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Feb 20 | 8:00 AM

Dr. Bhupen Desai: VAdding BETA BLOCKERS are preferred in view of the clinical profile Dr. Rashmit Pandya: Adding Alpha blocker would be the preferred choice in patients as per the guidelines Dr. Abhishek Rawal: Changing to newer CCB /ARB with emerging data may be a better choice

[Music] it's a pleasure to introduce doctor dhiran by dr rupin desai he did his mbbs and diploma in cardiology he did his md pgi chandigarh dnb dm cardiology he's a fellow of american college of cardiology he's a fellow of european society of cardiology either ex wadia bombay in nanawati hospital his ex carlos rnt bristol mayor squibb hospital ex senior cardiologist at quintless research he had more than 27 years of experience in cardiology practice he is at holy family bses karuna hospital mumbai inspiring carlos award he got from economic time so very decorated uh cv so without much you do i will request dr bhupen desai to start deliberation thank you should i introduce all three yeah yeah please introduce dr rashmit also and okay okay so dr rashmit pandya is a severe cardiologist from our city am the boss he is presently the senior intervention called lowest and apollo cvhf heart institute highway and he has the rare distinction of having to create the dual qualification of dm cardiology and dnb he received a dm super specialty degree through vijay medical college he's a research fellow in u.n method institute of cardiology he has done he has research papers publications and award in distinction so dr smith pandiya is a very renowned cardiologist of city of mdhawa now to the next ah it is again a pleasure to introduce dr abhishek raven who is from city of rajkut he is md dm assistant professor and interventional cardinalist at even meta he research he is specialized in cardiology congenital heart intervention interventional cardiology and stress cardiology non-invasive cardiology in echocardiography he has been at the faculty of the year at tct acr pacific 2018 organized by cardiovascular research foundation seal korea so floor is open to start deliberation so case should i read the case is a 55 year old male 1 his heart rate is 88 per minute abpm shows 150 2 by 98 millimeter of mercury and his funder shows hypertensive retinopathy grade 1 so so i will start i will request the speaker to start deliberation can you see my screen yeah we can see my voice and my video is clear right yeah yeah very clear please go ahead one second i'll just make it in a slight press so we have a patient with 55 year old his beep is 152 by 98 so bp is still uncontrolled he's on at least three drugs that is tell me certain floor cell down an amnoid event and plus his heart rate is 88 bits per minute so this is the background which we have how best to please this gentleman so what are the issues we have we have to reduce his blood pressure at the same time we have to reduce his heart rate because in 2022 heart rate of 88 is not acceptable and i'm going to discuss about this what choice do i have i can increase the dose of any one of the three existing drugs he's taking three drugs but they are not at full dose i can increase the dose of any one of the three drug or maybe i can increase the dose of all the three drugs but or what can i do i can add a new antihypertensive what will i do because increasing the dose of one medication is better than adding a new drug what does the data show it comes this is data from more than 11 000 participants from 42 tries and it says very clearly extra blood pressure reduction from combining drugs from two different class is approximately five times greater than doubling the dose of one drug so this gentleman is on five milligram of amd even i can make it 10 milligram or i can add something new but then i will get five times more better blood pressure reduction so doubling the dose of an existing medication does not help much and this is large data from 42 trials from 11 000 patients so what can i do it's already on diuretics he's already on calcium tunnel blockers then is already on ace inhibitors so can i give beta blocker can i give alpha blocker or can i give a newer ccb that is the most important question now we have decided that we will give him a new agent because we are expecting five times better reduction blood pressure compared to doubling the dose of the existing drug about alpha blocker i am not very greatly convinced because all heart trial has shown that it causes increased mortality it can cause postural hypotension patient might fall down and it will not reduce heart rate our target is also heart rate what about newer calcium channel blockers there are no convincing data mdp still remains the gold standard and patient is already on embroidepin so i would not like to disturb that also so my mind i think there are two issues which we have to settle in this gentleman we have to reduce his blood pressure to less than 130 by 80 which is the current standard of care and we also have to reduce his heart rate so what is the relevance of heart rate in the treatment of hypertension as you can see this look at this elevated heart