CLINICAL EXPOSURE VI

ASSIGNMENT

Steven Matuali
07120110055

Faculty of Medicine
Universitas Pelita Harapan

According to Standar Kompetensi Dokter Indonesia (SKDI) there is a list of

cardiovascular disease each with difference level of competence. The list below is
SKDI list of cardiovascular disease with competence level of 3 and above (3A, 3B, 4
and 4A)

Shock (septic, hypovolemic, cardiogenic, neurogenic)

Angina pectoris
Myocardial infraction
Heart failure
Cardiorespiratory arrest
Tachycardia (Supraventricular, ventricular)
Atrial fibrillation
Ventricular fibrillation
Atrial flutter
Extrasystole (Supraventricular, ventricular)
Cor pulmonale
Primary hypertension
Secondary hypertension

Shock
Septic shock (due to infections, Identified etiology of SIRS)
Hypovolemic shock (too little blood volume usually by massive blood loss)
Cardiogenic shock (due to heart problems)
Neurogenic shock (caused by damage to the nervous system usually trauma)
Primary prevention:
Septic shock: give extra attention in patient with greater risk for sepsis, patient under
chemotherapeutic drugs, malignancy, burns, severe trauma (open wound), DM,
advance age. Ventilatory support and invasive catheters further increase the risk of
infection. Avoiding the use of catheters or removing them as soon as possible may
prevent severe sepsis. Prophylactic antibiotics in the perioperative phase, particularly
after GI surgery, may be beneficial. The use of topical antibiotics around invasive
catheters and as part of dressings for patients with burns is helpful.
Hypovolemic shock: prevention of injury or further injury. Transport the patient to
the hospital as rapidly as possible, and initiate appropriate treatment in the field.
Direct pressure should be applied to external bleeding vessels to prevent further blood
loss. Splinting of fractures can minimize further neurovascular injury and blood loss.
immobilizing the patient (if trauma is involved), securing an adequate airway,

ensuring ventilation, and maximizing circulation.

Cardiogenic shock: Control high blood pressure (hypertension). Exercising,
managing stress,maintaining a healthy weight, and limiting salt and alcohol. Ask a
doctor whether you need to prescribe medications to treat hypertension. Maintain a
healthy weight. Lower the cholesterol and saturated fat in your diet. Exercise
regularly. Stop smoking. Regulary take medicine prescribe by doctor to treat preexisting condition especially condition that increase the risk of getting heart disease.
Neurogenic shock: There is no way to prevent neurogenic shock from occurring
other than to avoid any severe injuries that may cause damage to the nervous system.
Falls, accidents, and other traumas can be difficult to prevent, however. Use safety
precautions whenever possible. Immobilize the spine. Admit the patient to hospital as
fast as possible.
Secondary prevention:
Septic shock: Check the ABCDE (airway, breathing, circulation, disability,
exposure). Whether it meets the criteria of septic shock. If it meets, the treatment of
patients with septic shock has the following major goals: Start adequate antibiotic
therapy (proper dosage and spectrum) as early as possible. Resuscitate the patient,
using supportive measures to correct hypoxia, hypotension, and impaired tissue
oxygenation (hypoperfusion). Identify the source of infection, and treat with
antimicrobial therapy, surgery, or both (source control). Maintain adequate organ
system function, guided by cardiovascular monitoring, and interrupt the progression
to multiple organ dysfunction syndrome (MODS)
Hypovolemic shock: Check the ABCDE. Whether it meets the criteria of
hypovolemic shock. If it meets, maximize the oxygen delivery. Resuscitation.
Controlling further blood loss. Restoring normal circulating volume and BP prior to
definitive control of bleeding.
Cardiogenic shock: Check the ABCDE. Whether it meets the criteria of cardiogenic
shock. If it meets, initial management includes fluid resuscitation to correct
hypovolemia and hypotension, unless pulmonary edema is present. Oxygenation and
airway protection are critical; intubation and mechanical ventilation are commonly
required. All patients with cardiogenic shock require close hemodynamic monitoring,

volume support to ensure adequate sufficient preload, and ventilatory support.

