should be encouraged to adopt healthy lifestyle modifications to control and prevent the progression of disease. To achieve a healthy impact on patients quality of life, a suitable antihypertensive that is safe, effective and economic should be selected based on individuals clinical status.

3. Definition
Hypertension is defined as a clinical condition where a persistent elevation of arterial blood pressure (more than 120/80 mmHg) is observed in more than two consecutive recordings.

4. Classification
According to JNC classification, based on the extent of elevation in blood pressure, hypertension is classified as, pre-hypertension, stage-1 hypertension and stage-2 hypertension. CLASSIFICATION OF BLOOD PRESSURE Normal Pre-hypertension Stage 1 hypertension Stage 2 hypertension SYSTOLIC BLOOD PRESSURE (mmHg) <120 120-139 140-159 160 DIASTOLIC BLOOD PRESSURE (mmHg) <80 80-89 90-99 100

5. Epidemiology
Epidemiological studies have shown that hypertension affected approximately one billion individuals worldwide and this number is projected to increase to 1.56 billion by 2025. Hypertension is a major public health problem in India and other developing
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Annexure 9 A countries. In India, 57% of deaths occur due to stroke and 24% of deaths occur due to coronary heart disease secondary to hypertension. The epidemiological studies from rural and urban populations of India had shown that hypertension is emerging as a major health problem in India and is more in urban (25%) than in rural (10%) population. The Framingham Heart Study suggests that individuals who are normotensive at the age of 55 will have a 90% lifetime risk for developing hypertension. In the population aged 60 years, 60% of the individuals will have hypertension.

6. Etiology
Based on etiological factors hypertension is classified into two types: Primary hypertension and Secondary hypertension 1. Primary hypertension/essential hypertension: In primary hypertension, no specific cause can be identified however, there are certain risk factors that may contribute for development of hypertension. About 90-95% of hypertension cases belong to this type and usual onset of primary hypertension is at the age of 36 years. Risk factors for development of primary hypertension:

2. Secondary hypertension: In secondary hypertension, there is an identifiable underlying cause for the development of hypertension. About 5-10% of hypertensive patients belong to secondary hypertension and the usual onset of disease is after 55 years. The common causes of secondary hypertension are as follows: Renal disease like Chronic renal failure, Renal artery stenosis Endocrine disorders like Diabetes mellitus, Cushings syndrome, acromegaly, pheocroma cytoma and thyroid disorders
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Annexure 9 A Pregnancy Drugs such as steroids, estrogen, erythropoietin, NSAIDs.

7. Pathophysiology
Blood pressure is the mathematical product of cardiac output and total peripheral resistance. Hence, increase either in cardiac output or in total peripheral resistance leads to hypertension. Blood Pressure = Cardiac Output Total Peripheral Resistance

Potential Pathogenesis mechanisms

1. Increased cardiac output: Increased cardiac preload: Increased fluid volume from excess sodium intake or renal sodium retention (From reduced number of nephrons or decreased glomerular filtration). Venous constriction: Excess stimulation of renin-angiotensin-aldosterone system. Sympathetic nervous system over activity. 2. increased peripheral resistance: Functional vascular constriction: Excess stimulation of renin-angiotensin-aldosterone system. Sympathetic nervous system over activity. Genetic alterations of cell membranes. Endothelial derived factors. Structural vascular hypertrophy: Excess stimulation of renin-angiotensin-aldosterone system. Sympathetic nervous system over activity. Genetic alterations of cell membranes. Endothelial derived factors. Hyperinsulinemia resulting from obesity or metabolic syndrome. Normally Blood pressure is regulated by compensatory mechanisms that respond to changes in cardiac demand. An increase in cardiac output results in a compensatory decrease in total peripheral resistance hence blood pressure is maintained normal. Blood pressure is influenced by various neural and humoral factors. These include the adrenergic nervous system (which controls alpha and beta receptors), the renin angiotensin aldosterone system (which regulates systemic and renal blood flow), renal function and renal blood flow (which influence fluid and electrolyte balance), several hormonal factors (adrenal cortical hormones, vasopressin, thyroid hormone, insulin) and the vascular endothelium (which regulates the release of nitric oxide, bradykinin, prostacyclin and endothelin).

