In the 6 years since this video was posted, prices for angiotensin receptor blockers (ARBs) have come down in the US and are now similar to ACEIs, but have fewer side effects. So I'd definitely consider an ARB as appropriate initial monotherapy (@8:36). To the best of my knowledge, it's not known if their are ethnic or racial differences in ARB response. (Here is one of many papers that discuss this issue: www.ncbi.nlm.nih.gov/pubmed/29808707 ) In addition, data from 2020 shows that HCTZ is just as effective and has fewer side effects as compared to chlorthalidone: pubmed.ncbi.nlm.nih.gov/32065600/
@@gprokop My interpretation of what the authors argue in the conclusions is that essentially, we don't actually know if ARB monotherapy is a good option in black patients, but based on the available suboptimal data (which uses surrogate endpoints like blood pressure, and/or extrapolates from data on ACEIs), we can't say it is a good option with as much confidence as other options such as thiazides. Therefore, it should be avoided. I've been considering doing a deep dive on here on the topic of hypertension guidelines and race ("Are hypertension guidelines racist?")...but I haven't decided if it's too controversial to pull off successfully. Moderating the comments on my COVID-related videos is already exhausting enough!
Thank you for a great video as someone with Hypertension this was very informative. My HIM instructor assigned this to us for our Pharmocotherapy class and I am very happy that she did.
Eric's Medical Lectures , your lectures are really helpful! I'm a med student from Brazil and I'm really impressed by the way you explain the subjects so easily, even though it is in English hahahahah! Thank you so much! you are helping students down here!
Superior video to other videos I have seen on prescribing antihypertensive medications. It was concise with clear rationales for clinical decisions. Thank you for taking the time and effort to share your knowledge.
I WATCHED EACH AND EVERY VIDEO OF STRONG MEDICINE. I CAN CONFIDENTLY SAY THAT YOUR VIDEOS ARE THE BEST VIDEOS TO UNDERSTAND THE MEDICINE. THANK YOU SOOO MUCH DR. STRONG. I PERSONALLY REQUEST YOU TO PUT MORE VIDEOS ON OTHER TOPICS ACCORDING TO YOUR CONVENIENCE. I WISH I MEET YOU ONCE IN MY LIFE. THANK YOU.
Thank you, if i were in USA i sincerely would have come to you to thank you personally 9:20 , as afro people should not have ACEi or ARBs as first line in HTN but unfortunately, there is a trend of giving ACEi as first line in many african countries and USA pushed by big pharma and key GPs & cardiologists , thanks Dr Strong you are the GOAT
Most excellent presentation as usual I am in the UK and we don’t have such an aversion to Atenolol as you do…it is used commonly here though not initial first line
Dr. Eric wow this is the 1st time a Dr. really do this to name each HBP med & put them in class or group & what they do & how they function & what’s best for each person w the different HBP situation they have, this is so helpful, I can’t ThankU enough, in my HBP case for instance I have high readings, but average is like 150/90 & fluctuates at times it go up more, I’ve been on name brand Diovan for 10ys plus then just over 2yrs ago when I turned 65 I took the generic version & then start my dilemma about a month on this generic I started noticing my arms have under flaps & very noticeable & a little on my face, but b4 w the name brand I didn’t even know I had any health issue coz I just took 1 dose at anytime of day as a routine, until the generic, & my dose is 160 Valsartan & 12.5 HTZD compline it’s 1 pill, & now I see that you list HTZD as dose by itself instead of compining w another HBP med, I have tried Lindsinopril & it made me cough, & atenolol I take occasional my blood pressure still high 25mg & 12.5 HTZD but now I’ll try not to take at all, My diet I eat everything & lots of fruits & some veg.drink 2-3mugs of coffee daily, I play tennis 3x a wk & no headaches which I’m grateful for, but I’m still dealing w this water retention that I think is the side effect I really want to take a HBP med w out this, can u recommend something pls & I have subscribed I will listen n watch this video over n over so I can understand n learn more, thanks a lot & May God bless You & yours, Keith up the good work I really appreciate it, any advice on my HBP case will be wonderful, sincerely,
Thank you so much for this video! I've been put on Labetalol for about two years now and was feeling at least one or two of the side effects and didn't link it to this medication. And now they have switched me to Losartan because the Labetalol is not effective anymore. I'll ask them at my next BP check next week about the recommended antihypertensive you've listed. Thank you once again!!!
I can't speak about specific cases, nor give individualized medical advice to viewers, but losartan is a common and totally fine first-line anti-hypertensive.
