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Variability in Blood Pressure & its Implications in Clinical Practice

May 13 | 3:30 PM

Clinical blood pressure (BP) is recognized as the gold standard for the screening, diagnosis, and management of hypertension. There is a strong log-linear relationship between blood pressure levels and vascular outcomes. Short-term BP variations within 24-hours are heavily influenced by circadian variations, resulting in many important phenotypes, such as morning BP surge, morning hypertension, nocturnal dipping, and nocturnal hypertension. Calculating and measuring each individual patient's distinct BP fluctuations is crucial for estimating the extent of BP variability. Dr. Sunil Sathe, a leading cardiologist, joins us LIVE on Medflix to discuss the implications of BP variations in routine clinical practice!

[Music] welcome to all of you today we gathered here for a super interesting session on variability and blood pressure and its implications in clinical practice i think we can all unanimously agree that this is a must know for all physicians and on the super interesting topic we have with us we have the honor of having with us a renowned consultant cardiologist currently practicing at cardiac care and counseling center dr sunil satay welcome to medflixer we are really really looking forward to this opportunity to getting the chance to learn from you thank you for joining us dr sunil yeah thank you so without taking further time sir i will stop this presentation and get you started okay good evening to everybody all those who have joined this is a very simple talk actually this is because the hypertension is an important uh clinical topic which you see every day in our day to day practice so what we're going to look at is variations in the blood pressure bp variability and its clinical implications so if you see variability in disease so any patient diabetic patients ischemic heart disease patients if there is vp variability there is lipid variability glycemic variability and heart rate variability so imagine a patient who has variability in all these fields is bad news so out of this today because all these are topics by itself so we'll just start looking at the bp variability today so we will look at the types and mechanisms of bp variability the indices which tell us vp variability its clinical implications and more importance the therapeutic implications in day-to-day clinical practice now this is an interesting editorial which actually gave a good definition you know that blood pressure is characterized by that state of over lifetime it's interesting that means you know we always think bp is one time we take bb 149 no it's actually going on the dynamics of blood pressure variation and blood pressure is going on all the time in all of us throughout the life and that's why the concept of bp variability came several years ago so this is an interesting editorial which you must know so if you see baby variability it can be bit to beat which we see in our day to day when we do angiograms or angioplasties day to day big bit to it it may be positional it may be diurnal it may be in one day or visit to visit seasonal and yearly so depending upon the time they have sort of classified with its short-term or long-term bp variability what are the mechanisms short-term means b2b day-to-day visit to visit long-term is seasonal yearly yearly or you know caesar so and if you see the mechanisms it's important you see the mechanisms we are not going to details of these mechanisms there are a lot of mechanisms from arterial compliance to humoral effects to rheological effects your blood is thin your hemoglobin is high or low emotional factors behavioral influences and environmental influences your sleep your physical activity why i'm telling you all this is the so many times patients come to you they tell you sir my bp is fluctuating today it's 1280 tomorrow in the evening it is 170 t why is this happening so this is to tell you the dynamics of blood pressure that there are so many factors which actually decide your number which is going to happen minute to minute and that's why there are variations in general these variations are normally controlled by the body physiology but when they go out of control you want to get either short-term variability or long-term variability long-term variability obviously the factors are different they are usually behavioral seasonal or poor bp control or intermittent drug effects or even how many times the patient has missed his drug so there are a lot of other factors so remember depending upon what time or duration of vp variability there will be different factors this is what you must just know we don't go to details of these factors itself now how do you how do you measure vp variability now this was a basically simple statistic they're all statistical indices we don't go and have to go to details of all this for example if i do a 24 hour bp monitoring i know today itself there are variations they tell us what is my night vp what is my mean bp and we can know the variations the simplest one is coefficient of variation that means our standard deviation of the mean value that means you check your blood pressure today you check after three months you check after three months have four or five readings and see what is the standard deviation so there are simple formulas not really complicated but today they are trying to devise a parameter for vp variability which at the moment we are taking by standard deviation so just just we'll wait here and go to the next most important what are the clinical implications of bpa reality and there are four things which you have to discuss the clinical subsets which are important for a patient of hypertension the concept of postural variability the concept of circadian variability that is what happens during the day and what is finally what is called systemic hemodynamic thrombotic syndrome or shats very simple they're just names but i will take you through all the clinical conditions which will look at okay now the whole thing of bp variability or fluctuation started with this article in 2015 many years ago and what they did they actually this was a retrospective meta-analysis of almost 80 000 patients a very important thing and they found that very simple visit to visit systolic bp video that's very simple that means a patient comes to your clinic you have taken their blood pressure today noted it three months six months nine months one year and they followed this bp variability for five years remember and they found that even a visit to visit systolic bp variability is