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Annexure 9 A Kidneys play an important role in the regulation of arterial pressure through the renin angiotensin aldosterone system. A decrease in blood pressure or decreased renal blood flow, or volume depletion or decreased sodium concentration enhances the secretion of renin from the juxtaglomerulor cells in the kidney. This mechanism stimulates the conversion of angiotensinogen to angiotensin-I. Angiotensin converting enzyme (ACE) converts angiotensin-I to angiotensinII which is a potent vasoconstrictor that acts directly on arteriolar smooth muscles. Angiotensin-II also stimulates the production of aldosterone which in turn leads to the retention of sodium and water resulting in increase in blood pressure. There is a direct association between sodium and blood pressure. Patients with a high dietary sodium intake have higher prevalence of hypertension than those with a low sodium intake may be due to increased circulating natriuretic hormone. This in turn inhibits intracellular sodium transport, causing increased vascular reactivity and increased blood pressure.

8. Clinical features
8.1. Symptoms: Most patients are asymptomatic, however some patients complains of Headache Confusion and deficit memory Sleepiness Difficulty in breathing Tingling and numbness of hands and feet. 8.2. Signs: The only sign of hypertension is elevated blood pressure measured using sphygmomanometer.

9. Complications of hypertension
o Cardiovascular complications: Angina, myocardial infarction, Heart failure o Cerebrovascular complications: Stroke o Renal system complications: Renal failure, Nephropathy,Chronic kidney disease o Opthalmic complications: Retinopathy

10. Management of hypertension

Hypertension cannot be cured but can be managed by following two methods: 1. Non-Pharmacological method 2. Pharmacological method 10.1. Non-pharmacological methods: All patients with pre-hypertension and hypertension should adopt certain life style modifications. These approaches not only help in achieving the goal blood pressure and also reduce the progression of hypertension and antihypertensive drug dose requirement.

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Annexure 9 A JNC VII has recommended following life style modifications, which provide reductions in blood pressure: MODIFICATION RECOMMENDATION APPROX.SYSTOLIC BLOODPRESSURE REDUCTION Maintaining normal body weight (body mass index 18.5-24.9 Kg/m2) 5-20mmHg/10Kg weight loss

Weight reduction

Adopt DASH (Dietary Consuming a diet rich in Approach to Stop fruits, vegetables and Hypertension) eating plan low fat dairy products Dietary restriction sodium Restricting daily dietary sodium intake to less than or equal to 2.4 gram sodium or 6 gram of sodium chloride

8-14 mmHg

2-8 mmHg

Physical activity

Moderate alcohol intake

Regular aerobic physical activity like brisk walking at least 30 min/day. Limiting alcohol consumption to less than or equal to 30mL ethanol/day for men and 15mL ethanol for women

4-9 mmHg

2-4 mmHg

6.2. Pharmacological methods: Goals of the treatment: To decrease the elevated blood pressure. According to JNC 7 recommendations, for most patients the target blood pressure should be less than 140/90 mmHg and for those with diabetes and chronic kidney disease it should be less than 130/80 mmHg. To reduce hypertension associated morbidity and mortality that is related to target organ damage e.g. heart failure, stroke, retinopathy, chronic kidney disease.

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Annexure 9 A Various classes of anti hypertensive drugs are used to treat hypertension. The choice of the drug varies from patient to patient. An appropriate choice of drug is mainly based on patient condition and on other concomitant diseases. Classification of antihypertensive agents: Diuretics Beta-blockers Angiotensin converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) and Calcium channel blockers (CCBs) Alpha-blockers Central alpha2 agonists Peripheral adrenergic agonists and Vasodilators

1. Diuretics: Diuretics are the most commonly used first line drugs in the management of hypertension. Diuretics induce natriuresis (urinary excretion of sodium) that results in decreasing the plasma volume. The long-term blood pressure lowering effects are maintained because of sustained decrease in peripheral vascular resistance as a result of vasodilatation of smaller blood vessels. Diuretics are the drug of choice in elderly. Various types of diuretics are as follows: Type/Drug Dosage range(mg/day) Daily frequency Thiazide diuretics Hydrochlorthiazide 12.5-50 1 Chlorthalidone 6.25-25 1 Indapamide 1.25-2.5 1 Metalozone 2.5 1 Loop diuretics Furosemide 20-80 2 Torsemide 5 1 Potassium sparing Amiloride+ hydrochlorthiazide 5-10/50-100 1 Triamterene 50-100 1 or 2 Aldosterone antagonist Spiranolactone 25-50 1 or 2 Drug interactions: ACE inhibitors, NSAIDs, Aspirin, Paracetamol, Phenytoin, and Theophylline decreases the effects of diuretics. Increased auditory toxicity was observed when diuretics were used with Aminoglycosides. Diuretics increase the effect of Propranalol Counseling points: Ask the patient not to take any diuretic late in the evening as this drugs cause frequent urination in the night and may disturb the sleep.