rate is a predictor of cardiovascular outcomes resting heart rate that is what we call it rhr resting heart rate is a predictor of adverse compared cardiovascular with heart rate of more than 70 and people with a heart rate of less than 70. and head-to-head comparison has shown that fatal and non-fatal mi significantly increases need for coronary reverse creation also increase in persons who are hearted of more than 70 and most important hard point is cardiovascular death also increases if your heart rate is more than 70 so we have to bring his heart rate to less than 70. patient with a baseline heart rate of more than 70 have a significantly higher risk of full cardiovascular heart rate is the determinant of myocardial ischemia we all know about it the heart rate increases ischemia risk also doubles up and look at this data this is the data of different heart rates and mortality rates in normal tension as well as in hypertensive so look at let us discuss about this hypertensive look at this saffron bar hypertensive patient who has a heart rate of more than 80 he falls in this category his heart rate was 88 he's hearted falls into the saffron bar so heart rate increased heart rate causes more deaths per thousand patients all cause mortality is increased cardiovascular disease mortality increases and coronary heart disease moderately also increase if your heart rate is more than 80 like this gentleman has it and we all know that this is a large data from inverse study generalized 22 000 patients who had underlying cardio disease they were all hypertensive and they were followed up for a period of 2.7 years and as you can see as the heart rate goes above 80 the hazard issue starts rising look at this yellow right this hazard ratios our patient falls into this category so is a significantly higher estimated hazard ratio for adverse outcomes including death we need to control not only his blood pressure but also his heart rate higher baseline and follow-up resting heart rates were associated with increased adverse outcome risk we all know about this and this is the data from india it's a paper published by our own dr jamshed and he says that resting heart rate is important and this forum that is this dr jamshed dallas asia pacific region forum recommends that resting heart rate should be considered as an independent risk factor for cardio scale events and mortality country guidelines should be updated to include resting heart rate monitoring and pharmacotherapy should be considered in high-risk hypertensive patients with elevated heart rate controlling blood pressure is only half job done so how can we do this how can we help these gentlemen beta blocker is the key in my opinion to conclude my talk because i have been allotted only 10 minutes to conclude my talk i would say that heart rate is a risk factor for cardioscope mortality again i would repeat resting heart rate is a risk factor for cardiovascular mortality it is independent of other major conventional risk factors like smoking diabetes and hyperlipidemia heart rate should be used to assess the overall cardio is no risk and it should guide us to provide a tailor-made therapy for our patient like this gentleman whose vp was high and hearted was 88. beta blockers have documented efficacy in reducing heart rate blood pressure and also in improving the outcomes of patient with hypertension including those at high risk of cardiovascular risk like coronary artery disease heart failure and in diabetes so controlling blood pressure without controlling heart rate is not acceptable in 2022. thank you so much i will rest my case here thank you now daniel you are mute thank you sir for giving a very decent presentation excellent presentation rather and very forceful [Laughter] so beta blocker is the key now let us listen the next speaker who will be talking about alpha blocker okay am i audible doctor rashmi hi sir how are you very well fine sir i'll directly go to the uh i would rather prefer doing great procedures yes yes it is yeah i can see it so uh okay initially i clarify the case given to me the heart rate was like mentioned 80 80 bits per minute so if uh really this gentleman is 88 or 90 or something like that i would certainly also think about the beta blockers but if the heart rate is same with okay with 70 between 70 to 80 then i i certainly would like to examine other possibilities other kind of uh medicines which you can use in certain kind of patients now i'm not going to details about these things this is already an uncontrolled hybridization patient we would rather not label him resistant right now because he's not on the optimum doses of all the medicines but we all know that there are uh yes as sir had already said the heart rate is independent uh much more is the level of blood pressure whatever level of blood pressure you have uh even a two millimeter mercury decrease in systolic blood pressure would lead to a remarkable and drastic decrease in the heart disease motor key and also these top strokes so if we look at the combination therapies as it is obvious from the guidelines in india also we are more prone to combine the more