an important predictor of all cause mortality cardiovascular might be stroke and cardiovascular event so remember this so today in our practice just noting the dependency oh if everything is okay is not enough you must know what are the variations even the visit to visit blood pressure the second practical point they found out after analysis was that those patients who have blood pressure variability have a higher risk of developing kidney disease number one number two they are more likely to have ischemic heart disease and they are more likely to have lv mass or hypertrophy on the echo and dysfunction for the arterial stiffness that means their arteries have a property of stiffness and this is more seen in patients with vp variability this was the second subset analysis from this 80 000 patients the third important point was which is important in our day-to-day practice is more hypertensive emergencies more inorganic damage more hemorrhagic strokes emi and dissections and most important is if you have bp variability that means suppose somebody gets a stroke and there is significant fluctuation in the blood pressure blood pressure in the first three days 74 to 72 i see this bp result in the sub acute phase of ischemic stroke as poor functional outcome so having a significant large amount of fluctuations in the blood pressure after somebody develops a stroke is bad news you have to be careful that means they are likely to have a poor functional output so this is the importance of bp variability in these three small clinical subsets now the second important subset is what is called postural barrier we are not looking at postural hypotension per say that means suppose somebody is lying down he gets up his bp it falls down by 9 30 we are looking at this is an interesting concept this is simply due to orthostatic stress and what they did was a very important interesting study they tried to define what is healthy aging in elderly patients and what they did was they did orthostatic stress that means they the patient was lying on a table you tilt the table and what they did was they put a transgenial doppler trans cranial doctor remember on the area of the middle cellular artery and the posterior outside from outside simple doppler and they treated the patient and what they found was that patients who have personal variability and in those patients who had problems they had hypoperfusion of the posterior cerebral artery in that area when the tilt table was done so what they found was this was because of lower vessel reactivity of the pca territory now why is this important this is actually for elderly patients so many times you will find elderly patients will tell you i get up from the bed i start walking for the initial 10 minutes i sort of sway i'm not i'm unsteady and you know you do you do their you know ent test and mris and mri shows your average normal age-related cerebral hypertrophy you do all that tests there is no signal significant portion hypotension more than 22 actually said but this is a common a common problem in elderly patients and when they start walking they are a bit unsteady for the first 10 to 10 and this is what is called postural variability because of lower vaso reactivity to the posterior cellularity situation so whenever you have such a patient and such symptoms and all other tests are normal you explain this to the patient this is because of this particular factor so what they have to do is immediate change of posture should be much slower they have to adapt slowly and walk slowly for the first few minutes or first 10 to 15 minutes and this is an important second clinical subset of dp variability the third circuit in variability now remember i've just written this given the shown this slide early morning hours what happens see this throughout the day more arrhythmias more bp surges more incidence of ami poor response to thrombolysis if you have an ami and strokes so in the early hours of the morning these are the five things will happen out of which we are going to look at bp variability in the at night and during the day now this i'm not going to explain but we all know this that during night the bp is supposed to drop by at least less than 10 percent of the mean dbp so there are several technologies deepers non-deepers night risers early morning surge late night search depending upon the timing of the night and early day so we will not go into the semantics of it but you must know that there are going to be variations at night and during the early morning now what is the importance those patients who do not dip at night now see here forget the formula but suppose a normal deeper means you have to decrease the mean blood pressure as computer day by more than between 10 and 20 that is normal if you don't if you don't in fact it is said that nocturnal blood pressure is a better predictor of cardiac mortality as compared to daytime blood pressure now of course this requires a 24 hour bp monitoring now look here one more importantly if you are a extreme deeper that means the other way around sleeping at night and patient drops is the important cause of sweating at night during sleep out of the four causes number one congestive heart failure patients number two renal failure patients number three extreme differs and number four relative hypoglycemia these are the four causes where a patient will tell you in elderly patients of course in children of course it's content heart disease which shunts so this is one of the causes if somebody tells you is sweating at night regularly think of being extreme dippers now see this is one of our patients where the the bp dips at night this is a patient where it is a non-deeper you will find that there is no change in the blood pressure and this is an interesting patient it's a night riser nitrizer that means the bp actually rises at night during sleep mining it is not that the patient is awake at night and then the vp rise that's not called a non-deeper okay and an important paper which came in diabetics which you must know that if a patient is a diabetic do is 24 hour ability blood pressure monitoring if he has a non dipping of blood pressure and non dipping of pulsate simple at night that's bad news so here the importance is going to give him a nice dose of a small dose of beta blocker and a calcium chain blocker especially at night this is the important clinical message now the last and extremely important bp will have clinical implications what is called resonance hypothesis you know what that means is i just tell you this what is shats chats is a disease condition where there is acceleration of organ damage