Hipertensi dan Masalah disekitarnya

Lukman Muliadi

Apakah itu Hipertensi?
• Hipertensi atau Tekanan Darah Tinggi adalah suatu keadaan dimana tekanan darah di atas normal (>140 mmHg untuk
sistolik dan >90 mmHg untuk diastolik)

• Hipertensi bisa menyerang anak-anak atau orang dewasa, namun umumnya pada orang dewasa di atas 35 tahun

BP CLASSIFICATION
ESH-ESC & WHO-ISH 2003 BP Classification Optimal Normal High normal Grade 1 Hypertension (mild) Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension Systolic BP <120 / <80 120-129 / 80-84 130-139 / 85-89 140-159 / 90-99 160-179 /100-109 > 180 / >110 Isolated Systolic Hypertension Diastolic BP <120/<80 120-129 /80-84 130-139 / 85-89 140-159 / 90-99 >160 / >100 Stage 1 Hypertension Stage 2 Hypertension JNC VII Bp Classification Normal Prehypertension

> 140

< 90

J Hum Hypertens.275:1571-1576. . Weber MA et al. 1993.21(suppl 1):S1-S5.Hypertension Syndrome It’s More Than Just Blood Pressure (Tidak hanya tekanan darah yang meningkat) Decreased Arterial Compliance Obesity Endothelial Dysfunction Abnormal Glucose Metabolism Abnormal Lipid Metabolism Accelerated Atherogenesis LV Hypertrophy and Dysfunction Hypertension Neurohormonal Dysfunction Abnormal Insulin Metabolism Renal-Function Changes Blood-Clotting Mechanism Changes Kannel WB. JAMA.5:417-423. 1991. 1996. Dzau VJ et al. J Cardiovasc Pharmacol.

The Metabolic Syndrome : The Iceberg Concept .

Hypertension Linked To Chronic Renal Disease Among 332. et al.334(1):13-18. 1996. N Engl J Med.544 Men Screened for MRFIT 250 250 200 200 150 150 100 100 5050 00 180 160-179 140-159 130-139 120-129 <120 110 100-109 90-99 85-89 80-84 <80 Systolic BP (mm Hg) Adapted from Klag MJ. © Massachusetts Medical Society .

kontrasepsi hormonal .Steroid.Apa Penyebab Hipertensi ? • 90-95% hipertensi tidak diketahui penyebabnya • 5-10% disebabkan penyakit lain : – Gangguan ginjal – Gangguan pembuluh darah – Ganguan hormonal: hypertiroidi • .obat obatan : NSAID.

hipertensi (patogenesis) TEKANAN DARAH = CURAH JANTUNG x RESAISTENSI PERIFERA Hipertensi Preload K ontraktilitas Peningkatan CJ Peningkatan RP Hipertrofi struktural Konstriksi Fungsional Volume Cairan Redistribusi Cairan Retensi Na Ginjal As upan Na ekses Luas Filtrasi Gg genetik hiperaktif S.Simpatis Stress RAS Gangguan membran sel Gg Genetik Hiper insulinemi Obesitas EDF .

Perkembangan alamiah hipertensi esential tanpa terapi HEREDITER .LINGKUNGAN Umur 0 – 30 tahun PRE-HIPERTENSI 20 – 40 tahun 30 –50 tahun Normotensi HIPERTENSI DINI HIPERTENSI (KLINIS) TANPA KOMPLIKASI DENGAN KOMPLIKASI Hipertensi Maligne Jantung Hipertrofi Gagal Infark P.Darah Besar Aneurisma Diseksi Otak Iskemia Trombosis Perdarahan Ginjal Sklerosis Gagal Ginjal Gambar 1. Perkembangan alamiah hipertensi esential tanpa terapi .

77 . Am.Blood Pressure rises with age In the elderly. Cardioprotection and Antihypertensive Therapy. J. one out of two is hypertension 70 60 50 % 40 30 20 10 0 18-29 30-39 40-49 50-59 60-69 70-79 80+ Age Group Prevalence of Hypertension by age in USA Kannel-W. Cardiol 1996 .

5 mmol/L. 1993 . 330 mg/dL) Poulter N et al..5 x9 x16 .x1.6 Smoking x6 x4 Serum cholesterol level (8.Levels of Risk Associated with Smoking. Hypertension and Hypercholesterolaemia Hypertension (SBP 195 mmHg) x3 x4.

.