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Annexure 9 A Ask the patient not to drive automobiles or operate machinery as these drugs can cause drowsiness. Ask the patient to avoid alcohol, as alcohol consumption can add to drowsiness caused by the drug. Ask the patient to avoid prolonged exposure to sunlight and wear protective clothing, sunglasses or sunscreen as these drugs make skin, sensitive to sunlight. Adverse effects: Common: Orthostatic hypotension, hypotension, photosensitivity, anorexia, epigastric distress, palpitation, flushing, dizziness, light headedness, vertigo, weakness, restlessness, drowsiness, photosensitivity, hyperglycemia, hyperuricemia, hypokalemia, hypochloremia, metabolic alkalosis, hypocalcemia, hypomegnesemia, nausea, vomiting, anorexia, cramping, diarrhea, constipation, frequent urination and hearing impairment. Rare: Anaphylaxis, impotency, angioedema, alopecia, increased intraocular pressure and rectal bleeding 2. Beta-blockers: Beta-blockers act by blocking beta adrenergic receptors and decrease cardiac contractility and output, lower the heart rate, reduce central release of adrenergic substances and decrease renin release from the kidney. All these contribute to their antihypertensive effect. These are the drugs of choice in patients with myocardial infarction, angina and heart failure. Different types of beta blockers are as follows: Type/Drug Cardioselective Atenolol Bisoprolol Metoprolol Non-selective Nadolol Propranalol Timolol Intrinsic sympathomimetic activity Acebutalol Carteolol Pindolol Mixed alpha and beta blockers Carvedilol Labetalo Dosage Range(mg/day) 25-100 2.5-10 50-200 Daily frequency

1 1 2

40-120 160-480 10-40

1 2 1

200-800 2.5-10 10-60 12.5-50 200-800

2 1 2 2 2

Drug interactions: Aspirin and NSAIDs decreases the effects of beta-blockers. Methimazole, verapamil and Frusemide increases the effects of beta-blockers.
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Annexure 9 A Counseling points: Advice the patient not to stop beta-blockers without consulting their physician as sudden stoppage of these drugs may cause chest pain, heart attack or irregular heartbeats. Ask the patient not to drive automobiles or operate machinery as these drugs can cause drowsiness. Ask the patient to avoid alcohol, as alcohol consumption can add to drowsiness caused by the drug. As this drugs can cause dryness of eyes, advice the patient who is using contact lens to talk with their doctor for changing over to spectacle Advice the patient regarding possibilities of nocturnal dreams and impotence due to these drugs. Adverse effects: Common: Hypotension, dizziness, headache, bradycardia, tiredness, reduced exercise tolerance, cold peripheries, wheezing, impotence, chest pain, drowsiness, nightmares, constipation, depression, cold extremities, confusion and bronchospasm. Rare: Alopecia elevated liver enzymes, psychosis, photosensitivity, Steven Johnson Syndrome and toxic epidermal necrolysis. 3. Angiotensin converting enzyme inhibitors (ACEIs): ACEIs inhibits the conversion of angiotensin I to angiotensin II by competitively inhibiting angiotensin converting enzyme, which results in decreased levels of angiotensin II which is a potent vasoconstrictor. These are the drugs of choice in patients with heart failure, diabetic nephropathy. Drug Benazepril Captopril Enalapril Lisinopril Fosinopril Perindopril Ramipril Trandolapril Dosage range (mg/day) 10-40 12.5-15 5-40 10-40 10-40 4-16 2.5-10 1-4 Daily frequency 1 or 2 2or 3 1 or 2 1 1 1 1 or 2 1