Medication may include: Aspirin. Aspirin reduces blood clotting and helps keep your
blood flowing through a narrowed artery. Thrombolytics, this medicine help dissolve
a blood clot that's blocking blood flow to your heart. Clopidogrel and medications
called platelet glycoprotein IIb/IIIa receptor blockers, which are given intravenously.
You'll likely be given other medications, such as heparin, to make your blood less
likely to form clots. IV or injectable heparin usually is given during the first few days
after a heart attack. Inotropic agents. You may be given medications, to improve and
support your heart function until other treatments start to work.
Medical procedures to treat cardiogenic shock usually focus on restoring blood flow
through your heart. Angioplasty and stenting, if a blockage is found during a cardiac
catheterization, your doctor can insert a long, thin tube (catheter) equipped with a
special balloon through an artery, usually in your leg, to a blocked artery in your
heart. Once in position, the balloon is briefly inflated to open the blockage. A metal
mesh stent may be inserted into the artery to keep it open over time. In most cases,
you doctor will place a stent coated with a slow-releasing medication to help keep
your artery open.
Surgery
If medications and medical procedures don't work to treat cardiogenic shock, your
doctor may recommend surgery. Coronary artery bypass surgery. This involves
sewing veins or arteries in place at a site beyond a blocked coronary artery. Surgery to
repair an injury to your heart.
Neurogenic shock: Check the ABCDE. Whether it meets the criteria of neurogenic
shock. If it meets, firstly, the patients condition should be stabilised by paying
attention to the airway, breathing and circulation. The spine should be immobilised to
avoid further damage. The blood pressure should be brought up by giving intravenous
fluids and drugs like dopamine and dobutamine. In severe bradycardia, a drug called
atropine can be given. Intravenous steroids should be started if neurological signs are
seen. A neurologist or an orthopaedic surgeon should assess the injury, and if needed,
surgery should be undertaken in a well-equipped hospital with intensive care facilities
available.

Tertiary prevention:
The main idea of tertiary prevention in shock is to monitor and follow up the patients
ABCDE. Make sure to give patient the optimum dose of drugs, oxygen, fluid
resuscitation to treat each condition for optimal results. For patient in cardiogenic
shock, doctors should educate them to control their body weight, blood pressure,
glucose and cholesterol levels, healthy eating, regular exercise and to stop smoking
and consume alcohol since they are at higher risk of developing other heart problem
or repeated heart problem. Treatment of risk factors (hypertension, diabetes mellitus,
obesity, hyperlipidemia). For patient that undergo surgery make sure the surgery
undergoes in proper place and preparation to prevent any unwanted complication.
Beware of deep vein thrombosis(DVT) since the patient is immobilize for quite a long
time.
Angina pectoris (Myocardial ischemia) and Myocardial infarction

Non-modifiable risk factors: Increasing age, gender, ethnic groups, positive

family history

Modifiable risk factors:

hypertension, obesity

Smoking,

diabetes

mellitus,

dyslipidemia,

Primary prevention:
The main goal of primary prevention is to cut of the modifiable risk factors. Educate
the patient to stop smoking, control the blood glucose, cholesterol, pressure levels and
body weight by doing regular exercise and eating healty, to take medication indicated
by doctors to treat pre-existing abnormal metabolic condition. Reduce stress level.
Regularly check the possible risk factors especially in older person.
Secondary prevention:
Estimate the cardiovascular disease risk by using score such as TIMI Risk Score for
UA/NSTEMI, Grace ACS Risk Score and Mortality, Heart Score for Major Cardiac
Events and TIMI Risk Score for STEMI. If patient is at high risk doctors should do
some several test: Full blood count, serum creatinine, eGFR, glucose and lipid profile,
cardiac enzymes (CK-MB, troponin T and I), thyroid function test, ECG, angiogram,
Stress Test. Stabilize the vital sign. Check ABCDE
Treatment

Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels,
allowing more blood to flow to your heart muscle.
Aspirin. Aspirin reduces the ability of blood to clot, making it easier for blood to flow
through narrowed heart arteries.
Clot-preventing drugs. Certain medications such as clopidogrel (Plavix can help
prevent blood clots from forming by making platelets less likely to stick together.
Beta blockers work by blocking the effects of the hormone epinephrine, also known
as adrenaline. As a result, the heart beats more slowly and with less force, reducing
blood pressure.
Statins. Statins are drugs used to lower blood cholesterol. They may also help your
body reabsorb cholesterol that has accumulated in plaques in your artery walls,
helping prevent further blockage in your blood vessels.
Calcium channel blockers. Calcium channel blockers, also called calcium antagonists,
relax and widen blood vessels by affecting the muscle cells in the arterial walls. This
increases blood flow in your heart, reducing or preventing angina.
Medical procedures and surgery
Angioplasty and stenting and Coronary artery bypass surgery
Tertiary prevention
Stop smoking.
Eat a healthy diet
Talk to your doctor about starting a safe exercise plan.
If you're overweight, talk to your doctor about weight-loss options.
Regularly take your medications as prescribed and follow your doctor's directions.
Treat diseases or conditions that can increase your risk of the disease, such as
diabetes, high blood pressure and cholesterol. And regulary check them
Symptoms usually arise by exertion, pace and take rest. Try to find ways to relax.
Avoid large meals that make you feel overly full
For patient that undergo surgery make sure the surgery undergoes in proper place

and preparation to prevent any unwanted complication. Beware of deep vein

thrombosis(DVT) since the patient is immobilize for quite a long time.
Heart Failure
Risk factors: High blood pressure, coronary artery disease, heart attack, diabetes,
chronic anemia, some diabetes medications such as rosiglitazone and pioglitazone,
sleep apnea, congenital heart defects, viruses, alcohol, family history.
Primary prevention:
Life style modification. Educate the patient to stop smoking, control the blood
glucose, cholesterol, pressure levels and body weight by doing regular exercise and
eating healty, to take medication indicated by doctors to treat pre-existing disease that
could increase the risk of getting heart failure.Cut down the risk factor. Reduce stress.
Regularly check your heart and other possible risk factors especially in older person.
Secondary prevention:
Check the ABCDE. Classify the heart failure using NYHA or AHA scale and order
diagnostic testing such as Full blood count, creatinine, eGFR, glucose and lipid
profile, cardiac enzymes (CK-MB, troponin T and I), thyroid test, ECG,
echocardiogram, chest X-ray, Ct-scan, angiogram, Stress Test.
Treatment: Angiotensin II receptor blockers (for people who cannot tolerate ACE
inhibitor), Digoxin (to make heart pump harder) Beta blockers, Diuretics (for the
edema and volume overload), Inotropes (to improve heart pumping function and
maintain blood pressure) You'll probably need to take two or more medications to
treat heart failure. Other heart medications as such as nitrates for chest pain, and
drugs to lower cholesterol or blood-thinning medications to help prevent blood clots
Medical procedure and surgery: Coronary artery bypass surgery, heart valve repair or
replacement, heart transplant
Tertiary prevention: Almost the same as above in myocardial ischemia and
infarction.
Cardiorespiratory arrest
Modifiable risk factor: smoking, high blood pressure, high blood cholesterol, obesity,
diabetes, sedentary lifestyle, alcohol, drugs such as cocaine or amphetamines, low

potassium or magnesium nutrition.