evidence-based medicines and it is also true uh but if we see beta blockers uh they are hardly recommended as fast line treatment even second line not even second line some guidelines even have pushed them down to fourth or fifth because of few important uh risks that we have come across in recent years and major reasons will be two one is the increased risk of nuanced diabetes especially when it is used in combination with the thiazide and also with anything so here the patient is already on a centimeter and thiazide and if we if i think of it putting this pressure not beta blocker then the risk of nuanced diabetes is going to be exponentially high so that i think i must have to keep in mind and keep the patient in constant follow-up uh that again is a major problem with our patients who uh just forget to come to follow up and they turn up after three or four or five years and you may not be able to check his or her blood pressure and even these sugars regular the second reason is compared with other than beta blockers really are less effective in reducing cardiovascular events which is especially strong in few studies even stroke rate was noted to be higher in those patients treated with beta blocker particularly because they increase the central iotic blood pressure and which translates into increased amount of stroke if we see the uh various uh trials beta blockers diuretics when combined they definitely lead to much more increase in diabetes i'm not going too much updated these are all available but it is a known fact and combined with uh ac lipitor and diuretic they are going to be a disaster now if we look at the all hair trial sir had already mentioned this was the chief trial which resulted in a setback for alpha blockers in hypertension patients because in all a trial we registered a remarkable increase in heart failure it was not particularly uh mortality but it was the heart failure rate which increased almost uh double that of the other uh agents now uh if this because of this even the this arm of the trial was stopped prematurely uh then there were many meta-analysis and scrutiny why this happened because doxazosin is known to reduce hypertension to a very remarkable level so then they after there are many researches we have come to know that it was probably because of counter counter counteraction by the body which increases the body fluid so retention fluid retention in the oxo system that was probably one of the cheap reason why these happen so whenever we want to use alpha blacker then you may need to increase the diuretic close or keep a tab on patient's weight regularly that is what i uh that is what we have concluded but the as a third line therapy in the very major trial escort bple this was again powered on this was specifically uh to examine whether the heart rate the heart failure increases real or not and here we found out that the blood pressure lowering by the alpha blocker was to the tune of almost 12 millimeter mercury in systolic and seven industry and we are all aware most of the major drugs they produce a very modest decrease in the blood pressure included you know maybe five or seven millimeter marker so they are very impressive agents pushed back because of one or two negative trials but there are many important uh follow-up trials which we many times forget to take a note off so if you see the ascot bpla the heart failure rate incidence if you see it is almost similar to that of placebo so alpha blocker this was again a very major and large trial and this was actually specifically designed to see so we have to uh understand uh so if we i'm not going through this slide the there are many guidelines which correct clearly so that any individual having significant risk factor particularly early ckd the blood pressure has to be brought down to good levels uh maybe 130 to 80 or lower impression can tolerate so i'm not going to that details uh so initial three combination as this patient is receiving i am completely agree with the regimen which patient right now is going on with but if we see the uh let's see alpha blockers when everything fails there are all the guidelines when blood pressure is not controlled say uh with ac inhibitors uh ccbs or beta blockers or diabetic or whatnot then then the alpha blockers are brought in to reduce the blood pressure so now it is there is no uh disagreement that they are not effective in reducing the blood pressure beta blockers on the contrary they reduce they increase the diabetes and stroke both risk as we are aware alpha blockers reduces blood pressure remarkably but with that also protein area is remarkably reduced the this the lipids are brought down to a good level and in this patient as we have seen the serum creatine is already 1.6 patient is early ckd so this is the patient where you would certainly like to reduce the blood pressure to a more suitable level and alpha blockers just do that very effectively only incidence of this heart failure which i have shown in three four trials i'm going to detox because the time constraint but in post aloha there are at least two or three major trials where these pro and the heart filler