د لوړفشار نوي او معاصره درملنه

1. ‫درملنه‬ ‫فشار‬ ‫دلوړ‬
Treatment Of hypertension
Presented By:
Dr. Asmatullah Sapand

3. TREATMENT OF HYPERTENSION……..
‫شویدی‬ ‫برخوویشل‬ ‫لویو‬ ‫دوه‬ ‫په‬:
.1Non Pharmacologic
.2Pharmacologic
Non Pharmacologic‫پرهیز‬ ‫د‬ ‫درملنه‬(DASH-
Diet)‫یا‬(life style modification)‫توصیه‬ ‫په‬
‫نیسي‬ ‫صورت‬ ‫کولوسره‬.‫الرښوونې‬ ‫الندې‬ ‫او‬
‫کیږي‬ ‫ته‬ ‫ناروغ‬:

4. NON PHARMACOLOGIC TREATMENT
‫کول‬ ‫تمرین‬ ‫منظم‬
‫کنترولول‬ ‫دوزن‬
‫کول‬ ‫ډډه‬ ‫څکولوڅخه‬ ‫دسګرټ‬
‫کارول‬ ‫میوو‬ ‫اوتازه‬ ‫دشنوسبزیجاتو‬
‫استعمالول‬ ‫کم‬ ‫غوړو‬ ‫او‬ ‫دغوښو‬
‫منظم‬ ‫سم‬ ‫سره‬ ‫دډاکتردهدایت‬Visit
‫کمول‬ ‫فشارونو‬ ‫رواني‬ ‫او‬ ‫دتشویش‬

5. NON PHARMACOLOGIC TREATMENT……..
‫د‬ ‫درملنه‬ ‫نوموړي‬HTn‫ناروغانوکې‬ ‫الندې‬ ‫په‬
‫لري‬ ‫استطباب‬:
.1Prehypertensive‫ناروغان‬(120-139/80-89)
‫کوم‬ ‫چې‬risk factor‫یا‬ ‫او‬end organ damage
‫ونلري‬.
.2‫فشار‬ ‫خفیف‬ ‫چې‬ ‫ناروغان‬ ‫هغه‬(140-159/90-99)
‫کوم‬ ‫اما‬ ‫ولري‬risk factor‫اویا‬end organ
damage‫ونلري‬.

6. 2.PHARMACOLOGIC TREATMENT
‫پ‬ ‫او‬ ‫کیږي‬ ‫ترسره‬ ‫پواسطه‬ ‫درملو‬ ‫د‬ ‫تداوي‬ ‫نوموړي‬‫ه‬
‫لري‬ ‫استطباب‬ ‫حاالتوکې‬ ‫الندې‬:
.1‫د‬ ‫فشاریې‬ ‫دوینې‬ ‫چې‬ ‫ناروغان‬ ‫هغه‬ ‫ټول‬
160/100‫چې‬ ‫لدې‬ ‫بدون‬ ‫وي‬ ‫رسیدلی‬ ‫ترحده‬
‫فکتوراویا‬ ‫خطري‬ ‫کوم‬end organ damage‫ولري‬.
.2‫په‬prehypertension‫ناروغانو‬ ‫ټولو‬ ‫نورو‬ ‫او‬ ‫ناروغانو‬
‫د‬ ‫چې‬ ‫کې‬hypertension‫هر‬ ‫په‬stage‫قرار‬ ‫کې‬
‫کوم‬ ‫ورسره‬ ‫او‬ ‫ولري‬risk factor‫یا‬ ‫او‬end organ
damage‫ولري‬ ‫هم‬.

7. 2.PHARMACOLOGIC TREATMENT………
‫کیږي‬ ‫کارول‬ ‫منظور‬ ‫پدې‬ ‫درمل‬ ‫الندې‬ ً‫معموال‬:
.1Diuretics
.2B-blockers
.3ACE-inhibitors
.4Angiotensin receptor blockers
.5Calcium Channel Blockers
.6Renin inhibitors
.7Alpha-Adrenoceptor Antagonists
.8Central Sympatholytic Drugs
.9Arteriolar Dilators
.10Peripheral Sympathetic Inhibitors