because of a vicious cycle of hemodynamic stressor don't get complicated the variability can be day to day bit to beat diurnal season so if if two or three time frames come together in a patient where stiffness is high you will find it precipitates events very simple at least in clinical conditions in day to day practice okay see this that means suppose you have a bit to beat diagonal something comes together suddenly there is a bp surge and you will find that the cerebrovascular and cardiovascular events and what how it explains is this this is called resonance hypothesis or what is called systemic hemodynamic atrothomboric syndrome that means somewhere in some circulation of the body the patient is going to have a problem because two phases time phases have come together and the patient has an article stiffness suddenly there is a bp surge and which is going to cause events now see it can explain so many things it targets vulnerable plaques strain vessels and micro circulations that means what how does it cause clinical syndromes see this rectangle this is not uncommon in your practice that somebody tells you i have suddenly become blind by one eye so what happens he goes to the observation he says the tele artery is blocked then he goes to a cardiologist he says there are no clots he goes does an mri mri says nothing in the cerebral vessels except that your retinal artery so why this is occurred because the hypertensive patient has the bp variability two time zones have come together especially in the patient who has high vascular stiffness vascular stiffness is not mechanical stiffness it is a property of the hypotensive arteries to have stiffness when the vascular range that the patient's age is 55 is vascular age is 75 okay so this is this is uh this is why patients can have become blind suddenly by one eye in colonies it can throw an infection and most important strokes cerebral has cerebral perforating arteries so patients in fact i'm telling you 50 why they say 50 percent of strokes are hypertensives and why i like to give these lectures because all this can be preventable if you have a concept of bp variable that means we have to be extremely aggressive in keeping the blood pressure at one thirty eighty because then there is some chance you can give some scope for bp variability and this is important the other clinical things we can explain is [Music] vascular depression in fact it is now said that alzheimer's forget the genetic causes more important if you are a hypotensive you have a hypotensive patient elderly long standing where bp variability is significant he is likely to get dementia early so this is preventable similarly vascular depression of old age people so is is depressed was the world low this is vascular microcircular level because of certain hits of surges because of bp variables so this is important now so what's the difference now we're looking at these concepts we are now looking at what is called seamless bp modeling rather than dot dots means at one time today yes in our practices we are having patient comes to us i look at the bp 148 190 you are okay not okay that is not good enough seamless so why you won't do this see here because this is a patient where i want to see the surges how many hits of bp variations here's god throughout the day and one day all coming together this is good to hit his eyes or his brain or his coronaries or his kidneys and you are going to have either of the cerebrovascular or cardiovascular events so this is how now things are changing from dots to seamless bp now so today today in clinical practice studying clinical practice how are we going to think that what is perfect bp control remember this what is perfect bp control now in our practices remember we used to look at targets now i know today the target should be 130 80 for all patients okay 1419 very elderly patients now we are going a step further we want to have normal circuit and rhythm that means the patient should be a deeper and i want adequate bp variability all these definitions are going to change because we are going to be more aggressive in treating blood pressure now interestingly we know that the targets changed was 130 80 then they went to 1490 then they went to 1519 elderly now they have come back to 1380 in even with patients with renal disorder if you see the history the canadians were the only people who never changed from the target they said no it has to be 138. why is this important thing important parameter was vp variability so in good days 138 is great but in bad days you have a stress you have a physical stress you have a mental stress you have arterial stiffness all things coming together if there is a certain surge if your baseline is 1 30 18 if you have a sudden surge to 169 you are still okay but if your baseline is 140 90 1590 you have a certain search to 200 210 you are it's bad news you are likely to get an event and out of which stroke is the most devastating thing you can ever have and which is preventable if we have this concept of fluctuations or bp variability especially in all hypotenuse equations that is the importance of this lecture no we must be extremely aggressive in trying to have the target because that is the correct thing we can do right now but as shown in this slide in our practices today we go beyond this i want the patient to be deeper i want the patient to have adequate bp variability that means then truly i can prevent events in the patients now finally what are the therapeutic implications in these patients number one is chrono therapy what is chrono therapeutics chrono therapeutics means that when should the drug be given to the patient what is the best time to give a particular to the patient is called chrono therapeutics okay now second is which drugs to choose for bp variable in general in general long-acting calcium channel blockers long-acting arvs are overall better drugs than short acting to control bp variability this super support now the second important point is what time should you give this so bp wherever we know we know the clinical consequences right from stroke to bad functional output to coronaries to being blind retinal to having dementia depressions all is a part of the syndrome what is called chats that means this is a bp variability syndrome which i want to avoid so chrono therapeutics i just mentioned a word because it's a topic by itself so i cannot give this whole thing but see this therapeutic inflation is chrono therapeutics now here i'll just show you one try there's a trial called hygiene which clearly showed that if you give a good dose at bedtime in a hypotensive patient it