Hypertension problem based and case based

Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malbagh branch.
Honorary Consultant, Apollo Hospitals, Dhaka and
Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com
HYPERTENSION
(Case based and Evidence based)

1. Resistant Hypertension, complications, Target organ damage
2. newly diagnosed stage-1 hypertension, rationale of use of ARB and
comparison of Azilsartan with other ARBs
3. Hypertension with bronchial asthma
4. Hypertension with Diabetes Mellitus with proteinuria
5. Hypertension , Diabetes and IHD
6. Gestational Hypertension , rationale of use of drugs
7. Hypertension , Diabetes , ACS
8. Hypertension, Diabetes and Syndrome X
9. Hypertension and special situations drtoufiq19711@yahoo.com

Case Scenario

Case scenario
• Mr. J. K 35 years old business man
presented with headache , neck pain and
dizziness for last 15 days. He is smoker and
dyslipidemic. His B. P is 155/95 mm Hg on
both arms and pulse 80 b/min. What are the
management startagies?

Considering points
• Stage of hypertension? 155/95 mm Hg
• 1. Role of life style modifications?
• 2. Role of diets ?
• 3. first line of antihypertensives?

Case continued
• Pt was being treated with beta blockers (
Atenolol 50 mg once daily). After 10 days
patient came for follow-up. Now,
• Pulse-70 b/min
• BP- 140/95 mm Hg
• and he feels better but complained of
erectile dysfuntion.

What should be the next management?
• Considering
• 1. symptoms decreased
• 2. BP not controlled yet
• 3. Erectile Dysfuntion

• His drug beta blockers were stopped and
switched to calcium channel blockers (
Amlodipine 5 mg daily) and advised to
follow up after 15 days.

During follow-up
• Pulse- 80 b /min
• BP- 135/85 mm Hg
• But patient now complained of ankle edema
• What should be the next plan?

Considering points
• To control BP properly
• Ankle edema
• Shiftinng to another group of
drugs/cilnidipine
• Or add another drug to combat edema

Options
• Switch to another groups
• Add on ACEi/ ARB
• Add on Diuretics
• Time of follow up

Case Scenario
• Mr Khan 56 years old from Mymensingh
suffering from DM type 2 for 10 years ,
proteinuria for 5 years and Hypertension
for 3 years. His HbA1C is 5.9 % and B.P.
150/95 mm Hg and pulse 56 b/min. For
controlling HTN he is getting beta
blockers.( Bisoprolol 2.5 mg once dailyfor
the same period). What should be the next
management?

Considering points
• Diabetes and proteinuria
• Uncontolled HTN BP-150/95 mm Hg
• Getting BB
• To reduce cardiovascular and diabetic
related morbidity and mortality
• Shift to another drug/ add on another drugs

Case Scenario
• Mr. Alek 50 years old has been suffering from
DM and HTN for last 7 years and he is smoker for
10 years. He complained of chest discomfort on
exertion for last 3 months and it is increasing in
nature. His BP 78 b/ min, BP-155/95 mm Hg,
HbA1C 8.2%. ECG was normal, Echo showed mild
concentric hypertrophy and ETT was positive at
stage 2. He was being treated with BB with other
anti anginal drugs with proper anti-diabetic drugs. 1
month after follow up his BP became normal,
diabetes was controlled but his symptoms not
subsided significantly. So, he was advised to do

Case scenario
• A 30 years old lady referred by a respected senior
gynecologist for proper control of hypertension. The
lady gave birth of her 3rd female baby 5 days back.
Her Bp is now 160/100 mm Hg and she is getting
Nifedipine 20 mg bd and methyl dopa tab 250 mg 3
times daily. Pt was normotensive before pregnancy ,
habit to take extra salts with meal . She has now
sleep disturbance and sometimes palpitations. What
should be the next step of management?

Considering points
• 1. BP. – 160/100 mm Hg
• 2. Taking two antihypertensives already?
Can we increase the dose?
• 3. Can we add other anti-hypertensives?
• 4. Can we add ACEI/ ARBs?
• 5. Role of any anxiolytics?
• 6. effects on breast feeding?

Mr. AMF 62 years presented with
* central chest pain on exertion for last 4 months
*Hypertension(BP-220/120 mmHg) for last 4 years,
* taking 4 anti hypertensives.
*Diabetes for last 5 years (HbA1c-9.3%).
*Smoking for 8 years.
*Dyslipedemic for 3 years.
*H/o 5 times hospital admissions due to heart failure in last 3 years.
ECG-Anterior wall ischemia
EF-58%
During careful clinical exam- renal bruit on left side

Follow up
• Mr AMF now have no chest pain on exertion after
3 months of coronary angioplasty.
• Now BP is controlled (130/85 mm Hg), taking B
blockers and ARB due to intolerance of ACE
inhibitors.
• No hospital admission during this period.
• Diabetes and serum lipids are controlled.

Case Scenario
• Mrs. FN 45 years old lady from Kurigram
presented with bronchial asthma for last 10
years . Now her BP is 160/110 mm Hg. She is
getting anti-asthmatic drugs for the same
duration. What should be the strategy o
manage her hypertension?

Considering points
• BP-160/110 mm Hg/ Which stage of HTN?
• Asthma
• Which drug for hypertension?
• Rationale for use of B blockers
• Rationale for use of CCB/Diuretics/ ACEI/ ARBs
• Which combinations?

Thank you all

Hypertension problem based and case based

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