8. DIURETICS
‫لوړفشارکموي‬ ‫میکانیزم‬ ‫الندې‬ ‫په‬ ‫درمل‬ ‫نوموړي‬:
.1‫کموي‬ ‫حجم‬ ‫وعایي‬ ‫داخل‬
.2‫کموي‬ ‫مقاومت‬ ‫محیطي‬ ‫داوعیو‬
‫د‬Diuretic‫د‬ ‫ګروپونه‬ ‫درې‬ ‫الندې‬HTn‫کې‬ ‫درملنه‬ ‫په‬
‫کیږي‬ ‫کارول‬:
.1Thiazide Diuretics
.2Loop Diuretics
.3Aldosterone inhibitors

9. 1. THIAZIDE DIURETICS
 Tab: Hydrochlorothiazide 12.5-25mg OD up to
12.5-50mg OD.
SIDE EFFECTS:
 ↓ K+, ↓Mg2+,↑ Ca2+,
 ↓ Na, ↑uric acid,
 ↑glucose, ↑LDL cholesterol,
 ↑triglycerides; rash,
 Erectile dysfunction.

10. 2. LOOP DIURETICS
 Tab: furosemide 20mg bid up to 40-320mg
bid/tid
SIDE EFFECTS:
 Same as thiazides, but higher risk of
excessive diuresis and electrolyte imbalance.
 Increases calcium excretion.

11. 3. ALDOSTERONE RECEPTOR BLOCKERS
 Tab: Spironolactone 12.5-25mg OD up to
12.5-100mg OD.
SIDE EFFECTS:
 Hyperkalemia,
 Metabolic acidosis,
 Gynecomastia.

12. B-BLOCKERS
‫کوي‬ ‫تاثیر‬ ‫میکانیزم‬ ‫الندې‬ ‫په‬:
‫د‬HR‫او‬CO‫سره‬ ‫کمولو‬ ‫په‬HTn‫راکموي‬.
.1‫د‬renin‫راکموي‬ ‫فعالیت‬.

13. DOSES OF VARIOUS BBS
 Tab: Atenolol 25mg OD up to 25-100mg OD
 Tab: Metoprolol 50mg bid up to 50-200mg
bid
 Tab: Bisoprolol 2.5mg OD up to 2.5-10mg
OD
 Tab: Propranolol 20mg bid up to 40-640mg
bid
SIDE EFFECTS: bronchospasm, bradycardia
or AV block, nasal congestion, Raynaud
phenomenon, Fatigue, erectile dysfunction

14. ACE-INHIBITORS
‫میکانیزم‬ ‫الندې‬ ‫په‬HTn‫کموي‬:
.1‫د‬R-A-A-S‫کوي‬ ‫بالک‬.
.2Sympathetic nervous system activity‫کموي‬.

15. DOSES OF ACEIS
 Tab: captopril 25mg bid up to 50-450mg bid/ tid.
 Tab: ramipril 2,5 mg OD up to 2.5-20mg OD/bid
 Tab: lisinopril 5-10mg OD up to 5-40mg OD
SIDE EFFECTS:
 Cough
 Hypotension
 Dizziness
 Kidney dysfunction
 Hyperkalemia
 Angioedema
 Taste alteration and rash (may be more Frequent with captopril)
 Proteinuria
 Blood dyscrasia.
 Contraindicated In pregnancy.

16. AIIRBS
 Tab: losartan 50mg OD up to 25-100mg OD/bid.
 Tab: valsartan 80 mg OD up to 80-320mg OD.
SIDE EFFECTS:
 Hyperkalemia, kidney dysfunction.
 Rare angioedema.
 Combinations have additional side effects.
 Contraindicated in pregnancy.

17. CCBS
‫په‬ ‫اوعیو‬ ‫محیطي‬ ‫د‬vasodilation‫سره‬HTn‫کموي‬.
DOSES OF CCBS (NONDIHYDROPYRIDINES)
 Tab: verapamil SR 180-240mg OD up to 180-480mg OD/bid.
 Tab: diltiazem 90mg bid up to 180-360mg bid.
SIDE EFFECTS:
 Edema, headache,
 Bradycardia, AV block
 GI disturbances
 Dizziness
 Heart failure
 Urinary frequency

18. CCBS
‫په‬ ‫اوعیو‬ ‫محیطي‬ ‫د‬vasodilation‫سره‬HTn‫کموي‬.
DOSES OF CCBS (DIHYDROPYRIDINES)
 Tab: Amlodipine 2.5mg OD upto 2.5-10mg OD
 Tab: Nicardipine 20mg tid upto 20-40mg tid.
SIDE EFFECTS:
Edema, dizziness, palpitations,
flushing, headache,
hypotension, tachycardia,
GI disturbances, urinary
frequency, worsening of
heart failure .