prevents cerebrovascular and cardiovascular events more than when you give these patients when you give these patients in uh during the day so should i change today from daytime to night time now this is a topic i just give you the gist the current consensus is i am not going to switch if you see the japanese and the koreans here in them the concept of this atrotrobotic syndrome and chronologies they are extremely aggressive in fact they are the performance of nighttime dosing because they say if you have a long acting you have a long acting drug if it hits early morning you give in the evening or late or at night and throughout the day if the bp will be whether why not give at night so they think but of course it's a trial called life trial which is going on which finally tell you but we cannot always wait for guidelines to tell us this is common sense there's a lot of articles with this so suppose you have a night riser if you do ambitibility in general remember ambulatory vp should be done in patients who have stage two hypertension or more or have an end organ damage or have a history of at least one stroke recovered at least in them one at least once an ambulatory 24 rep should be done now in this patient in general after all this focus in our practices also even we switched and i have switched significantly from daytime to night time loses or at least give divided whenever possible but given nighttime dose because it will help in in avoiding the normal because each and every question we cannot do ambiguity dp monitoring so we want the ability to be monitoring but each and every patient we cannot do it so at least make use of this make use of this data to tell us that why not give nature so at least think today what practices say i was doing 30 35 years ago in my practice today i have to change because so many things people think what is there in happiness you just give a door saying everything is okay that's not all those days are gone today in my practice i have to see the hypertensive profile of a patient and then think of so many factors and then decide what is the appropriate drug and what time of the day so this is chrono therapeutics in general remember that yes today in our practice we should think of giving one dose night time or divided doses morning and evening that doesn't mean you cannot give single dose in the morning you can still give this because the trials are coming but you must know this concept what is the future of hyper engine in fact it's interesting we have to have newer indexes today in my in my we have actually present this paper we are publishing this paper in japan we i have done three thousand patients we have done what is called periscope that means we have done their studies from outside where it we just are just a vascular age will not believe this patient hypertensive patient whose age is 55 is vascularity is 75 and interestingly this is dynamic which we learned i had given this thesis to one of my students and we gave drugs for three months proper drugs and looked at the vascular age and in those patients where the blood pressure was perfectly controlled their vascular ages dropped from 75 to 60 65 so vascular age in hypertensive patients is a dynamic thing it changes but for that we have to have perfect bp control so your indices newer pressure measurements and what is called indeed what is called anticipation medicine anticipation medication and we have to anticipate what is called anticipate anticipation medicine or medications where i can anticipate that a patient hypothesization is likely to have a particular event in his lifetime so we have to become now we have to become more prognostic you have to think that in the hypotensive equations how can i prevent so many events 50 percent of strokes are in because of hypertension which is possible that we look at so many factors and change our practices in treating hypertension now so in conclusion this is the importance of bp variability of fluctuations and blood pressure this tells you to explain number one simple fluctuations a patient comes to you without my bp is structured either supers in each other you tell them short term there are several factors so it is not please explain to your patients that the bp cannot be on a plateau 1280 all the time it's not possible in anybody not possible so there are will be fluctuations and then normally i go and look whether they are humoral factors geological as i mentioned so many factors we want to know and then see whether the day-to-day fluctuations in the patient can be managed that's number one we should know the types of types of evidence means short-term long-term and depending upon the type the portion laterally portions why this explains a simple clinical syndrome where my patient tells me i start walking i am unsteady i swear for like this is postural variability because of visor reactivity low in the posterior so we know the syndromes you can explain to them then it has explained all clinical events retinal embolization strokes coronary events renal dysfunction all this can be explained because remember i showed you that figure surgeries of blood pressure coming in and out of the day throughout the day and now this new equipment which has come in fact we have actually acquired that i've done around 200 patients it's on the wrist it gives you online blood pressure it tells you the actual surges it's interesting so all these things have to change so the fourth i'm telling you newer methods of vp measurement and management this is going to happen we are now using more amputee vp at least once to know whether the patient is a deeper or non-deeper if it's a non-deeper yes i want to give a bedtime medicine i would like to see so depending upon that i want to use chrono therapeutics to see and what is called zero risk medicine it's great it's a great achievement if you can even think of batteries you should aim at having what is called zero this is possible but for this to be possible you number one you have to start number one first being extremely aggressive see if the patient and eating doctor is casual about the blood pressure so many times people there are there are so many physicians general practitioners you know they are really busy if you don't blame them 100 patients 150 patients everybody somebody else patient comes somebody else takes the baby outside patient sits in front of you i said okay it says okay okay that's not okay this is not that we treat medicine in 2022. you don't treat hyperlinks in 2022 today every patient i want to see what is this bp profile so i want zero experience but i want to prevent the stroke in this