both incidents has not shown to be as much as the projected in the older trials so we have an agent which is very effective in reducing the blood pressure neutral on lipids neutral on sugar no increase in the diabetes no increase in the heart failure contrary to what was suggested and it reduces the protein so again this is one of very important thing which is which probably which makes our case very strong for the alpha blocker here the albumin creatinine ratio this again is a very important parameter and in this ascorb vpl trial and many other trials this also is shown to be significantly reduced with alpha blockers so this was an early trial echocardiographic trial where ejection fraction is shown to improve in those patients having congestive heart failure so we should not be very of using alpha blocker uh in a patient where patient is already on three drugs particularly if the heart rate is just okay say 80 i would be okay using alpha blocker 90 or something then certainly beta blocker is one of the choice another choice in this patient would have been uh aldosterone antagonist like spironolactone but in indian patients we do have to keep in mind that they as i said do not come up turn up frequently for follow-up and if you are using a spiral electron or a proline then this patient needs to be monitored for hyperkalemia every three months at least so if that patient is not able to follow that schedule then it is probably better to go for some agent which is more safe so already three drugs including active diabetic ckd is already set in heart rate is not too high as per given to me it was 80 so uh in this case we certainly have to think about uh small dose of alpha blocker probably would do wonders thank you thank you dr smith for giving a very illustrative discussion on this alpha blocker alpha blocker actually late 90s rather late 80s dr kaplan he was very fond of promoting alpha blocker and unfortunately it could not stand for long time yes abhishek your audible yeah i am extremely thankful uh for this uh home introduction as well as a uh warm welcome in addition uh i congratulate dr uh designer and dr schmitzer for uh their wonderful presentations which made my joke you are not seen on the screen uh yeah just coming let me share yes [Music] please yeah so i open the slides are these slides visible no you need to share them please click on share screen button below are you sharing stop sharing and then again click on share screen and then go share your slides yeah otherwise uh may someone from uh technical team share i will send the presentation to them also yes sir please share uh share on particular melanie yeah neelam please do needful uh in the meanwhile we can have some discussion chairpersons uh for the two presentations so that we can save time discussion can be pre-formed and yes it was a clear cut uh here in this patient uh if you want to bring down the heart rate it would be more much more to prompt this patient for doing so we have a bishop slide here abhishek you can go ahead with your presentation we will come back to discussion you have to just say change next slide and then she'll do next slide please yeah so this is the summary of uh our case is a 55 years old male 1 indonesia oh clear data the function has not been mentioned uh in this uh okay so uh i think uh from that point of view patient is uh uh stable next next slide yeah so this is the spring tile trial who emphasizes the control of systolic blood pressure to uh less than uh 140 and diastolic blood pressure to uh less than 90 which reduces the significant uh mobility and mortality next next slide so this is also emphasized doing uh next [Music] next someone please change the slide yeah so different guidelines in decision making regarding the selection of integrity so this is a jnc eight um big slide uh this is the gnc eight where they emphasize uh air vision is in the primary treatment uh next uh naturally less than ninety and seconds [Music] no [Music] within one month of treatment we should optimize the dosage and the selection class would be according to the recommendation six data isotopics calcium channel blockers arbs or ac inhibitors and if the blood pressure is not controlled then we may either the optimize drug simultaneously or uh sequentially so jnc 7 engine c8 not specifically mentions the other class of drug is a primary treatment and they they have asked to aid the alpha blockers as well as aldosterone antagonists only when the optimum dosage of these primary drugs have achieved and which is not in our case where our patient is not on the optimum dosage of other nth potentials so we need to optimize the these classes as well as we may change the molecule amongst these classes prior to switching over to other molecules like beta blockers alpha blockers or others next slide in addition regarding the beta blocker but still the as far as the anti patterns tensions are concerned the panel of jnc 8 does not recommend the beta blockers for the initial treatment of hypertension when the other drugs are not optimized this is because the beta blocker cell increase the primary composite endpoint of cardiovascular