Drug interactions: Aspirin decreases the effects of ACE inhibitors. ACE inhibitors decrease the effects of loop diuretics. Counseling points: Advice female patients, to inform her doctor if she is pregnant or if become pregnant while taking these drugs as these drugs can harm the fetus. Adverse effects: Common: Hypotension, dizziness, cough, rashes, taste disturbance, angioedema, nausea, vomiting, diarrhea, anorexia, constipation, increased urea and serum creatinine, tachycardia and fatigue Rare: Gynaecomastia, ataxia, increased liver enzymes, blurred vision, bronchospasm, ototoxicity, photosensitivity, psychosis and impotency.
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Annexure 9 A 4. Angiotensin receptor blockers (ARBs): ARBs are angiotensin receptor antagonists, which acts by competitively blocking the angiotensin receptors resulting in decreased vasoconstriction. These are the drugs of choice in patients who are intolerant to ACEIs. Drug Losartan Candesartan Irbesartan Telmisartan Valsartan Dosage range Daily frequency (mg/day) 50-100 1 or 2 8-32 1 or 2 150-300 1 20-80 1 80-320 1

Drug interactions: Fluconazole increases the effects of ARBs. Rifampicin decreases the effects of ARBs. Counseling points: Advice female patients, to inform her doctor if she is pregnant or if become pregnant while taking these drugs as these drugs can harm the fetus. Adverse effects: Common: Edema, headache, weakness, orthostatic hypotension, fever, first dose hypotension, weight gain, abdominal pain, dyspepsia, nasal congestion, sinusitis, flu like syndrome, palpitations, anxiety and depression Rare: Anaphylactoid reaction, psychosis, alopecia, angioedema, elevated liver enzymes, peripheral neuropathy and vertigo. 5.Calcium channel blockers (CCBs): CCBs relax vascular smooth muscles by inhibiting calcium ions from entering the slow channels or voltage sensitive areas of vascular smooth muscles and myocardium during depolarization. These are the drug of choice in elderly with isolated systolic hypertension, patients with myocardial infarction and angina. There are two types of CCBs namely, dihydropyridines and non-dihydropyridines. Type/Drug Dosage (mg/day) range Daily frequency