patient how can i do it because i know number one i must see that my target it is not good enough you cannot tell the beginning ah 140 90 140 it is 150 94 it's okay but you have no it's okay it's not okay be aggressive keep two targets think of variations think of deeper non-peoples think of ambulatory blood pressure think of the newer measurements it will come within five years everybody will have a different profile but this all this is basically because i want to prevent the complications of hypertension that is the importance of this lecture that hypertension is being treated by so many lakhs and lacks of doctors and there are lacks and millions of patients but the way we are to treat hypertension today has to change we have to be more aggressive no casual approach either by the patient doctors and we are going to look at different varieties fluctuations variabilities parameters to see that i can at least i should be trying to be somewhere near what is called zero risk medicine in treating patients with hypertension thank you very much over dear doctor hi sir thank you so much i think this session has been an eye eye-opener for all of us and i think everyone will agree which is giving a moment to our doctors to put in their questions in the comment box uh thank you so much uh we are all going to try and imbibe the zero risk medicine concept it has been amazing listening about it from you thank you okay so we have thank you so i loved it yeah just starting dr amok says very informative lecture dr siemaa says very informative but after specialization in other fields we tend to forget all this stuff so we have a question from one of our doctors is the mechanical stiffness same as vascular stiffness yeah mechanical vascular stiffness is a property of the arteries remember mechanical stiffness is mechanical in elderly people the arteries measured by a machine called periscope there are sensors there are four we put four cuffs uh two arms and two legs and it measures these as a sensor to measure the blood pressure from inside the arteries and all the parameters this is called vascular thickness mechanical surfaces for extremely elderly patients where your arteries are rigid when you can palpate in the brake caliper that is not that different that's why in fact i am nowadays doing routine vascular stiffness for so many patients and you will find that the vascular age is so high and there are now a lot of papers coming in from the west which are trying to tell us that if stiff high you have to be more aggressive about targets and more aggressive about lifestyle modification and a lot of papers which are coming in thank you so much sir taking the next one we have a lot of questions coming in uh so how to assess vascular age asks dr sakshi yeah so i told you this is a machine called periscope it's a non-invasive test it's a very simple test i have done around 5000 of them and we are publishing a paper where so it's a knowledgeable test where it takes around 10 to 15 minutes the patient lies down comfortably on a bed after resting for 5-10 minutes you just cannot come and make the patient sleep and then you you connect these four cuffs to the arm and the everything else is done by the machine it gives out a three to three page print out and gives you different parameters systolic diastic pulse pressure and different pattern now there is one parameter just to mention because you are now those normal person normal you are normal you have no hypertension i do a periscope on you if your augmentation index is high 50 to 80 percent of patients where augmentation index is high will develop blood pressure after the age of 50 so that is how we use it in our clinical practices how so different indices give you different information is simple non-invasive and we are now using it more and more in our clinical practice but this is not but this is not being is not a commercial equipment because it is yet to come as a routine in clinical practice okay so dr tharini i'm coming to your question just kindly give me a moment please thank you for answering that sarah uh so just coming to dr tarani asks uh sir could you please repeat the three types of individuals whom we are supposed to do ambulatory bp monitoring any patient with stage two plus that means bp is more than one sixty ninety patient comes with the first time 180 plus hypertension number one target organ damage patient has linear dysfunction patient has hypertrophy patient as cba where anything which is targeted organic is to once you must do the patients with at least even ti or strokes i would like to run android tpp because i know strokes or amis strokes are early morning hours so at least once once i'm not saying it's going to be repeated again and again i would like to do ammunitive number and number four are that when a patient is on multiple trucks at different timings it's a good idea to do an ambulatory so three or four trucks more than three drugs i would like to do amputee marketing because i want to know if i'm going to have three or four drugs i would lose i want to give a different timings and see to it that the 24 hour cycle yes thank you doctor tarani i hope that answers your question so dr sarthak asks um can the periscope predict as to when and how the patients will get the spike in hypertension no no it cannot you cannot predict because as i said the surge has so many factors that's why you know you have actually didn't show the whole slide there's so many factors it just tells you you have to be more aggressive likely to have more surges so be careful and prevent things thank you sir uh next question dr niharika how to proceed with diabetic patients with bp very producer no see whether it's diabetic or non-negative in diabetics i have mentioned that article because if a diabetic patient variability especially at night it's a non-deeper and with the heart rate also it doesn't dip down which normally in all of us should dip down it is that means they are like significant significant cellular vascular or cardiovascular events so that's number one number two in these patients i'll be extremely aggressive in this diabetic management in lifestyle modification and hyperdensity so especially in diabetics i would be more aggressive in trying to target all the aspects of the disease in a very aggressive manner that is how we should look at it yes sir thank you coming to the next question sir dr durjoy asks how to deal with hypotensive patient complaining of vertigo see basically now i'll tell you what if your high potency if this postural hypotension remember original hypertension is treated by giving short acting drugs number