death mi stroke compared to uses of arbs or other antioxidants and with increment in uh central blood pressure these may be these beta blockers may need to increment in the risk of stroke so as per the agency eight the role of beta blocker soul is a anti potential which is uh which is required in this patient is uh not supported next slide so this is the gradient algorithm and uh the red mark suggest that we may maximize the first medication like first medication in this case maybe either ccb tell me certain 40 milligram which may we may increase to 40 milligram 80 milligram or we may change to uh high other potent arbs like uh azil certain etc or uh we may or if we are considering gamble depends as the first medication then we may either make it to uh 10 milligram a day or 10 milligram twice a day or may switch over to some newer calcium channel blockers who are highly important like benedi pin iphone ed pin or sleeping rather than uh switching over directly to alfalfa beta blocker so we may we may optimize the both drugs simultaneously next slide and uh this uh jnc8 is seven days is rather than heading next slide this is also showing the same net head and titrator next slide hello someone please change next slide next slide please the optimization of these primary drugs because primary drugs are more proven uh as far as [Music] this is the another guideline which is uh also newer as compared to jnc 8 and this is previous slide please so esc guideline was also suggesting of a control control with these primary drugs antagonist was a recommended potential flare in diabetic which is uh extremely helpful to counter the breakthrough so nice guidelines are also suggesting for optimizing the primary types other other different guidelines are also uh considering uh these primary potentials as a primary drugs and beta blockers head on therapy uh after optimization of these agents next next next slide we have experienced that for eight milligrams of benefit may control the blood pressure in uh most patients other important molecule uh in uh nta potentials as far as the ccbs is concerned is a phony pin which uh apart from uh blocking the l type of calcium internal blockers which uh amlodipine blocks is also a potent blocking agent for t type of calcium channel block the micro vessels capillary vessels as well so it leads to uh alleviation with uh is um your voice is not coming abhishek if you can listen to me your voice is not there kindly unmute your mic [Music] i think it is better we start discussing because there is some problem with the abhishek's mic and other things so let us start discussion i wish that you can join in the discussion you can give your views and everything so there are three options as i understand uh one is the beta blocker other is calcium channel blocker or third is titanium or alpha blocker so as far as i think my experience goes and i think most of the people will agree amlodipine is still the most powerful ccb rather than this newer agent they may be having less side effects but most of these the newer ccbs they are not as potent as amnesty especially if you use in the full dose then that is 20 milligram and alpha blockers uh nowadays you use in the as the last step only i think the best well just take opinion of dr bhupen desai and dr rashford pandey is also there he can also give his expert opinion and you are also there so there are so many gurmeen is also there yes so let us start discussion you can also join in this particular patient uh small dose of beta blocker would have solved all the issues uh alpha blocker like processing are quite difficult to tolerate it may cause many side effects like it may increase the resting heart rate and cause posterior hypotension also so we might create a new problem rather than solving already uh yeah i agree at 88 heart rate beta blocker is that is what we usually practice but uh if the patient's blood say heart rate is in the range of 70 then it's probably it would be good and again another choice would be is parallel inhibited for electron like that i think that also is a very very important drug which many times we forget another thing in this patient which we can do is we can sometimes switch over if expression is not on optimal voices of any medicine so we like to increase [Music] was uh just to emphasize the status of the guidelines like uh jnc8 nice and uh uh esco adding the beta blockers or alpha blocker kind of agents sold as entire potential we should optimize the dosage of uh ccbs ard arbs and thiazides so we may increase the dosage in this patient tell me certain mdp into the dosages which has been studied uh in uh trials and if we can't uh uh if we can't achieve the targeted blood pressure without optimizing the dosage of switch over to either newer agents or we may add the beta blockers or alpha blockers however still i suggest data we need to optimize and uh titrate the primary trucks other than going to uh other newer agents okay doctor you wanted yes yes thank you very much dr jesby i think uh there is no question that beta blockers is definitely drug to be referred question is whether you are which side of