19. RENIN INHIBITORS
‫او‬ ‫لري‬ ‫تاثیر‬ ‫الندې‬ ‫درمل‬ ‫نوموړي‬HTn‫راکموي‬:
 Angiotensinogen _________
Angiotensin I
 Tab: aliskiren 150mg OD upto 150-300mg
OD.
SIDE EFFECTS: Angioedema, hypotension,
 hyperkalemia

20. AAAS
‫د‬ ‫اوعیودجدار‬ ‫د‬ ‫درمل‬ ‫نوموړي‬Alpha‫په‬ ‫آخذو‬
‫په‬ ‫مقاومت‬ ‫وعایي‬ ‫د‬ ‫کې‬ ‫پایله‬ ‫په‬ ‫او‬ ‫کولو‬ ‫نهي‬
‫کنټرولوي‬ ‫فشار‬ ‫دوینې‬ ‫سره‬ ‫کمولو‬.‫ډول‬ ‫الندې‬‫ونه‬
‫لري‬:
 Tab: Prazosin 1mg upto 2-20mg bid/tid at
bed time.
 Tab: terazosin 1mg upto 1-20mg OD/bid at
bedtime.

21. SIDE EFFECTS OF AAAS:
 Syncope with first dose; postural
hypotension, dizziness,
 palpitations, headache,
 weakness, drowsiness, sexual dysfunction,
anticholinergic effects, urinary incontinence;
 first-dose effects may be less with doxazosin.

22. CENTRAL SYMPATHOLYTIC AGENTS
‫کمولوسره‬ ‫په‬ ‫مقاومت‬ ‫وعايي‬ ‫د‬ ‫هم‬ ‫درمل‬ ‫نوموړي‬
‫لري‬ ‫مثالونه‬ ‫الندې‬ ‫او‬ ‫راکموي‬ ‫فشار‬ ‫دوینې‬:
 Clonidine 0.1mg bid upto 0.2-0.6mg bid
 Methyl dopa 250mg bid upto 500-2000mg
bid.
 Guanafacine 1mg OD upto 1-3mg OD.
 Guanabenz 4mg bid upto 8-64mg bid.

23. SIDE EFFECT OF CSAS:
 Sedation, dry mouth, sexual dysfunction,
headache,
 bradyarrhythmias; side effects may be less with
guanfacine.
 Contact dermatitis with clonidine patch.
 Methyldopa also causes hepatitis,
 hemolytic anemia,
 fever.
 Rebound Hypertension following withdrawal.

24. ARTERIOLAR DILATORS:
‫په‬ ‫مقاومت‬ ‫دمحیطي‬ ‫دشراینو‬ ‫درمل‬ ‫نوموړي‬
‫کمولوسره‬vasodilation‫او‬ ‫کوي‬ ‫رامنځته‬HTn
‫د‬ ‫یې‬ ‫ورکړه‬ ‫شکل‬ ‫یوازې‬ ‫په‬ ‫اما‬ ‫کموي‬reflex
tacchycardia‫د‬ ‫امله‬ ‫همدې‬ ‫نوله‬ ‫ګرځي‬ ‫سبب‬
BBs‫او‬diuretics‫شي‬ ‫ورکړل‬ ‫باید‬ ‫یوځای‬ ‫سره‬.
 Hydralazine 25 mg bid upto 50-300mg
bid/qid.
 Minoxidil 5mg OD upto 10-40mg OD.

25. SIDE EFFECT OF ARTERIOLAR DILATORS
 GI disturbances, tachycardia
 headache, nasal congestion
 rash
 fluid retention
 hirsutism
 pericardial effusion
 thrombocytopenia

26. PERIPHERAL SYMPATHETIC INHIBITORS
 Tab: reserpine 0.05mg OD upto 0.05-0.25mg
OD
SIDE EFFECTS:
 Depression (less likely at low dosages, ie, <
0.25 mg),
 night terrors, nasal stuffiness,
 drowsiness, peptic disease,
 Gastrointestinal disturbances,
 bradycardia.