Non-modifiable risk factor: previous episode of cardiac arrest or heart attack or other
heart disease and family history of heart disease, age (>45 for male, >55 for female)
and male are more susceptible than female.
Primary prevention:
Cut down the modifiable risk factor to minimize the risk of getting cardiac arrest
specially for those who already have non-modifiable risk factor. Healthy life style and
diet. Treat pre-existing condition that could increase the risk of getting cardiac arrest
or any heart disease. Reduce stress. Regularly check your heart and other possible risk
factors especially in older person.
Secondary prevention:
Check the ABCDE. If the patient is unconscious give CPR immediately. Defibrillation
for ventricular fibrillation. Order diagnostic testing such as ECG, full blood count,
creatinine, eGFR, glucose and lipid profile, cardiac enzymes (CK-MB, troponin T and
I), electrolyte, drugs test, thyroid test, angiogram, chest x-ray. therapeutic
hypothermia (cooling to prevent injury to vital organs).
Treatment: beta blocker, ACE inhibitor, calcium channel blocker (anti-arrhythmia)
Medical procedure and surgery: implantable cardioverter-defibrillator (ICD). The ICD
constantly monitors your heart rhythm. If it detects a rhythm that's too slow, it paces
your heart as a pacemaker would. Coronary angioplasty. Coronary artery bypass
surgery.
Tertiary prevention:
Repeat the primary prevention, regularly take the anti-arrhythmia as the doctor
prescribe, undergo implantable cardioverter-defibrillator (ICD) to prevent another
cardiac arrest, buy an automated external defibrillator (AED), tell people you live
together to train how to do CPR. Beware of DVT after surgery

Tachycardia (Supraventricular and ventricular)

Modifiable risk factor: Heart disease, high blood pressure, smoking, heavy alcohol
and caffeine use, use of recreational drugs, psychological stress or anxiety and anemia

Non-modifiable risk factor: family history of heart rhythm or disease and age.
Primary prevention:
Cut down the modifiable risk factor to minimize the risk of getting Tachycardia
specially for those who already have non-modifiable risk factor. Healthy life style and
diet. Treat pre-existing condition that could increase the risk of getting tachycardia or
any heart disease. Reduce stress. Limit caffeine intake. Regularly check your heart
and other possible risk factors especially in older person.
Secondary prevention:
Check the ABCDE. Order ECG. Tilt table test. Give oxygen
Treatment: beta blocker, ACE inhibitor, calcium channel blocker (anti-arrhythmia)
Medical procedure and surgery: Catheter ablation. This procedure is often used when
an extra electrical pathway is responsible for an increased heart rate. Electrodes at the
catheter tips can use heat, extreme cold or radiofrequency energy to damage (ablate)
the extra electrical pathway and prevent it from sending electrical signals.
Pacemaker. A pacemaker is a small device that's surgically implanted under your skin.
When the device senses an abnormal heartbeat, it emits an electrical pulse that helps
the heart resume a normal beat.
Implantable cardioverter-defibrillator (ICD)
Open-heart surgery may be needed to destroy an extra electrical pathway.
Tertiary prevention:
Repeat the primary prevention. Some people with tachycardia have an increased risk
of developing a blood clot that could cause a stroke or heart attack. Your doctor may
prescribe a drug-thinning medication, such as warfarin. Regularly take antiarrhythmia drugs as prescribe by the doctor and undergo medical procedure in
secondary prevention to prevent another episode of tachycardia. Beware of DVT after
surgery.
Atrial fibrillation and atrial flutter
Risk factors: Age, heart disease, high blood pressure, thyroid problems, sleep apnea,
metabolic syndrome, diabetes, chronic kidney disease or lung disease, drinking
alcohol, obesity, family history of atrial fibrillation or other heart disease.