Hi Eric we use diltiazem as an anti-anginal drug in New Zealand, not sure if you guys do the same in the States. We don't yet have aliskiren (still being reviewed, will hopefully be approved soon); we also use minoxidil for HTN refractory to the other meds mentioned above, if that was of interest. That's a great coverage of antihypertensives and I've learnt something new - thank you for that. Now I'll have to think of something to replace someone's atenolol.
hiimcanadian In the US, diltiazem is typically only used for angina related to coronary vasospasm (a.k.a. "variant angina"). Minoxidil is, as you mentioned, typically used here only for severe refractory HTN - a fourth or fifth line agent in patients with advanced, but pre-dialysis dependent renal failure.
Great video! ACEi is normally used in CKD to protect the kidney. So its good for the kidney. However, you said that one of the side effects of ACEi is renal dysfunction. Could you please explain more about this? Thank you very much.
The effect of ACE-I on renal function is a complicated topic. In brief, ACE-I helps to prevent progression of renal failure in chronic kidney disease by a general decrease in blood pressure, a reduction of protein loss through the glomerulus that is independent of hemodynamic effects of the med, and ACE-I are also antifibrotic. However, acutely, since they dilate both the afferent (preglomerular) and efferent (postglomerular) arterioles, and have a disproportionately stronger impact on the efferent arterioles, there is a overall reduction in the arteriolar pressure driving glomerular filtration. So even though, over the long-term, ACE-I are protective in CKD, they can cause decreases in the glomerular filtration rate (GFR) in the short term. It's estimated that 1-2% of patients started on an ACE-I need to have it discontinued shortly thereafter because of an unacceptable decrement in renal function.
Thank you sir for another excellent lecture! I had a question for you. Aren't you gonna finish your chest x-ray series? I have been waiting for your last video of that series. Loved it.
Megh o Roddur, sorry about leaving you one video short with the CXR series. My preclinical med students at my home institution are in the middle of a cardiology block right now, thus the recent focus on EKGs. Will finish off the CXR series, and the PFT series as well, in the upcoming several weeks.
I’m not a doctor, I’m just a guy with hypertension and I think the reason that atenolol doesn’t reduce all cause mortality is because when it wears off there’s a tremendous rebound effect
Yes, this is one of the hypotheses about atenolol. Essentially, it is dosed as a once daily medication, but its effect may not last 24 hours. Of course, one could just split the dose and take it twice daily instead, but in that case, you might as well take metoprolol or carvedilol, both of which have much better data in a variety of clinical situations.
I discuss the differences between the JNC 5-8 near the beginning of the previous video on treatment thresholds and lifestyle modifications (ru-vid.com/video/%D0%B2%D0%B8%D0%B4%D0%B5%D0%BE-tS-iF9DtUR0.html). JNC-8 released guidelines in 2013 - the major updates were with those thresholds more than choice of meds, and were not without controversy. Was there a specific update that seems missing?
Strong Medicine I actually missed that one....I just watched it. i really liked the subjects covered...i long for more details on escalating strategies..on the other hand ..it was concise and handy.. facts on non phar strategies were so intresting.
Great videos! Regarding your elderly patient recommendations, amlodipine causes so much swelling, in your experience have you seen better side effect profiles with the other dihydro CCBs? Thanks!
There is a 2011 meta-analysis in the Journal of Hypertension that compared rates of peripheral edema between different CCB. In addition to the finding that the dihydropyridines cause more edema than non-dihydropyridines, they found that a new subclass of lipophilic dihydropyridines, consisting of lacidipine, lercanidipine and manidipine, were about half as likely to cause edema as the older dihydropyridines. Unfortunately, to the best of my knowledge, none of those three newer CCB are available in the US. Also to the best of my knowledge, and experience, there is no significant different in edema rates with amlodipine vs. felodipine vs. nifedipine. Because edema from the dihydropyridines is unrelated to renal sodium handling, it cannot be treated with diuretics, but has been reported to respond to ACE-I and ARBs. (Admittedly, I've never started an ACE-I or ARB on a patient with that specifically in mind.) Although the edema can be annoying, it's not dangerous (i.e. doesn't clearly lead to CHF in a similar way to meds causing primary sodium retention - NSAIDs, prednisone, etc...), which is why I personally prefer it in the elderly, a population who could become quite altered and risk injury in the setting of electrolyte and renal imbalance from alternative antihypertensives.