29. TREATMENT OF HYPERTENSIVE CRISIS

30. RESISTANT HYPERTENSION
‫درملو‬ ‫مناسبو‬ ‫ددرو‬ ‫چې‬ ‫فشار‬ ‫هغه‬(‫د‬diuretic
‫شمول‬ ‫په‬)‫کنټرول‬ ‫هم‬ ‫سره‬ ‫ډوزونو‬ ‫مکملو‬ ‫په‬
‫مقاوم‬ ‫د‬ ‫نشي‬(resistant)‫یادیږي‬ ‫نوم‬ ‫فشارپه‬.
‫له‬ ‫دي‬ ‫عبارت‬ ‫اسباب‬ ‫معمول‬ ‫فشار‬ ‫ډول‬ ‫ددا‬:
.1‫کول‬ ‫قضاء‬ ‫او‬ ‫نلرل‬ ‫علقه‬ ‫سره‬ ‫ددوا‬.
.2‫خوړل‬ ‫نه‬ ‫ددوا‬ ‫ډوز‬ ‫شوي‬ ‫توصیه‬ ‫په‬.
.3‫د‬combination therapy‫نه‬ ‫ډول‬ ‫ښه‬ ‫په‬
‫کول‬ ‫مراعات‬.
.4‫مساعدکوونکواو‬ ‫دنورو‬ ‫یوځای‬ ‫دفشارسره‬
‫موجودیت‬ ‫فکتورونو‬ ‫دفشارتشدیدوونکو‬.

31. HYPERTENSIVE CRISIS
Hypertensive crisis‫عبارت‬ ‫څخه‬ ‫حالت‬ ‫بحراني‬ ‫هغه‬ ‫له‬
‫د‬ ‫چې‬ ‫کې‬ ‫کوم‬ ‫په‬ ‫دی‬HTn‫وي‬ ‫اړتیا‬ ‫ته‬ ‫کنټرول‬ ‫ژر‬ ‫او‬ ‫بیړني‬.
‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬DBPً‫معموال‬>130 mmHg‫اودهمدې‬ ‫وي‬
‫ګرځي‬ ‫سبب‬ ‫تخریب‬ ‫وعايي‬ ‫د‬ ‫کیدل‬ ‫دوامدارپاتې‬ ‫حالت‬.
Hypertensive Crisis‫شوی‬ ‫ویشل‬ ‫برخو‬ ‫عمده‬ ‫دوه‬ ‫په‬:
.1Hypertensive Urgency
.2Hypertensive Emergency

32. HYPERTENSIVE URGENCY
‫کنټرول‬ ‫دڅوساعتونودننه‬ ‫فشار‬ ‫باید‬ ‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬
‫شي‬.‫وي‬ ‫شدید‬ ‫فشار‬ ‫ناروغ‬ ‫د‬ ‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬ ً‫معموال‬
(>220/>125)‫کوم‬ ‫او‬ ‫وي‬ ‫عرضه‬ ‫بې‬ ‫اکثره‬ ‫ناروغ‬ ‫خو‬end
organ damage‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬ ‫چې‬ ‫وي‬ ‫نه‬ ‫موجود‬
‫د‬ ‫تداوي‬Oral agents‫کیږي‬ ‫ترسره‬ ‫پواسطه‬.
‫ممکن‬ ‫کې‬ ‫ناروغانو‬ ‫ځینو‬ ‫په‬optic disk edema‫او‬
‫پرمختلونکي‬end organ damage‫دې‬ ‫په‬ ‫چې‬ ‫موجودوي‬
‫وریدي‬ ‫بیړنۍ‬ ‫باید‬ ‫صورت‬parenteral‫شي‬ ‫ترسره‬ ‫درملنه‬.

33. HYPERTENSIVE EMERGENCY
‫په‬ ‫او‬ ‫يوناڅاپه‬ ً‫معموال‬ ‫فشار‬ ‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬
‫لوړیږي‬ ‫شدیدډول‬(DBP>130 mmHg.)
‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬end organ damage‫موجودوي‬
‫شویدي‬ ‫ذکر‬ ‫الندې‬ ‫چې‬:
1. Brain: Hypertensive encephalopathy
(headache, altered mental status, confusion,
irritability), intracranial hemorrhage.
2. Kidney: hypertensive nephropathy
(hematuria, proteinuria and progressive renal-
dysfunction).

34. ‫ادامه‬........
 Heart: Unstable angina/MI, Pulmonary
edema.
 Eyes: Hypertensive retinopathy.
 Others: Aortic dissection, preeclmpsia-
eclapmsia.
Malignant Hypertension:‫لوړفشارچې‬ ‫هغه‬
‫پکې‬encephalopathy‫یا‬nephropathy‫له‬
hypertensive retinopathy‫یوځای‬ ‫سره‬
‫د‬ ‫موجودوي‬malignant hypertension‫پنوم‬
‫یادیږي‬.