Dihydropyridines Amlodipine 2.5-10 1 Felodipine 5-20 1 Isradipine 5-10 2 Nicardipine 60-120 2 Nifedipine 30-90 1 Non-dihydropyridines Diltiazem 180-320 2 Veerapamil 100-400 1 Drug interaction: CCBs produce additive effects when used with beta-blockers. Effect of verapamil/Nifedipine decreases when used along with phenytoin or Rifampicin
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Annexure 9 A Counseling points: Advice the patient to avoid alcohol as CCBs may increase the effects of alcohol Adverse effects: Common: Swollen gums, chest pain, swollen joints, flushing, edema, postural hypotension, headache, constipation, dizziness, light-headedness, palpitation, male sexual dysfunction, muscle cramps, dyspnoea, rash, pruritus,myalgia, elevated liver enzymes, tremors and photosensitivity Rare: Alopecia, depression, migraine, tinnitus, weight loss, skin discoloration, Steven Johnson Syndrome. 6.Alpha blockers: These are selective alpha 1 blockers that inhibits catecholamine uptake in smooth muscle cells of the peripheral vasculature resulting in vasodilatation. These are the drugs of choice in patients with dyslipidaemia. Drug Dosage range (mg/day) Daily frequency Prazosin 2-20 2 or 3 Terazosin 1-20 1 or 2 Doxazosin 1-8 1 Drug interactions: Alpha blockers produce additional hypotensive effects when used along with other antihypertensives NSAIDs decreases the effects of alpha blockers. Counseling points: If the patient is taking alpha blockers for the first time, ask them to take alpha blockers just before going to bed. Inform to patient alpha blockers may cause dizziness, lightheadedness and fainting when they get up too quickly from lying position. Advice the patient to get out of the bed slowly by resting their feet on the floor for few minutes before standing up. Ask the patient to sit or lie down if they experience dizziness or lightheadedness. Adverse effects: Common: Dizziness, palpitations, edema, postural hypotension, drowsiness, nervousness, nausea, vomiting, diarrhea, constipation, increased urinary frequency, weakness, reddened sclera and nasal congestion Rare: Allergic reactions, alopecia, hallucinations, impotence, leucopenia, tinnitus, dry mouth and blurred vision. 7.Centrally acting alpha 2 agonists: These agents lower blood pressure by stimulating alpha 2 adrenergic receptor in the brain, which reduces sympathetic outflow from the vasomotor centre and increases vagal tone. Peripheral stimulation of presynaptic alpha 2 receptor leads to reduction in sympathetic tone hence there is a decrease in heart rate, cardiac output, total peripheral resistance and plasma renin activity. Methyldopa is the drug of choice in
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Annexure 9 A pregnancy and patients with resistance hypertension unresponsive to first line therapy. Drug Dosage range Daily frequency (mg/day) Clonidine 0.5 0.8 2 Methyldopa 250 - 1000 2 Drug interactions: Clonidine masks the hypoglycemic symptoms caused due to oral hypoglycemic agents or insulin Alpha 2 agonists produce additive CNS effects when used along with barbiturates and other CNS depressants Beta-blockers potentiate bradycardia when used along with Clonidine Tricyclic antidepressants decrease the effects of Clonidine. Counseling points: Advice the patient not to stop taking alpha 2 agonists suddenly as it can cause abrupt rise in blood pressure, nervousness, headache and confusion Ask the patient not to drive automobiles or operate machinery as alpha 2 agonists can cause drowsiness. Advice the patient to avoid alcohol as alcohol may worsen the side effects of these drugs Adverse effects: Common: Drowsiness, sedation, vertigo, headache, weakness, dizziness, lightheadedness, bradycardia, edema, weight gain, nausea, vomiting, diarrhea, dry mouth, myalgia, decreased libido, breast enlargement, Gynaecomastia and amenorrhea. Rare: Hemolytic anemia, fever, black tongue, blurred vision, increased blood urea nitrogen. 8.Peripheral adrenergic agonists: These agents deplete norepinephrine from sympathetic nerve endings and block the transport of norepinephrine into its storage granules. When the nerve is stimulated, less than the usual amount of norepinephrine is released into the synapse. This results in reduced sympathetic tone, decreasing peripheral vascular resistance and blood pressure. Drug Dosage range Daily frequency (mg/day) Reserpine 0.05-0.25 1 Drug interactions: Reserpine produces additive hypotensive effects when used along with betablockers and diuretics Tricyclic antidepressants decreases the hypotensive effects of reserpine. Counseling points: Advice the patient not to stop taking reserpine abruptly. Ask the patient not to drive automobiles or operate machinery as reserpine can cause drowsiness. Advice the patient to avoid alcohol as alcohol may worsen the side effects of reserpine.
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Annexure 9 A Adverse effects: Common: Fatigue, drowsiness, depression, headache, dizziness, anxiety, bradycardia, abdominal cramps, diarrhea, nausea, vomiting, anorexia and edema. Rare: Dysuria, lacrimation, blurred vision, galactorrhea and gynaecomastia 9.Direct arterial vasodilators: These agents cause direct arteriolar smooth muscle relaxation. These are the drugs of choice in patients with resistance hypertension unresponsive to first line therapy. Drug Dosage range Daily frequency (mg/day) Hydralazine 20-100 2 to 4 Minoxidil 10-40 1 or 2 Drug interactions: Hydralazine increases the serum levels of beta-blockers NSAIDs decreases the effects hydralazine Minoxidil produces additive hypotensive effects when used with other antihypertensive agents. Counseling points: Advice the patient to avoid alcohol as alcohol may worsen the side effects of these drugs. Inform patient that vasodilators may cause chest pain and advice patient to see their doctor immediately if chest pain occurs or worsens. Ask the patient not to drive automobiles or operate machinery as vasodilators can cause drowsiness. Adverse effects: Common: Headache, edema, weight gain, tachycardia, hypertrichosis (elongation, thickening and increased pigmentation of fine body hair). Rare: Breast tenderness, gynaecomastia, elevated liver enzymes. Management of hypertension in special populations: Special population Elderly With Hypertension alone Hypertension with angina Hypertension with diabetes or heart failure Children and adolescent Drug of choice Diuretics, CCBs Beta-blockers ACE inhibitors Alternatives ARBs Drugs to avoided be

-Diuretics,Betablockers, ACE inhibitors, -Calcium channel blockers Methyldopa Beta-blocker (Labetalol) CCBs ACE inhibitors and ARBs (in women of child bearing age) ACE inhibitors and ARBs

Pregnancy (Preeclampsia)

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Annexure 9 A Hypertension asthma or COPD Hypertension dyslipidaemias with -with Alpha-blockers ACE inhibitors CCBs Thiazide diuretics Beta-blockers -Non selective Beta-blockers