+DrVarun Reddy The bottom line is that atenolol hasn't been shown to be helpful for reducing mortality, and hasn't consistently been shown to reduce most cardiovascular endpoints, even in comparison to other beta blockers, and may increase risk of stroke (in comparison to other drugs) - though this last finding was challenged by a paper last year. Three of the more relevant papers about this issue: www.ncbi.nlm.nih.gov/pubmed/?term=15530629 www.ncbi.nlm.nih.gov/pubmed/?term=16257341 www.ncbi.nlm.nih.gov/pubmed/?term=17488499
I\'m not sure but ,if anyone else is searching for best high blood pressure medication try Trefendous Simple Pressure Tips (Have a quick look on google cant remember the place now ) ? Ive heard some unbelievable things about it and my co-worker got cool success with it.
Diaa Mehanna After catching multiple college professors plagiarizing entire slide sets of mine, I don't provide PPT files to viewers any more. However, if you email me (estrong at Stanford dot edu) your own email address, I can send you a PDF version of the hypertension slides.
Hi there, Thank you very much for wonderful lectures. I am just a beginner in Medicine. We usually (almost strictly) use lisinopril once a day in practice and patient specifically like this thing about ACE inhibitors. Any thoughts regarding the effectiveness of once or twice a dosage? Thanks
From Systematic Review: Antihypertensive Drug Therapy in Patients of African and South Asian Ethnicity (pubmed.ncbi.nlm.nih.gov/27026378/) This is a metaanalysis and review; it included 28 trials of antihypertensive medications in patients of "African ethnicity" with blood pressure as the primary outcome. Under ""Patients of African Ethnicity": "...Thus, the aggregated data show a greater effect of calcium blockers and diuretics, while beta-adrenergic blockers and ACE inhibitors are the least effective drugs to lower SBP and DBP, respectively. The cause of these differences in drug responses is largely unknown. Our findings are in accord with the suppressed activity of the renin-angiotensin-aldosterone system in hypertensive patients of African ethnicity, and the high activity of creatine kinase, promoting vasoconstriction and salt retention. As a consequence, patients of African ethnicity are significantly less sensitive to drugs that block the renin-angiotensin-system (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers) and beta-blockers." This finding has been widely found and cited beforehand by other researchers. Unfortunately, they don't report how the individual trials identified a patient's ethnicity (e.g. self-reported by the patient, guessed by the researcher based on physical appearance, etc...), which is obviously problematic.
Dr strong i have read in many well-known and respected books that beta blockers as treatment for conditions unrelated to the heart are contraindicated if the patient has CHF, one book says "active CHF", but it's known that beta blockers reduce mortality from heart failure. Could you clear this up for me? thanks.
+yousef ss circ.ahajournals.org/content/128/16/e240.full.pdf+html 7.2. Stage B: Recommendations 6. Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI. (Level of Evidence: C) 7.3.2.4.3. Beta Blockers: Risks of Treatment. Initiation of treatment with a beta blocker may produce 4 types of adverse reactions that require attention and management: fluid retention and worsening HF; fatigue; bradycardia or heart block; and hypotension. The occurrence of fluid retention or worsening HF is not generally a reason for the permanent withdrawal of treatment. Such patients generally respond favorably to intensification of conventional therapy, and once treated, they remain excellent candidates for long-term treatment with a beta blocker. The slowing of heart rate and cardiac conduction produced by beta blockers is generally asymptomatic and thus requires no treatment; however, if the bradycardia is accompanied by dizziness or lightheadedness or if second- or third-degree heart block occurs, clinicians should decrease the dose of the beta blocker. Clinicians may minimize the risk of hypotension by administering the beta blocker and ACE inhibitor at different times during the day. Hypotensive symptoms may also resolve after a decrease in the dose of diuretics in patients who are volume depleted. If hypotension is accompanied by other clinical evidence of hypoperfusion, beta-blocker therapy should be decreased or discontinued pending further patient evaluation. The symptom of fatigue is multifactorial and is perhaps the hardest symptom to address with confidence. Although fatigue may be related to beta blockers, other causes of fatigue should be considered, including sleep apnea, overdiuresis, or depression.
+PhilaPeter so beta blockers should be temporarily discontinued if pulmonary edema develops, because from what i understand this is the major issue of a decompensated heart failure, after its resolution they should be restarted
No disrespect to the UK, but NICE guidelines specifically are not something that I incorporate into my clinical practice. However, you are correct that the information in this video is out-of-date, and worthy of an update at some point. Major updates, in extreme brief: - For many (not all) patients diagnosed with hypertension, dual therapy of low dose meds is preferable over monotherapy (i.e. the increased effectiveness of dual therapy outweighs the downside of cost and side effects). - Since the cost of ACEI and ARBs is now equivalent, and ARBs have better side effect profiles, ARBs are preferred over ACEIs , in pretty much all circumstances. - Thiazides (and "thiazide-like" diuretics) are now emphasized less than previously.
