Question from Audience: Sir, from the morning, we have heard lectures on the basics of hypertension and also the panelist have talked about it, but nobody has talked especially about stress and it is effect on hypertension or coronary artery disease and the interaction. Is it that we talk about it only when we have episodes or events in cardiologist or physicians who have these cardiovascular events. I mean that is one issue. The second thing is, Dr. Hiremath very rightly said in the secondary prevention beta-blockers with ACE inhibitors or ARBs should be the drugs of choice. If that is so, suppose we get a big amount of patients in the age group of around 30 with a very strong family history of coronary artery disease who were only hypertensive and dyslipidemic.
Dr. Siddharth Shah: In Mumbai, every one has got stress, but acute stress does cause problems and that acute stress has to be managed, it does cause problem.
I think Dr. Kasliwal is known for his lifestyle modification, what do you think about the stress and hypertension.
Dr. R. R. Kasliwal: Absolutely correct, what you said acute stress can to the extent cause dissection of aorta because of huge rises in pressure, but truly in the environment that we all are, whether it is Mumbai or Delhi or wherever, there is huge chronic stress and that actually adds to the other co-existing risk factors of the psychosocial stress with cigarette smoking or obesity or metabolic syndrome. I think that is what we are talking about and why no body talked about individually because it was clumped as lifestyle measures, so I think that chronic stress has definitely contributed towards increase of blood pressure and its aftermath.
Dr. Satyavan Sharma: Let me define your question, the question which you asked. There are two aspects of stress; one is the role of stress in causation of chronic diseases. Right, I do not think any one of us was allowed to speak on that, so nobody touched it. What you are trying to ask is the role of stress as a trigger in some short of acute coronary syndromes or in short of some acute situations. Now, these are completely two different things. Stress plays a role in triggering many acute coronary syndromes, sudden cardiac death, acute hypertensive episodes, but that is different than the role of stress and causation of hypertension, causation of diabetes, and causation of coronary artery disease, so these are two different areas.
Dr. C. Venkata S. Ram: I think we talked about heart rate, the role of ivabradine and outcomes.
Dr. Ravi Kasliwal: If there is hypertension and increased heart rate, there is no role of ivabradine, beta-blocker should be given, nebivolol, bisoprolol what ever your choice is.
Dr. M.S. Hiremath: Suppose it is hypertension with bronchial asthma and tachycardia?
Dr. Ravi Kasliwal: If it is hypertension with bronchial asthma, still bisoprolol is a better choice than to give ivabradine.
Dr. C. Venkata S. Ram: There are no comparative studies between chlorthalidone and indapamide, but there are comparable outcomes studies with the drugs. With indapamide, I think somebody has mentioned the HYVET, PROGRESS, EUROPA. With chlorthalidone SHEP, SHEP extension, so they are separate, nobody has compared chlorthalidone with indapamide. Anybody wants to differ?
Dr Kunal Kothari: One comment, I would like to know what happens say continued use of diuretic particularly in elderly has been advocated. Is there are any role of giving twice a week or once a week or twice a week giving diuretic and taking care.
Dr. C. Venkata S. Ram: Let me tell you one comment I have and then we will go to the goal pulse pressure, what happens with the diuretics is the volume reduction that happens, it only happens initially. With long-term diuretic therapy, the volume comes back to baseline, so the continued use of a diuretic does not mean you cause continued volume depletion because if you cause continued volume depletion, there is a consequence, known as death, people die with continued volume depletion, so what happens is volume goes down, but it comes back again, so other mechanism that is coming into play. Now, Ravi, are there any guidelines for goal pulse pressure.
Dr. R. R. Kasliwal: I do not think so. The only thing they have eluded to is in the European Society Guidelines, but not to that extent, I think systolic and diastolic.
Dr. C. Venkata S. Ram: I will ask one question, where you can also comment, for Dr. Shah. Hypotension, I do not know how one defines this is hypotension. Do you want to treat it with sodium intake.
Dr. Siddharth Shah: First of all comment is that hypotension is not a known entity. It has been conjured up to and I do not think hypotension is a relative term and if it is due to drug, then it has to be treated; otherwise, hypotension per se does not exist.
Dr. C. Venkata S. Ram: Sodium treatment for hypotension is only for people who have adrenal insufficiency. People who have adrenal insufficiency, if you do not give sodium supplements, they are going to very, very ill.
Dr. M.S. Hiremath: Incidentally, there is something like tablet Mephentine, which is available in the market.
Dr A N Rai: I think one should treat the underlying cause of hypotension, not the sodium supplementation.
Dr. N.R. Rau: I think best way hypotension be seen in clinical practice, now that summer is coming, acute gastroenteritis, then we start with treatment.
Dr A N Rai: Treat the underlying cause.
Dr. C. Venkata S. Ram: Multiple medicines, the blood pressure is not controlled, the next option? Let us presume the patient is compliant, let us not question patient's compliance, because then there is no discussion.
Dr A N Rai: Sympathic renal denervation is the one for resistant hypertension.
Dr. C. Venkata S. Ram: And proper use of aldosterone antagonist.
Dr. Santanu Guha: It is mentioned that if the patient has not received the aldosterone antagonist whether he has resistant hypertension it is a question.
Dr. M.S. Hiremath: I think we should go further to eplerenone also.
Dr. C. Venkata S. Ram: In fact, some other renal denervation studies have been criticized that the patients were inducted into RDN trial without sufficient exposure to spironolactone. Dr. Hiremath mentioned the renal denervation does reduce heart rate, but Dr. Kasliwal will be pleased to know that it also has been shown to decrease pulse wave velocity, so multiple things happen.