11. Important counseling points: All hypertensive patients must be counseled about the disease, medication and life style modifications in order to improve their clinical condition. Counseling about the disease: Patient must be counseled about the signs and symptoms of the disease such as headache, confusion, sleepiness, deficit memory etc. Patient must be told that hypertension is not curable disorder, however patients must be reassured that the disease can be well controlled by taking medications regularly and also by adopting certain life style modifications. Patient must be made aware of consequences of untreated hypertension. The attempts should be made that the patient must understand and believe that hypertension is a serious condition that needs treatment. Counseling about the drugs: Patient must be made aware of treatment that they are receiving for controlling hypertension. Patient must be told about the name, purpose, dose, when to take (morning or afternoon or at night), how to take (before food or after food), and storage condition for all the drugs. Patient must be told that they have to take their medication regularly throughout their life in order to control the blood pressure. Patient should be made aware of all the possible adverse reactions to the drugs and should be encouraged to report such reactions if at all they experience the same. Patients must be encouraged to take the medications regularly without fail at same time every day. In cases if they forgot to take their medication patient must be told that they can take medication as soon as they remembers it but if the time is very close to next dose they should not double the dose in such situations they must avoid previous dose and simply take the drug during next dose. Counseling about the life style modification: Patient must be encouraged to adopt certain life style modifications like salt restricted diet(< 2.4 gram/day), low fat diet, weight reduction if overweight, physical activity like brisk walking, restricting alcohol consumption, if alcoholic (<30mL/day for men and < 15mL/day for women). Patient must be encouraged to visit his/her physician regularly that helps him/her to have a better understanding about their clinical outcome, modifications in their treatment according to clinical outcome.

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Annexure 9 A

12. Activity for the participants

Mr. KS a 40 year old circle inspector, complaining severe headache visited your pharmacy for a prescription. Upon enquiry, Mr. KS mentioned that, in recent times he has experienced this type headache and sometimes he felt that he was going in to a state of confusion. His social history reveals that he is a regular smoker and smokes about 1 packet of cigar a day for the last ten years. Twice or thrice a week he drinks 180 ml of rum. He expresses a feeling that he might have developed hypertension and seek for BP check up. what steps would you follow to record B.P? B.P Recording Steps 1. Use appropriate sized cuff 2. Ensure tight wrapping of cuff around the arm 3. Place the bladder over the brachial artery 4. Palpate the radial pulse while cuff is inflated 5. Position the stethoscope over the brachial artery 6. Inflate the cuff rapidly to 20 -30 mmHg above estimated blood pressure 7. Deflate the cuff at a rate of 2 mmHg/sec while listening to Korot Koff sounds 8. Observe the manometer simultaneously to record blood pressure.

13. Case Studies Case-1

Mr. VK a 45-year-old marketing executive weighing 85 Kgs and whose height is 510, complaining of severe headache and consulted a general practitioner. On examination, Mr. VKs B.P was 150/95 mmHg. His social history says that he is a known smoker and smokes one pack of cigarettes every day. He also drinks about 90 ml of alcohol two to three times a week. a) What do Mr. VK symptoms represent? b) What objective and subjective parameters are necessary to confirm the diagnosis? c) What risk factors led him to the present situation? d) What is the appropriate management in Mr. VKs case? e) What counseling points are necessary for Mr. VK regarding the medications, diet and other life style modifications?

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Annexure 9 A

Case 2
Mr. JK, A 35 year old man weighing 90 Kgs, visited the pharmacy with a prescription containing Metoprolol 25 mg OD. His case record suggests that his BP was 155/95 mmHg. On enquiry, he told that he is real estate broker and he smokes more than 15 cigarettes a day and drinks 180 ml of whiskey every day. a) What are the causes of Mr. JKs elevated blood pressure? b) What is the medicine prescribed to Mr. JK and how does this drug benefits him? c) What consequences Mr. JK may experience if his blood pressure is not controlled? d) What are the counseling points for Mr. JK?

Case -3
Mr. SR a 48 year old marketing executive received a prescription for his elevated BP (151/92 mmHg). His social history reveals that every day he smokes 2 packs of cigarettes and two drinks of whisky. His lab data reveals that triglycerides were elevated. His parents were also hypertensive and his father died with acute MI six months ago. His doctor has prescribed him Rx. Tab. Amodep AT Tab. Atorva 10mg 1 OD morning after breakfast 1 OD at bed time.

1. What are the probable risk factors for Mr. SRs elevated BP? 2. What counseling points should be provided to Mr.SR regarding his medication? 3. What dietary and life style modifications are required for Mr.SR?

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