000 person-years 100 90 80 70 60 50 40 30 20 10 0 Systolic BP DBP Systolic BP 130 DBP 80 150 90 *Multiple Risk Factor Intervention Trial. Adapted from Neaton et al. 1992. 170 100 mm Hg 190 110 210 120 .Systolic BP is a better indicator of CAD risk than diastolic blood pressure (DBP) MRFIT*: CAD death and BP Age-adjusted CAD death rate per 10. Arch Intern Med.

1999.BP directly correlates with risk of stroke MRFIT: elevated systolic BP confers increased risk of stroke 9 Relative risk of stroke 8 7 6 5 4 3 2 1 0 Systolic BP DBP Systolic BP DBP <112 <71 11271- 11876- 12179- 12581- 12984- 13286- 13789- 14292- ≥151 ≥98 mm Hg Adapted from He and Whelton. . J Hypertens.

000 person-years 250 Patients without diabetes 200 150 100 50 0 <120 120-139 140-159 160-179 180-199 Systolic BP (mm Hg) Stamler et al. ≥200 .Elevated systolic BP interacts with diabetes to increase CVD risk MRFIT: men with diabetes and elevated systolic BP are at greater risk of CVD than those without diabetes Patients with diabetes 300 CVD deaths per 10. Diabetes Care. 1993.

.

” JNC VII 2003 . achieving a sustained 12-mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.Importance of blood pressure control “It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors.

JAMA 2003. each increment of 20 mmHg in systolic BP or 10 mmHg in diastolic BP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mmHg” BP.289:2560-2572 . CVD. blood pressure. cardiovascular disease JNC VII.Millimetres matter … “For individuals 40-70 years of age.

coronary heart disease. et al.155:701-709 .Millimetres matter … “A 2-mmHg reduction in DBP would result in … a 6% reduction in the risk of CHD and a 15% reduction in the risk of stroke and TIAs” DBP. Arch Intern Med 1995. TIA. CHD. diastolic blood pressure. transient ischaemic attack Cook NR.

Circulation 2001. diastolic blood pressure.0 0. systolic blood pressure. (SBP) .103:1245-1249 . et al.5 * -1.5 25 35 65 75 * The difference between SBP and DBP proportional hazard regression coefficients. DBP.008 Favours DBP 45 55 Age (years) Favours SBP (SBP) (DBP) -0.5 0. CHD.(DBP).Relative importance of SBP and DBP as predictors of CHD risk as a function of age 1.0 p=0. was estimated for each age group SBP.0 -1. ie. coronary heart disease Franklin SS.

1991 .Natural history of coronary heart disease Myocardial Infarction Arrhythmia Myocardial Ischemia Coronary Artery Disease LV Hypertrophy Atherosclerosis Remodelling Sudden Death Ventricular Dilatation Heart Failure Risk factor : • Hypertension • Hyperlipidemia • Diabetes • Insulin resistance Death Dzau & Braunwald .

Kidney Renal Insufficiency ESRD / Gagal Gnjal Heart Left Ventricular Hypertrophy Chronic Heart Failure Myocardial Infarction Congestive Heart Disease Arrhythmia Hypertension Brain Stroke Vessel Arteriosclerosis Peripheral Vascular Disease Coronary Heart Disease .

The pioneers Vasodilation treatment with fever-producing or antimalarial agents : ► Fries 1940s:  This was the first time we had seen reversal of the signs of malignant hypertension following an antihypertensive drug. It was an exciting experience ► Page 1949 :  I need hardly say this an unpleasant treatment butconsidering the danger of the diseaseto the life of the patient it is a small price to pay for the benefits .

Year
1935 1937 19371941

Blood pressure
162/98

A case of untreated hypertension

Complications Treatment

136/78 (age 53) Phenobarbital Low salt and low fat diet/massages/digitalis

170-180/90-100

1941

188/105

Cardiac enlargement Probable lacunnar infarcts
CHF Renal failure Cerebral haemorrhage-death, age 63

1944 19441945 April12, 1945

186/108 180-230/110-126

Pengukuran Tekanan Darah

Contoh tekanan darah Normal : 120/80 mmHg
Tinggi : >140/>90 mmHg

Pengukuran Tekanan Darah
• Ada 2 angka yang terukur dalam pengukurang tekanan darah :
– Sistolik (tekanan ketika jantung memompa) – Diastolik (tekanan ketika jantung menerima darah kembali)
Sistolik (tekanan yang lebih tinggi) saat ini dianggap LEBIH BERPERAN dalam menyebabkan komplikasi: PJK, stroke dan gagal ginjal

Hipertensi ringan diulang setelah 1 minggu . “Cuff” sesuai lingkar lengan 4. Air raksa dipompa sampai denjut hilang. 5. Pasien harus tenang / relaks. bunyi hilang = TDD 6. diturunkan pelahan : 2-3 mm/detik. tangan ditopang. Bunyi pertama = TDS. Sebaiknya ½ jam setelah makan / merokok 3. Manometer harus tegak lurus.Tehnik Pengukuran Tekanan Darah 1. lengan baju longgar 2.