Is amdolphine 5 mg safe? I was on lozartan hctz for about an year an i have exprerience heart palpataions and shortness of breath.Wanted your input thanks :)
Amlodipine is a well tolerated medication, and 5mg is a middle-of-the-road dose. However, I recommend discussing any concerns you have about your medications with your doctor - I am not able to provide individualized medical advice on here.
Chlorothalidone proved better in the trials due the hawthorne effect. Patients were compliant. However in the real world, chlorothalidone makes patients urinate more often than hydrochlorthiazide which they don't like and thus decreases their compliance. Hydrochrlothiazide is favored in patients because they are more likely to take it.
That's an interesting idea. Essentially, compliance may be worse with chlorthalidone than HCTZ because it actually works better! Do you happen to know of a reference?
Dario, your question is a good one. I anticipated some viewers might wonder about the recommendation for chlorthalidone over HCTZ, in addition to the twice daily dosing of lisinopril (instead of the more common once daily dosing). My impression is that the available data suggests that chlorthalidone may have more hypokalemia, but the question is not settled. I will probably post a short supplementary video expanding on this specific issue, along with the twice daily lisinopril recommendation, and maybe 1-2 other specific points from the video that other viewers raise questions about. I considered including a discussion about this in this particular video, but I was also trying to keep it relatively short.
+Joelthedon22 I'm sorry, but I can't give individualized medical advice on here. However, in general, if a patient has been stable on a specific anti-hypertensive without problems, I usually don't change it, even if the literature suggests an alternative might be generally more beneficial in a particular population as a whole. My only exceptions to this are when I see a patient on either a beta blocker or verapamil just for hypertension, and who lack additional indications for those meds. Beta blockers and verapamil are not sufficiently useful for hypertension to justify their use. However, patients with hypertension, plus either heart failure or who have had a heart attack, may benefit from beta-blockers. And some patients with hypertension and certain abnormal heart rhythms may benefit from verapamil.
@@StrongMed thanks Dr strong , very nicely explained; means B blocker should be taken only when there is heart failure condition,other wise we can avoid b blocker??
I can't offer individualized medical advice on here, but the situation has changed a bit in the 6 years since this was posted (I just posted a pin comment above to reflect this). Losartan is a totally fine initial choice of antihypertensive, and metoprolol is fine as a second-line med to add if the first was insufficient. However, please discuss all concerns you might have with you physician!
+انين الالم Here are 2 of several references: www.pharmacylearningnetwork.com/articles/ashp-twice-daily-lisinopril-dosing-outperforms-once-daily and www.ncbi.nlm.nih.gov/pubmed/14668568 The number of patients in those studies are very tiny, and in retrospect, if I were redoing this video, I might take a stance that was slightly less promoting a twice daily dosing of lisinopril. Specifically, because decreased compliance may be a larger downside than the possible small incremental benefit in effectiveness.
@@powerofyourbrains I appreciate your point and that the overwhelming majority of physicians prescribe lisinopril as a once daily medication. However, it's half-life is 12 hours, and at least one retrospective study found that twice daily lisinopril was more effective: onlinelibrary.wiley.com/doi/full/10.1111/jch.13011 Certainly, a once daily medication will have higher patient adherence, which the prescribing clinician should take into consideration. And ultimately, as I say in the video, those are just my personal recommendations - that specific section is clearly not intended to be conveying common practice and/or the standard of care. EDIT: Here's another, admittedly very small study of twice daily lisinopril using surrogate outcomes in patients with heart failure: www.ncbi.nlm.nih.gov/pubmed/14668568 If I were to make the video again, I probably would promote twice daily lisinopril a little less strongly, but that would be mainly because it's counter to the overwhelming majority of people's experience. I still think it's probably pharmacologically superior.
The image on the thumbnail (which is a screenshot from the video) literally has the recommendations for first-line anti-hypertensives for black patients: thiazide diuretic (e.g. chlorthalidone, HCTZ) or a non-hydropyradine calcium channel blocker (e.g. amlodipine, felodipine).
This is an introductory video for med students and residents, and is not intended to supplement a graduate-level course in pharmacological chemistry. Chlorthalidone (or chlortalidone, if you prefer) is described in every resource I've seen as either a thiazide, "thiazide-like", or "thiazide-related". It has the same general mechanism as thiazides, acts in the same location in the tubules, has same indications and side effects, and aside from its specific molecular structure, is in every other way belonging in the thiazide class. The distinction is trivial and of no clinical relevance.