Dr. M.S. Hiremath: I think sleep apnea, which correlates so much with hypertension that also is expected to benefit with RDN therapy.
Dr. C. Venkata S. Ram: What is this, nobody asking from the right side, this is like Lok Sabha or something, only one section is voiceless, what happened right side. We want some balance.
Dr. Siddharth Shah: In Mumbai, every one has got stress, but acute stress does cause problems and that acute stress has to be managed, it does cause problem.
I think Dr. Kasliwal is known for his lifestyle modification, what do you think about the stress and hypertension.
Dr. R. R. Kasliwal: Absolutely correct, what you said acute stress can to the extent cause dissection of aorta because of huge rises in pressure, but truly in the environment that we all are, whether it is Mumbai or Delhi or wherever, there is huge chronic stress and that actually adds to the other co-existing risk factors of the psychosocial stress with cigarette smoking or obesity or metabolic syndrome. I think that is what we are talking about and why no body talked about individually because it was clumped as lifestyle measures, so I think that chronic stress has definitely contributed towards increase of blood pressure and its aftermath.
Dr. Satyavan Sharma: Let me define your question, the question which you asked. There are two aspects of stress; one is the role of stress in causation of chronic diseases. Right, I do not think any one of us was allowed to speak on that, so nobody touched it. What you are trying to ask is the role of stress as a trigger in some short of acute coronary syndromes or in short of some acute situations. Now, these are completely two different things. Stress plays a role in triggering many acute coronary syndromes, sudden cardiac death, acute hypertensive episodes, but that is different than the role of stress and causation of hypertension, causation of diabetes, and causation of coronary artery disease, so these are two different areas.
Dr. C. Venkata S. Ram: I think we talked about heart rate, the role of ivabradine and outcomes.
Dr. Ravi Kasliwal: If there is hypertension and increased heart rate, there is no role of ivabradine, beta-blocker should be given, nebivolol, bisoprolol what ever your choice is.
Dr. M.S. Hiremath: Suppose it is hypertension with bronchial asthma and tachycardia?
Dr. Ravi Kasliwal: If it is hypertension with bronchial asthma, still bisoprolol is a better choice than to give ivabradine.
Dr. C. Venkata S. Ram: There are no comparative studies between chlorthalidone and indapamide, but there are comparable outcomes studies with the drugs. With indapamide, I think somebody has mentioned the HYVET, PROGRESS, EUROPA. With chlorthalidone SHEP, SHEP extension, so they are separate, nobody has compared chlorthalidone with indapamide. Anybody wants to differ?
Dr Kunal Kothari: One comment, I would like to know what happens say continued use of diuretic particularly in elderly has been advocated. Is there are any role of giving twice a week or once a week or twice a week giving diuretic and taking care.
Dr. C. Venkata S. Ram: Let me tell you one comment I have and then we will go to the goal pulse pressure, what happens with the diuretics is the volume reduction that happens, it only happens initially. With long-term diuretic therapy, the volume comes back to baseline, so the continued use of a diuretic does not mean you cause continued volume depletion because if you cause continued volume depletion, there is a consequence, known as death, people die with continued volume depletion, so what happens is volume goes down, but it comes back again, so other mechanism that is coming into play. Now, Ravi, are there any guidelines for goal pulse pressure.
Dr. R. R. Kasliwal: I do not think so. The only thing they have eluded to is in the European Society Guidelines, but not to that extent, I think systolic and diastolic.
Dr. C. Venkata S. Ram: I will ask one question, where you can also comment, for Dr. Shah. Hypotension, I do not know how one defines this is hypotension. Do you want to treat it with sodium intake.
Dr. Siddharth Shah: First of all comment is that hypotension is not a known entity. It has been conjured up to and I do not think hypotension is a relative term and if it is due to drug, then it has to be treated; otherwise, hypotension per se does not exist.
Dr. C. Venkata S. Ram: Sodium treatment for hypotension is only for people who have adrenal insufficiency. People who have adrenal insufficiency, if you do not give sodium supplements, they are going to very, very ill.
Dr. M.S. Hiremath: Incidentally, there is something like tablet Mephentine, which is available in the market.
Dr A N Rai: I think one should treat the underlying cause of hypotension, not the sodium supplementation.
Dr. N.R. Rau: I think best way hypotension be seen in clinical practice, now that summer is coming, acute gastroenteritis, then we start with treatment.
Dr A N Rai: Treat the underlying cause.
Dr. C. Venkata S. Ram: Multiple medicines, the blood pressure is not controlled, the next option? Let us presume the patient is compliant, let us not question patient's compliance, because then there is no discussion.
Dr A N Rai: Sympathic renal denervation is the one for resistant hypertension.
Dr. C. Venkata S. Ram: And proper use of aldosterone antagonist.
Dr. Santanu Guha: It is mentioned that if the patient has not received the aldosterone antagonist whether he has resistant hypertension it is a question.
Dr. M.S. Hiremath: I think we should go further to eplerenone also.
Dr. C. Venkata S. Ram: In fact, some other renal denervation studies have been criticized that the patients were inducted into RDN trial without sufficient exposure to spironolactone. Dr. Hiremath mentioned the renal denervation does reduce heart rate, but Dr. Kasliwal will be pleased to know that it also has been shown to decrease pulse wave velocity, so multiple things happen.
Dr. M.S. Hiremath: I think sleep apnea, which correlates so much with hypertension that also is expected to benefit with RDN therapy.
Dr. C. Venkata S. Ram: What is this, nobody asking from the right side, this is like Lok Sabha or something, only one section is voiceless, what happened right side. We want some balance.
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