Perubahan Tekanan Darah Terkait Aktivitas Aktivitas Rapat Bekerja Jalan Berpakaian Telepon Makan Kerja tulis menulis Membaca Nonton TV Relaks Tidur TDS(mmHg) +20.0 +12.9 +1.0 +13.0 +11.5 +8.1 0.0 TDD(mmHg) +15.2 +1.9 +0.6 .0 -10.2 +9.0 -7.0 +9.6 +5.5 +9.3 0.8 +5.2 +5.2 +16.5 +7.3 +2.

Faktor Risiko Hipertensi • Tidak dapat dimodifikasi – Usia lanjut – Keturunan • Dapat dimodifikasi – – – – – Kegemukan Asupan garam berlebih Kurang bergerak/beraktivitas Stress Merokok .

Oslo Study . HDFP. % % Improvement Total morbid events Total mortality Cerebrovascular events . % Treated No.2 0.0 5.2 417 252 76 46 6.2 1.6 4. fatal & nonfatal Fatal coronary events 563 342 140 79 9.Proof of Benefit ► 1960s to 1980s several major clinical trials establish the facts that early treatment of hypertension would prevent complication and prolong life  VAS. USPHS.1 1.7 27 24 50 42 Data from a subset of patients in VACS. AustS.4 2. USPHCS. HDFP ► Benefits of therapy : Complications Control No.

001 ns -13% -18% -1% <0.01 <0.001 <0.001 ESH-ESC 2003 .14% <0.001 <0.02 <0.01 ns .23% <0.Relative risk reduction of fatal events and combined fatal and nonfatal events in patients on active treatment versus placebo or no treatment S-D hypertension Risk reduction Mortality all cause cardiovascular noncardiovascular Fatal and non fatal events stroke coronary .01 -14% -21% -1% SIS-hypertension Risk reduction P P <0.42% .30% .

.BP Control Rates Trends in awareness. and Blood Institute. Wolz. Percent II 1976–80 51 Awareness Treatment Control 31 10 II (Phase 1) 1988–91 73 55 29 II (Phase 2) 1991–94 68 54 27 1999–2000 70 59 34 Sources: Unpublished data for 1999–2000 computed by M. treatment. and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey. National Heart. Lung. JNC6.

5% 20% 19% England 6% France 24% Germany Scotland 22.March 2000 .5% India 9% > 65 yr only European heart journal suppl B vol 2 .% Patients with controlled BP world-wide < 140 / 90 mmHg USA Canada 27 % 22% < 160 / 95 mmHg Finland Spain Australia 20.5% 17.

@ Keeping in mind.Goals of treatment JNC VII ( 2003 ) : @ < 140 / 90 mmHg or < 130 / 80 mmHg for those with Diabetes or Chronic Kidney disease. however. that systolic below 140 mmHg may be difficult to achieved in elderly( more flexible ) . ESH ( 2003 ) : @ At least below 140 / 90 mmHg ( lower values if tolerated ) @ Below 130 / 80 mmHg in Diabetics. @ Achieve SBP goal especially in persons >50 years of age.

Goals BP BP Threshold & Target BP (mmHg) Low and medium risk >140/90 <140/90 High risk DM <160/90 <140/90 <130/<80 JNC 7 . 2003 .WHO/ISH –ESH-ESC.

et al. mean arterial pressure. et al. systolic blood pressure Bakris GL. diastolic blood pressure.345:851-860. Am J Kidney Dis 2000. J Clin Hypertens 2002.4:393-404 . N Engl J Med 2001.Multiple antihypertensive agents are needed to achieve target BP Trial Number of antihypertensive agents Target BP (mmHg) 1 2 3 4 DBP <85 DBP <75 MAP <92 DBP <80 MAP <92 SBP <135/DBP <85 UKPDS ABCD MDRD HOT AASK IDNT ALLHAT SBP <140/DBP <90 DBP. MAP.36:646-661. Lewis EJ. SBP. et al. Cushman WC.