one questionable hypothesis is treated by giving if you are giving one given night that sometimes helps okay and sometimes it is said that non-selective beta blockers help in coastal hypothesis which we normally don't give because they cause peripheral vasoconstriction and of course keeping good fluid intake that is number one however if you have vertigo which is only because of hypotension now there is a drug what is called middle which has come it's an alpha agonist so which was not there for so if you have a patient who is truly hypothetive and he is getting postal hypotension and you cannot correct it not on antioxidants then give this drug what is called mitotin 2.5 milligram twice a day easily available now and a fantastic drug for hypotensive patients honestly it's a good question we never had a drug for hypertension except for cortisone for you know someone who had a healthy label is positive otherwise now this drug has come for truly hypotensive which are rare but you can give this drug okay so i have a question from my end when do we start introducing calcium channel blockers in the regimen because it has an edge over arbs and ace inhibitor should we start immediately no in general in general elderly patients more the chances of stroke calcium channel blockers long acting better younger the patient less chances of stroke more sense of coronary disease arvs and ace nymphs are better overall but in general the patients who come to us who are stage two hypotension usually require a combination because the combination works perfectly commonly means you give both especially in stage 2 but otherwise yes thank you sir for answering that we'll take the next question uh so we have a comment from dr madison who says this is a very informative session and thank you so much moving to the next one sir uh approach to hypertension in children asks dr miss park in children basically in children we always like to rule out secondary cause of happening that is the number one because children should not have friends so when a child comes with apprenticeship look for right from family history to all the secondary causes of hypertension including including renal artists and so many other factors so first in children what i would say is this is the bacteria of tests where i would like to rule out a secondary cause of hyperinfluence rarely rarely children younger than 18 years will be hypertensive because of essential hypertension nowadays 20 to 30 is not uncommon because of the stresses we have seen a lot of patients between above 25 to 35 no secondary cause are becoming hypertensive because of increased over sympathetic activity so sympathetic increase over simple activity in younger patient patients okay but this is in not children not less than 18 years it's about that so this is an important substrate which you should never see say 10 years ago it's always 45 plus 50 plus but now it's 25 plus and this is because of the stresses and increased symbolic activity we'll just take the next question uh we have a question from dr sonam patient on tell me saturn and hydrochlorothiazide with bp 160 over 110 variable 150 over 90. how do we how could we treat further patient on tell me saturn and hydrochlorothiazide number one if the dose should be adequate that is at least 80 of television at least 12.5 of hydrochlorothiazide minimum of 25 or 12.5 depending upon what you are using because i don't know but however that is not sufficient you must add a calcium channel block so remember with one sub optimal to maximal dose of one if it doesn't control don't be satisfied add one more drug normally the gap given is supposed to be between two to three weeks after each drug so they say average three weeks three weeks if it doesn't work you either increase the dose or add a drug overall thank you so much uh can we deduce blood pressure from heart rate variabilities it asks dr anand rakash no you cannot reduce that they're measuring it but in different forms sometimes by a normal method which we do sometimes home monitoring sometimes ambulatory monitoring so there are different methods of measuring bp variability by different methods suppose i tell the person to take his home bp several times i do have the standard deviation it still be prevalent a visit to visit in my clinic i still look at the deviation so there are different methods of measuring divide different methods of measuring blood pressure okay so uh coming in we have a question from dr viveks a patient with edema and creatinine more than three and uncontrollable blood pressure what would be your drug of choice here sir see in general remember if somebody is on dialysis we tell them that volumes in general remember in ckd volume status is the most important thing for their blood pressure number three resistance to diabetics is the second one because if you try to give them that it doesn't work and that is why in general calcium channel blockers the newer ones right from celidypine to berindipin to azildipine and ethrodep these work better in better in renal patients but in general if somebody has edema then this is volume dependent blood pressure and you will not be able to control volume dependable pressure unless you reduce the volume and this sometimes is difficult without dialysis because the diabetics don't work the way they work in other patients so you have to have a balance between diabetics dialysis and your calcium child blockers to treat secrets still secretly is not easy sometimes we have to use centrally acting drugs in security patient was the thing okay so thank you um next questions are in epileptic case what kind of complications can occur keeping the context of bp variations uh see in april we say usually usually in general we have not seen too many epileptics but an elderly patient epilepsy is not that common and it was a hyperdensity you can have a hypertensive surge during the epilepsy fit because you know it is basically isometric it's it's isometric contraction of your muscles so when you have an isometric contraction of your muscles during the feet your bp will go on and go high so rarely we have seen that people may have tis transient ischemic attacks doing that but in general the the lot of patients who have epilepsy are not these elderly people and that is why we don't see the complication of hyperinsulin during epilepsy as compared to what we think but this is this is the mechanism why it can have a bp surge understood so we have a question related to pregnancy-induced hypertension and the best drug of choice there i mean there are different drugs you know you can have you can use the philippine you can use