Primary prevention:
Cut down the modifiable risk factor to minimize the risk of getting Tachycardia
specially for those who already have non-modifiable risk factor. Healthy life style and
diet. Treat pre-existing condition that could increase the risk of getting atrial
fibrillation or any heart disease. Reduce stress. Limit caffeine intake. Regularly check
your heart and other possible risk factors especially in older person.
Secondary prevention:
Check the ABCDE. Order ECG, echocardiogram, thyroid test, chest x-ray.
Generally, the treatment goals for atrial fibrillation are to: reset the rhythm or control
the rate and to prevent blood clots
Treatment: beta blocker, ACE inhibitor, calcium channel blocker (anti-arrhythmia),
digoxin.
Medical procedure and surgery: Electrical cardioversion, an electrical shock is
delivered to your heart through paddles or patches placed on your chest. The shock
stops your heart's electrical activity momentarily. When your heart begins again, the
hope is that it resumes its normal rhythm.
Catheter ablation or AV node ablation
Surgical maze procedure. Using a scalpel, doctors create several precise incisions in
the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue
doesn't carry electricity, it interferes with stray electrical impulses that cause atrial
fibrillation.
Tertiary prevention:
Repeat the primary prevention. Regularly take the drugs such as anti-arrhythmia,
digoxin, warfarin as the doctor prescribe and undergo medical procedure to prevent
another episode of atrial fibrillation and to prevent blood clots.
Ventricular fibrillation
Modifiable risk factor: smoking, high blood pressure, high blood cholesterol, obesity,
diabetes, sedentary lifestyle, alcohol, drugs such as cocaine or amphetamines, low
potassium or magnesium nutrition.

Non-modifiable risk factor: previous episode of ventricular fibrillation or other heart

disease and family history of heart disease.
Primary prevention:
Cut down the modifiable risk factor to minimize the risk of getting ventricular
fibrillation specially for those who already have non-modifiable risk factor. Healthy
life style and diet. Treat pre-existing condition that could increase the risk of getting
ventricular fibrillation or any heart disease. Reduce stress. Regularly check your heart
and other possible risk factors especially in older person.
Secondary prevention:
Check the ABCDE. Emergency treatment CPR and defibrillation. Order diagnostic
testing such as ECG, full blood count, creatinine, eGFR, glucose and lipid profile,
cardiac enzymes (CK-MB, troponin T and I), electrolyte, drugs test, angiogram, chest
x-ray.
Treatment: beta blocker, ACE inhibitor, calcium channel blocker (anti-arrhythmia)
Medical procedure and surgery: implantable cardioverter-defibrillator (ICD) Coronary
angioplasty. Coronary artery bypass surgery.
Tertiary prevention:
Repeat the primary prevention, regularly take the anti-arrhythmia as the doctor
prescribe, undergo implantable cardioverter-defibrillator (ICD) to prevent another
cardiac arrest, buy an automated external defibrillator (AED), tell people you live
together to train how to do CPR. Beware of DVT after surgery

Extrasystole (Supraventricular and ventricular)

Risk factors: Can occur in normal hearts, where the prevalence of extrasystoles
increases with age, hypertension, heart disease (including acute myocardial infarction,
valvular heart disease, cardiomyopathy, ventricular hypertrophy and cardiac failure),
electrolyte disturbances (hypokalaemia, hypomagnesemia, hypercalcaemia), drugs,
(digoxin, aminophylline, tricyclic antidepressants, cocaine, amphetamines), alcohol
excess, infection, stress, surgery, hyperthyroid and caffeine may have a role.
Primary prevention:
Cut down the modifiable risk factor to minimize the risk of getting extrasystole
specially for those who already have non-modifiable risk factor. Healthy life style and