25:1105–87 TOD = target organ damage .ESH–ESC: Algorithm for Treatment of Hypertension Choose between Mild BP elevation Low/moderate CV risk Conventional BP target Marked BP elevation High/very high CV risk Lower BP target Low-dose single agent Low-dose 2-drug combination Not at BP goal Full dose of single agent Switch to different agent at low dose Full dose of 2-drug combination Add a third drug at low dose Not at BP goal 2–3 drug combination at full dose Full-dose single agent Full doses of 2–3-drug combination Task Force for ESH–ESC. J Hypertens 2007.

Updated UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension 55 years or black patients at any age CCB or thiazide-type diuretic <55 years Step 1 ACEI (or ARB*) Step 2 ACEI (or ARB*) + CCB or ACEI (or ARB*) + thiazide diuretic Step 3 ACEI (or ARB*) + CCB + diuretic Add further diuretic therapy. Consider seeking specialist advice Step 4 . α-blocker. or β-blocker.

ARB. Yes 2-AHDs combination for most (usually thiazide-type D and ACEI or ARB or BB or CCB Modified from JNC VII .ACEI.CCB) Thiazide-type D for most. Other AHD as needed.Management of Hypertension (JNC VII) BP Classification Lifestyle modification Initial Drug Therapy (-) compelling (+) compelling Indication indication Normal PreHypertension Stage 1 Hypertension Stage 2 Hypertenssion Encourage Yes Yes No AHD indicated AHD (s) for the compelling indications AHD(s) for the compelling indications. Other AHDs (D. may consider other AHD. AHD(s) for the compelling indications.BB.

or diabetes Associated clinical conditions Lifestyle changes Drug treatment and lifestyle changes Drug treatment and lifestyle changes Drug treatment and lifestyle changes Immediate drug treatment and lifestyle changes Drug treatment and lifestyle changes Immediate drug treatment and lifestyle changes Immediate drug treatment and lifestyle changes Immediate drug treatment and lifestyle changes Immediate drug treatment and lifestyle changes ESH/ESC Guidelines 2003.21:1011-1053 . target organ damage. then drug treatment Immediate drug treatment and lifestyle changes 1-2 risk factors Lifestyle changes Lifestyle changes Lifestyle changes for several months. then drug treatment if preferred by the patient and resources available Lifestyle changes for several months. J Hypertens 2003.Treatment initiation: ESH/ESC 2003 Blood pressure Other risk factors and disease history No other risk factors Normal High normal Grade 1 Grade 2 Grade 3 No BP intervention No BP intervention Lifestyle changes for several months. then drug treatment Immediate drug treatment and lifestyle changes 3 or more risk factors. then drug treatment Lifestyle changes for several months.

ESHESC Recommendations for Combining BP-lowering Drugs and Availability as Single-pill Combinations Diuretics -blockers Angiotensin receptor blockers (ARBs) a-blockers Calcium channel blockers (CCBs) Angiotensin-converting enzyme (ACE) inhibitors Available as a single-pill combination Less frequently used/combination used as necessary Task Force for ESH–ESC. J Hypertens 2007.25:1105–87 .

bahkan pada usia lanjut.Mitos-mitos di seputar Hipertensi • Tekanan darah diastolik (angka yang lebih rendah) lebih penting dari sistolik – FAKTA: • Tekanan darah sistolik dan diastolik samasama penting. tekanan darah sistolik lebih harus dikontrol .

sudah biasa tekanan darahnya tinggi.Mitos-mitos di seputar Hipertensi • Pada orang tua. tekanan darah HARUS di bawah 140/90 mmHg untuk mencegah komplikasi . sehingga tidak perlu diobati (100 + umur mmHg adalah wajar) – FAKTA: • Baik orang muda maupun orang tua.

Mitos-mitos di seputar Hipertensi • Jika saya minum obat hipertensi dan tekanan darah saya terkontrol baik. obat tersebut tidak perlu diminum lagi – FAKTA: • Tekanan darah terkontrol tsb. hanya dapat dikendalikan. karena disebabkan oleh obat. Jika obat dihentikan maka tensi akan meningkat kembali. Jadi obat hipertensi harus terus diminum sesuai instruksi dokter . Hipertensi tidak dapat disembuhkan.

Mitos-mitos di seputar Hipertensi • Jika kita pusing-pusing dan leher terasa kaku. itu berarti tensi kita sedang naik. tensi kita normal – FAKTA: • Hipertensi itu penyakit yang umumnya tidak bergejala. Periksalah tekanan darah secara teratur untuk mengetahui berapa tekanan darah kita. . Jika tidak terasa apa-apa. Untuk mengetahui apakah tensi kita naik atau tidak hanyalah mengukur dengan tensi meter.