with alpha methyl dopa and where we where you it's a certain search you can give labrador alpha beta blocker is the dog of choice when you want to suddenly decrease the between a pregnancy pair in a pregnant patient otherwise in general nephite pain and alpha methyl dopa can be safely used in these patients so we still have a lot more questions would be okay if i take five more minutes of your time for one hour but i have decreased because i didn't know who the audience was ah so drug of choice and hypertensive emergency in ckd yeah yes sir that's the question but doctor we wake yeah see normally it depends you know some people in sickening we give nephilim you know normally they don't give but we give leopardy never even sublingual because that is emergency wise that is the best to give in that particular city otherwise you know for emergencies nowadays from laboratories iv blockers to networks into sonar depending upon the emergency the different iv trucks but nowadays in fact previously when we did medicine it was said that if it means supplement today i'm still telling you when you not you have nothing in the peripheries we stream the best truck in general remember if your systolic bp is more than 220 then it is worth breaking the pill and uh you you pour liquid sublingually otherwise otherwise give it orally so that is safer give oral timing i always tell my patients keep that tension from dipping with you i know people say oh this was old stuff but still it works because in the peripheral situation this is the best drug at least halfway that it will come down yes sir perfect ah so patient on nerdy for long term is there any risk for heart block asks dr krishna prayasa no nitrogen over we have given for anjana for years together unless the patient has a conduction defect so if you have an elderly patient whose pr interview is prolonged he has a conduction defect he has six sinus syndrome then dtsm is bad otherwise overall in the normal contact system you can give it for years nothing will happen wonderful sir question from dr sakshi how do we approach a blood pressure patient with autonomic dysfunction autonomic dysfunction see basically it is not easy because the fluctuations and variability is very high in autonomic dysfunction especially or you can have something what is called a steady state that means the heart rate and the bp it just doesn't move but it remains at 100 so in automatic dysfunction it is difficult there mainly we try to do this by giving multiple dosages so here you know because the fluctuations i have to be multi i do a 24 hour big monitoring and try to give them doses uh drugs in divided doses so i keep i keep a factor off i can have permutation combinations so that certain surges are avoided that is what you should do in such patients autonomic dysfunction yes i know we have a question from dr mandel hypertensive patient taking antipsychotic medications due and having postural hypotension frequently what should be the drug of choice here sir it is difficult but giving a dose at night sometimes because actually with antipsychotics because they tend to have postural hypertension so here the given night dose give divided doses and the maximum dose you give at night this sometimes helps but otherwise it's difficult sometimes if the hypertension is not you know this sometimes does happen we give them fluorocortisone it sometimes does help sometimes it doesn't okay thank you sir uh dr vivek asks cutoff limit for arv use in relation to seem creative levels say in general people say that if your egfr is less than 30 you should not start but simple one people don't calculate j bar create of 2.5 plus you should be careful in starting arvs but now what do you see in all hypertensive patients or even if you have to deal you should not start but i'm telling you what if you have real dysfunction you start arvs wait for a while there may be a jump there might be a increase in the create but overall later on it will decrease but you have to have that patience number one so if you want to know whether arv is harming the kidney the criteria is if there is more than 25 percent jump in creatinine value after you start s arb or army stop the medicine but in general 2.5 is a good cut off where you have to be extremely careful and potassium touching 5 to the start with so potassium 5 react 2.5 be careful don't start or you have to then see the you have to be very very aggressive in doing their uh lab reports weekly got it sir thank you we have a question from doctor madhav sir where should we use clonidine chronic is in resistance i'll tell you what when you have more than four drugs including diuretics then we use centrally acting drugs okay now in fact in fact interestingly if you see guyton 1961 or 1965 editions blood pressure was a disease of the brain it was thought that there is abnormal setting of the bp value in the brain and that's why all the anti-apprehensive management started with centrally acting drugs there were no peripheral acting drugs in my practice when i did my md the commonest drug used was adelphina citrix okay so certainly exactly recently acting drug and it worked the best in fact centrally acting drugs work the best but the side effect profile was so bad and that is why the focus shifted from centrally acting to peripherally acting drugs overall human so whenever you have resistance yes you should try centrally uh centrally acting drugs but you have to be careful because of the side effects thank you so much for that inside sir oh we have a question from dr aruj can you please explain the management that we should follow in a pregnant lady who is having fits because of hypertension see basically you have to first the first thing is relation and control fix that itself takes care of the penetration because it is you know it is just during that time you are doing a search after the patient's feet is controlled then you look at the hypertensive episodes so depending upon that's usually when the feet is controlled the bp comes down after that particular period if it doesn't we're still high then in pregnant patients iv laboratory level is the drug of choice to get it down okay i hope that answers your question dr arud we have a question from dr can we stop delmar 20 suddenly in younger patients with hypertension doesn't do anything easily it's a very mild remember so with bp of 180 over 100 can we use combination of calcium channel blockers and ace inhibitors and you must use 180 above you have to have minimum two drugs or three drugs in good doses the problem in india is the dosing people have their fear when the dtsm dose has to be 90 they