35. ‫د‬HYPERTENSIVE ENCEPHALOPATHY‫تداوي‬
‫چې‬ ‫څرنګه‬hypertensive emergency‫بیړنی‬ ‫یو‬
‫د‬ ‫او‬ ‫دی‬ ‫حالت‬end organ damage‫پرمختګ‬
‫بیړنی‬ ‫کبله‬ ‫همدې‬ ‫له‬ ‫نو‬ ‫موجودوي‬parenteral
‫لري‬ ‫اړتیا‬ ‫ته‬ ‫درملنې‬.
‫د‬ ‫فشار‬ ‫باید‬ ‫کې‬ ‫حالت‬ ‫دې‬ ‫په‬1-2‫داخل‬ ‫ساعتونوپه‬
‫د‬ ‫لومړی‬ ‫کې‬25%‫او‬ ‫شي‬ ‫کړی‬ ‫راټیټ‬ ‫اندازه‬ ‫په‬
‫راتلونکو‬ ‫د‬ ‫وروسته‬2-6‫تر‬ ‫کې‬ ‫جریان‬ ‫ساعتونوپه‬
160/100 mmHg‫شي‬ ‫راټیټ‬ ‫پورې‬.
‫په‬ ‫او‬ ‫کې‬ ‫وخت‬ ‫کم‬ ‫په‬ ‫څخه‬ ‫وخت‬ ‫پورته‬ ‫له‬ ‫چیرې‬ ‫که‬
‫د‬ ‫نو‬ ‫شي‬ ‫کړی‬ ‫ټیټ‬ ‫فشار‬ ‫ډول‬ ‫سریع‬coronary,
cerebral‫او‬renal‫کیږي‬ ‫سبب‬ ‫اسکیمیا‬.

36. ‫ادامـــــه‬........
‫له‬ ‫دي‬ ‫عبارت‬ ‫کیږي‬ ‫کارول‬ ‫منظور‬ ‫دې‬ ‫په‬ ‫چې‬ ‫درمل‬ ‫وریدي‬ ‫مهم‬ ‫هغه‬:
 Inj: Nicardipine 5 mg/h by iv infusion; may increase by 1–2.5 mg/h
every 15 minutes to 15 mg/h
 Onset: 1–5 minutes
 Duration: 3–6 hours
SIDE EFFECTS:
 Hypotension
 tachycardia
 headache
 May precipitate
 myocardial
 ischemia.

37. ‫ادامـــــه‬........
 Inj: Labetalol 20–40 mg iv every 10 minutes
to 300 mg OR 2 mg/ min infusion.
 Onset: 5–10 minutes.
 Duration: 3–6 hours
SIDE EFFECTS:
 GI, hypotension, bronchospasm
 bradycardia
 heart block.
 Avoid in acute LV systolic dysfunction and
asthma. Maybe continued orally.

38. ‫ادامـــــه‬........
 Inj: Nitroglycerine initial 5 μg/min, then titrate by
5 μg/min at 3–5-min intervals; if no response is
seen at 20 μg/min, incremental increases of 10–
20 μg/min may be used
 Onset: 2–5 minutes
 Duration: 3–5 minutes
 SIDE EFFECTS:
 Headache, nausea
 hypotension
 Bradycardia
‫په‬Acute MI‫تمامیږي‬ ‫موثر‬ ‫کې‬.

39. ‫ادامـــــه‬........
 Inj: Furosemide 10-80mg
 Onset: 15 mins minutes
 Duration: 4 hours
 SIDE EFFECTS:
 Hypotension
 Hypokalemia
‫د‬ ً‫معموال‬Vasodilator‫ورکول‬ ‫هم‬ ‫یوځای‬ ‫سره‬
‫کیږي‬.

40. ‫ادامــــــه‬......
‫ډوز‬ ‫شروع‬ ‫دوام‬ ‫تاثیرات‬ ‫جانبي‬

41. ‫ادامــــــــه‬.......
‫ډوز‬ ‫شروع‬ ‫دوام‬ ‫تاثیرات‬ ‫جانبي‬

43. ‫د‬HYPERTENSIVE URGENCY‫درملنه‬
‫ډوز‬ ‫شروع‬ ‫دوام‬ ‫تاثیرات‬ ‫جانبي‬

44. ‫مـــــنــــــنـــــه‬
THANK
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