the table when you are discussing when you want to say about against beta blocker you use all beta blockers like catanol or something which have been proven to have side effects but the near beta blockers like pixel prolonged or navigable definitely are much better and they are no the same beta blocker that we used to see the side effects so i personally feel and as we see that the use of pizza problem and navy wallow is definitely the one which is going to help a lot all situations okay rashmi you wanted to tell something yeah i as i uh clarified in the start only if patient is having techy cardia it is not acceptable and we need to reduce it down probably uh based with either napoleon or visa caller srs3 that is i would definitely like that uh only if the patient's heart rate is controlled and still blood pressure is uh not controlled then we should not try of using alpha blockers as a catalyst we get a fairly large number of patients where patients are blood pressure is not controlled with many agents and there these alpha blockers and even clonidine which is left out in most of the trials and discussions these things are not bad you can we can use them definitely use that in alpha blocker what is your preference okay doctor why is that doctor yes sir i'm there i'm very much there doctor yes you want something else no i think i have convinced you all that everybody has agreed that this patient requires beta blocker i think if doctor smith spoke about a role of alpha blocker i fully agree if your heart it is less than 70 there is no point in adding beta block it will cause more harm but in current clinical practice i think alpha blocker comes as a fifth drug after you use first three line drugs the first choice particularly india becomes beta blocker we are all little hyper people you know we have increased sympathetic activity in our population our resting heart rate in the normal population is 82 or so there is one study called india heart study and which have found that indian people do have a higher resting heart because we are a little high in our sympathetic overactive so beta blocker is very very important in my opinion and whatever things spoken about beta blocker against it right increased incidence of stroke or increased incidence of diabetes they are with 18 not we got a bad name for the beta blockers so newer drugs like navy villal and visual are too good i mean i would say probably a very good molecule we must use it more frequently in our purpose though it has not come into guideline because there are no big randomized control trials and that is why it has not become a part of any guidelines but absence of data does not mean the drug does not deserve its right place and guidelines are not guidelines guidelines are not guidelines we have to use our own clinical judgment and we can use in our population beta blocker our president also wanted to tell something yes sir your mic is mute your mic is mute yeah yeah yeah visoprolol basically is a very old molecule is not a new molecule and unfortunately it is a european molecule so it was never used much in usa that is why visible only used less otherwise it's a wonderful molecule i have used for last 30 years almost and it is given a wonderful reason we are publishing our own tenacity investigator initiated study which is part of the e-poster today uh in the session we published and it's going to be published in europe in our journal as well we have looked at in acute coronary syndrome however it's not in the settings of hypertension but because you were mentioning about beta blockers i think uh heart rate is an important determinant here but for alpha blockers we do have a strong role uh especially in patients with ckd and patients with already uh having diabetes these two are the subgroups where you can still not completely rule out alpha blockers and newer ccbs do have good evidence as far as egfr and kidney protection is concerned but i think cv outcomes as i think uh uh both the speaker guppies and rashford they pointed out is something that people will be able to have to look as the time comes and the data evolves so because there are many agents many drugs which they come and go they come with a big o and then they are thrown into dustbin because of many side effects on all these so any new agents whatever however promising it is unless it is shown to be effective and safe in large trials we senior consultants would definitely be very of using them yeah there i fully agree with there are no convincing data about any of the newer ccvs or any of the newer arbs there's no convincing data i think their market in india because this regular drug like mktp has gone into price control so companies are not making any money out of it so they come up with some uh fancy newer calcium channel blockers at five times the cost of mrdp so in spite of having so many issues actually uh in transfer transferring your wishex messages and everything we could conclude that yes the discretion is lying with the physician and cardiologist what to use when to use how to use and what rules and everything


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