diet. Treat pre-existing condition that could increase the risk of getting extrasystole or
any heart disease. Reduce stress. Regularly check your heart and other possible risk
factors especially in older person.
Secondary prevention:
Check the ABCDE. Initial investigations are ECG, complete blood count, thyroid test,
electrolytes, serum calcium and magnesium, echocardiography, exercise stress testing,
chest x-ray.
Management: Low-risk patients with no other cardiac problems and no symptoms (or
minor symptoms only) can be reassured. Other patients (those with cardiac disease,
cardiac risk or significant symptoms) will usually need further assessment, treatment
or follow-up. Treatment options are: Drugs - beta-blockers (eg, atenolol, metoprolol).
Radiofrequency catheter ablation of the ectopic focus (in suitable cases). Patients with
a high intake of caffeine or other stimulants may be advised to try reducing their
intake, to see whether or not this improves their symptoms or the extrasystoles.
Management of atrial extrasystoles
- If symptoms are troublesome, try beta-blockers (atenolol or metoprolol).
- Atrial extrasystoles arising from the pulmonary veins may be treatable by the
procedure of pulmonary vein isolation.
- Catheter ablation
Management of ventricular extrasystoles
Depends on:Whether there is underlying heart disease. Patients with no
symptoms/minor symptoms only - no heart disease (including normal LV function),
infrequent ventricular extrasystoles, these patients can be reassured.
Reducing caffeine intake (if high) can be tried to see if this reduces symptoms. If
treatment is desired, consider beta-blockers.
Patients with no heart disease, but with frequent ventricular extrasystoles No
treatment is required, but these patients may merit long-term follow-up, with periodic
reassessment of LV function, particularly for those with very high-frequency
extrasystoles.
Patients with no heart disease, with frequent unifocal ventricular extrasystoles and
particularly if ventricular tachycardia or salvos is induced on exercise: Consider
catheter ablation - this may be curative and results are often good.
Patients with cardiac disease: Ventricular extrasystoles may indicate either an

arrhythmia risk or the severity of the underlying disease; therefore, consider the level
of risk for sudden cardiac death. Beta-blockers may be indicated either for the
underlying cardiac disease, or because they may reduce the frequency or symptoms of
ventricular extrasystoles. Consider implantable cardiac defibrillators if at high risk of
serious ventricular arrhythmia. Consider catheter ablation as adjunctive treatment.
Also treat any underlying cardiac disease and contributing factors - eg, hypertension,
electrolyte abnormalities, ischaemia or cardiac failure.
Tertiary prevention:
Repeat the primary prevention, regularly take the medication as the doctor prescribe,
undergo medical procedure if the doctor tell that your condition needed other medical
procedure to prevent future extrasystole that could lead to other dangerous condition
such as fibrillation. Try to limit the caffeine intake and see if anything gets better.
Treat other cardiac disease and contributing factors if you have one. Beware of DVT
after surgery.
Cor pulmonale (Acute and chronic)
Primary prevention:
Although anyone can develop either type of pulmonary hypertension, older adults are
more likely to have secondary pulmonary hypertension, and young people are more
likely to have idiopathic pulmonary hypertension. Idiopathic pulmonary hypertension
is also more common in women. Some genes could be linked to idiopathic pulmonary
hypertension. These genes might cause an overgrowth of cells in the small arteries of
your lungs, making them narrower. If one of your family members develops
idiopathic pulmonary hypertension and tests positive for a gene mutation, your doctor
or genetic counselor may recommend that you or your family members be tested for
the mutation. Healthy life style (exercise, eating, doesnt smoke and consume alcohol,
low stress level) is a good way to prevent this disease.
Secondary prevention:
Asses the ABCDE. A physical exam may reveal abnormal heart rhythms, fluid
retention, and protruding neck veins. Your doctor will also need to perform CBC,
blood tests to detect antibody levels and brain natriuretic peptide Brain natriuretic
peptide is an amino acid made in the heart. Testing will also include: CT scans, ECG,
echocardiogram, chest X-ray lpha-1 antitrypsin levels if considered relevant,
thrombophilia screen if there is suspected chronic venous thromboembolism (proteins

