nA variety of neurohormonal systems, especially the renin-angiotensin-aldosterone and sympathetic nervous systems may be activated in response to the left ventricular dysfunction
nThe progression to more severe stages of left ventricular dysfunction can be significantly reduced by effective therapy with ACEIs, BBs, and diuretics
nIn the stage A group (New York Heart Association [NYHA] class I),
nACEIs may be appropriate due to their beneficial effects on mortality in patients at high risk for CVD
nThiazide-iuretic therapy is useful in preventing disease progression
nIn stage B HF (NYHA class I), defined by the presence of reduced left ventricular function (ejection fraction [EF] ≤40 percent) in otherwise asymptomatic individuals,
nACEIs
nand BBs are recommended
nStage C HF patients
n(NYHA class II–III) manifest left ventricular dysfunction and overt symptoms;
nACEIs and BBs
nAldosterone antagonists
nPatients with stage D HF (NYHA class IV) may require
nadvanced care, such as inotropic drugs,
nimplantable defibrillators, biventricular pacemakers,
nmechanical-assist devices, or transplantation,
nin addition to the treatment described for stage C patients
Diabetes and Hypertension
nACEIs may be used alone for BP lowering but are much more effective when combined with a thiazide-type diuretic or other antihypertensive drugs
nThe ADA has recommended ACEIs for diabetic patients older than 55 years of age at high risk for CVD, and BBs for those with known CAD
nWith respect to microvascular complications, the ADA has recommended both ACEIs and ARBs for use in type 2 diabetic patients with CKD because these agents delay the deterioration in GFR and the worsening of albuminuria
nA BB is indicated in a diabetic with IHD but may be less effective in preventing stroke than an ARB
nCCBs may be useful to diabetics, particularly as part of combination therapy to control BP.
Chronic Kidney Disease
na goal BP for all CKD patients of <130/80 mmHg and the need for more than one antihypertensive drug to achieve this goal
nmost patients with CKD should receive an ACEI or an ARB in combination with a diuretic, and many will require a loop diuretic rather than a thiazide
Hypertensive emergencies- management
nPatients with hypertensive emergencies should be admitted to an intensive care unit for continuous monitoring of BP and parenteral administration of an appropriate agent
nThe initial goal of therapy in hypertensive emergencies is to reduce mean arterial BP by no more than 25 percent (within minutes to 1 hour), then if stable, to 160/100–110 mmHg within the next 2–6 hours.
nExcessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia should be avoided
nFor this reason, short-acting nifedipine is no longer considered acceptable in the initial treatment of hypertensive emergencies or urgencies.
nIf this level of BP is well tolerated and the patient is clinically stable, further gradual reductions toward a normal BP can be implemented in the next 24–48 hours
nThere are exceptions to the above recommendation—patients with an ischemic stroke.
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