give 30 half bdd when amniotipine dose should be 5 to 10 they give 1.25 twice a day people are so worried about hypnosis so that is the sub optimal dosing in india i have not seen anywhere else in the world and that's why we have to be careful in hypertension adequate those yes side effects you decrease so give sub optimal doses of two or three drugs but at least you should be near the normal value there is not coming side effects right thank you we have a question uh related to hyperthyroidism in patients with hyperthyroidism what a drug of choice would be other than beta blockers the first beta blocker second control hyperthyroidism and then if required you can give a arb says doesn't matter really because it is not that specifically it doesn't matter beta blockers hyperthyroid control and then any any other depending on age and other factors it doesn't matter perfect i hope that answers your question of this actually so thank you nice our questions i'm just going through them uh how do we manage mild hypotension in patients with pericardial effusion asks dr abubakar no because if pericardial diffusion causes hypotension you must tap it if you have signs of tamponade on the echo and if you started getting hypotension then you should tap it i mean or it is very very mild you can just give some but you tap in and leave fluids that is what you should do yes uh dr ashok says very nice lecture in patient management of all aspects have been covered many thanks sir oh yes sir so seems like we've covered all the topics here people are tired they are hungry they must be eating except you and me [Music] yes so best antihypertensive for diastolic hypertension last one in general a high dose of arvs high dose is good for diastolic hypertension you know saturn's are good but high dose small dose doesn't cause anything and systolic in general calcium channel blockers are better for systolic hypertension indomite is better for systolic hypertension but it's it's not systolic and dash in general you can use any drug for anything but those have to be straight forward asphyxiation thank you so much sorry raise hand request could i accept it so that he can direct your question to you directly would that be okay yeah dr dilip i have accepted your request could you please turn on your audio and video thank you ma'am hello yeah hello sir tell me sir myself actually i had a patient sir he's a young patient 31 years his bpa was recording around the for three three continuous settings the bp was 140 100 so diastolic [Music] okay we started with a lifestyle modification he was was doing well sir he's uh shed off some uh weights around six to seven kg but one fine day he came with a severe headaches but that time the bp was 170 100 tensor so we we gave them like a humbling 10 mg and the bp was controlled then after that the telma 20 was started so now we compressed of uh giddinesser uh actually the tablet is heard uh is we are giving a night dosa 20 mg the bp was controlled but uh sometimes the complaints of guiltiness the bp is like it's coming it's systolic is coming 97 when lifestyle modification decreases your blood pressure first say remember this the consistency of lifestyle modeling is the problem you know they start they stop when you think it's okay so what happens you start getting confused because of that but you're doing very well with lifestyle modifications run this you know there's a there's no consistency in that this we have seen very commonly especially in young people they don't have time for their lifestyle motivation pattern decreases what actually has initially gave you the good result and that is why the same or is the other way around sometimes you know they become very aggressive in the lifestyle modifications you have to reduce the dose so it is possible that you have to stop your 20 see that it doesn't go beyond 1490 only on lifespan modification and tell him sometimes it is possible that once in a while when you are not doing well we might have to give you a drug this also can be done depending upon how he is going about lifestyle modification and the drug dose otherwise it is not that 20 will cause every time he's going to have a giddiness so this sometimes are episodic so you have to weigh both the situations and these are practical that's all okay that can can we like uh we have not done ambulatory blood blood what i always say that anything which is odd in the hypertensive treatment management you must do ambition it is possible that you know when it comes to you the bp is low at home he's a he's a must have attention so that is why he's having a problem so that is why you have to sort of look at this when you have a odd thing going on you must look at diabetes so can we stop like can we stop for 10 days then we have to do ambulatory but monitoring our depends you can see suppose you do it on on drugs because he's requiring it for a long time do it on drugs you will find that mass temperature is there or you will really find that no throughout the days bp is 120 and low you stop it so i would do it on drugs initially okay okay thank you yeah so one more request can i go ahead see last one sir talk hello doctor geeker i have accepted yeah yeah hello good evening i have a patient sir uh she's a a case of eclampsia presented with a fit previously in pregnancy she did not have any readings of high blood pressure suddenly she presented with the fit and with the iud we had to do a history and deliver a now uh after uh putting her on levitt law tid she did not respond well so we've put her on telvas beta 40 by 25 bd and cylinder pin bead is a 10 mg in spite of that also she's having high blood pressures in the evenings especially from 6 to 10 o'clock so can we do anything for her sorry and she's having that 180 110 that kind of bps in the evenings from six o'clock and then you change the timing of your tablets so suppose she's thinking early when you start hello give the maximum tablets that is how it helps okay okay oh okay thank you sir thank you so much sir i hope that answers your question dr viveka yes thank you so much uh we have a comment that i would like to read out dr tabu says excellent explanation in less time and most important points have been covered up so smoothly thank you so much sir we all agree with her we consider ourselves lucky to have had this opportunity to learn from you today about this topic okay no problem good night thank you sir we would love to see you on netflix again i hope the audience agrees everybody put up a thumbs up if you would love to see dr sunil again yes thank you good night

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