C and S, antithrombin III, factor V Leiden, anticardiolipin antibodies, homocysteine

levels)
Management
Acute cor pulmonale is treated by trying to rapidly correct the underlying precipitant,
which is often acute pulmonary embolism or an infective exacerbation of COPD.
Standard treatment for these conditions is used in an attempt to correct the underlying
cause of acute right heart failure. Similarly, in chronic cor pulmonale, treatment of the
underlying cause is combined with specific management as below: Long-term oxygen
therapy (LTOT)/nocturnal oxygen therapy (NOT), diuretics such as furosemide and
bumetanide, vasodilators such as nifedipine and diltiazem, inotropic drugs(diazepam),
methylxanthine bronchodilators such as theophylline, anticoagulation, venesection,
Transplantation of heart/lung.
Tertiary prevention:
Repeat the primary prevention. Get plenty of rest. Avoid becoming pregnant or using
birth control pills. Avoid traveling to or living at high altitudes. Avoid situations that
can excessively lower blood pressure, these include sitting in a hot tub or sauna or
taking long hot baths or showers. Take medication or undergo medical procedure as
the doctor prescribe or told to.
Hypertension (Primary and Secondary)
Primary prevention:
Genetic factors may play a role in essential hypertension. Essential hypertension is
four times more common in black than white people. Diet, stress, smoking, alcohol,
drugs and being overweight may increase your risks of developing primary
hypertension hypertension. The greatest risk factor for having secondary hypertension
is having a medical condition that can cause high blood pressure, such as kidney,
artery, heart or endocrine system problems. Healthy life style (exercise, eating,
doesnt smoke and consume alcohol, low stress level) is a good way to prevent
hypertension. Regularly check your blood pressure especially in older person.
Regularly take medication of pre-existing condition that may cause secondary
hypertension regularly.
Secondary prevention:
Measure the vital signs. Stage the hypertension whether it is pre-hypertension,

hypertension stage I or stage II. Order a blood test, CBC, potassium and sodium level,
total cholesterol and triglycerides, blood glucose. Urinalysis. ECG. Find if theres any
other disease that may cause secondary hypertension and do appropriate diagnostic
test.
Medication: The following are drug class recommendations for compelling
indications based on various clinical trials
Heart failure: diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antagonist
Postmyocardial infarction: beta-blocker, ACE inhibitor, aldosterone antagonist
High coronary disease risk: diuretic, beta-blocker, ACE inhibitor, CCB
Diabetes: diuretic, beta-blocker, ACE inhibitor, ARB, CCB
Chronic kidney disease: ACE inhibitor, ARB
Treatment can sometimes be complicated. You may need more than one medication
combined with lifestyle changes to control your high blood pressure. The most
common medication include: beta blockers, calcium channel blockers, angiotensinconverting enzyme (ACE) inhibitors, angiotensin II receptor blockers, renin
inhibitors.
Treat pre-existing condition that may contribute a secondary hypertension such as
diabetes, heart disease, kidney disease.
Tertiary prevention:
Hypertension is a lifelong disorder. For optimal control, a long-term commitment to
lifestyle modifications and pharmacologic therapy is required. The Seventh Report of
the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure (JNC 7) recommendations to lower blood pressure (BP) and
decrease cardiovascular disease risk include the following, with greater results
achieved when 2 or more lifestyle modifications are combined:
- Weight loss helps to prevent hypertension (range of approximate systolic BP
reduction [SBP], 5-20 mm Hg per 10 kg); recommendations include the DASH
(Dietary Approaches to Stop Hypertension) diet (range of approximate SBP reduction,
8-14 mm Hg), which is rich in fruits and vegetables and encourages the use of fat-free
or low-fat milk and milk products
- Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men (ie, 24

oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100-proof whiskey) or
0.5 oz (15 mL) of ethanol per day for women and people of lighter weight (range of
approximate SBP reduction, 2-4 mm Hg)
- Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium or 6 g sodium
chloride; range of approximate SBP reduction, 2-8 mm Hg)[6]
- Maintain adequate intake of dietary potassium (approximately 90 mmol/d)
- Maintain adequate intake of dietary calcium and magnesium for general health
- Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall
cardiovascular health
-Engage in aerobic exercise at least 30 minutes daily for most days (range of
approximate SBP reduction, 4-9 mm Hg)
Regularly take anti-hypertensive medication as the doctors prescribe and regularly
measure the BP. If you are secondary hypertensive patient with other pre-existing
disease, regularly consume the medication prescribe by the doctor and asses it.