SERANGAN JANTUNG DAN GAGAL GINJAL • Hipertensi dapat dikontrol untuk mencegah komplikasi tersebut .Hipertensi = “Silent Killer” • Sebagian besar hipertensi TIDAK bergejala • Tekanan darah tinggi bisa merusak organorgan tubuh yang berhubungan erat dengan pembuluh darah • Hipertensi adalah penyebab utama STROKE.

” William B. 1996. Kannel. . bukan saat baru mulai terapi.” “Pada beberapa keadaan.” “In some respects.” William B. Kannel. MD Department of Medicine Boston University Medical Center “Menunnggu sampai gejala dan tanda penyakit jantung koroner timbul baru diberi terapi sudah tidak benar .Don’t wait to treat hypertension “Awaiting overt signs and symptoms of coronary disease before treatment is no longer justified. timbulnya atau telah adanya gejala justru menggambarkan kegagalan tindakan medis. Atherosclerosis and Coronary Artery Disease. MD Department of Medicine Boston University Medical Center — Kannel. the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.

2. Berkonsultasi dengan dokter secara teratur 8. Berhenti merokok 7. paman. 3. Latihan fisik sesuai anjuran dokter 9.10 kewajiban penderita hipertensi 1. Menjalani kehidupan secara normal dan sehat 10. Makan makanan rendah lemak 6. anak dll) untuk memeriksakan tekanan darah secara teratur (risiko keturunan) . adik. kakak. Menganjurkan keluarga (orang tua. 4. Mengukur tekanan darah secara teratur Jangan lupa mengkonsumsi obat sesuai aturan dokter Mengontrol berat badan Tidak mengkonsumsi garam berlebih (menghindari makanan bergaram tinggi) 5.

Obat-obat yang ideal • • • • • Efektif menurunkan tekanan darah Efek samping minimal Diminum sekali sehari Efek penurunan tekanan gradual Memiliki “drug holiday protection” (melindungi pasien yang lupa minum obat) • Tidak perlu memilih obat yang penurunan tekanan darahnya cepat (kecuali kasus emergency) .

minyak dan lemak Kurangi porsi makanan Kurangi daging dan pilihlah ayam atau ikan (kulit ayam disingkirkan) • Konsumsi buah dan sayuran lebih banyak • Konsumsi susu yang rendah lemak • Aktivitas fisik 30-60 menit 3-6 kali seminggu .Tips untuk mengurangi berat badan • • • • Kurangi makanan yang digoreng Kurangi mentega.

Tips untuk mengurangi asupan garam • Kurangi jumlah garam dalam masakan • Tambahkan bumbu dan penyedap untuk mengimbangi rasa masakan • Kurangi kripik kentang dan jagung asin. ikan asin. burger yang banyak mengandung garam • Tambahkan konsumsi buah dan sayur segar dan bukan kalengan • Perhatikan LABEL kandungan garam dalam makanan . hot dogs.

Tidak menghentikan pengobatan sendiri atau merubah dosis dan segera mengunjungi dokter jika ditemukan adanya efek samping . tidak mengharapkan terapi yang “ajaib” yang cepat menurunkan tekanan darah • Memberi kesempatan pada tubuh untuk menyesuaikan dengan obat yang mungkin memerlukan waktu untuk mengendalikan tekanan darah • Obat diminum sesuai dengan anjuran dokter.Obat-obat anti-hipertensi • Bersikap sabar dalam menjalani pengobatan.

Obat-obat anti-hipertensi • • • • • • • • Diuretik Beta bloker Antagonis kalsium ACE inhibitor Alfa bloker Angiotensin II antagonis Central agonist dan vasodilator Anti Renin .

CCB. calcium channel blocker. angiotensin II receptor blocker. ESH/ESC 2007 . ARB. through treatment of Beta blockers elevated BP and all associated reversible risk factors DHP.Development of Antihypertensive Therapies Effectiveness Tolerability 1940s 1950 Direct vasodilators Peripheral sympatholytics Ganglion blockers Veratrum alkaloids 1957 1960s 1970s 1980s 1990s ARBs 2005+ Renin Inh ACE Alpha blockers inhibitors Thiazide diuretics Central alpha2 DHP CCBs agonists Non-DHP CCBs The primary goal of treatment is to achieve maximum reduction in total CV risk. dihydropyridine.

AMLODIPINE • Obat yang mempunyai masa kerja panjang dari generasi kedua antagonis kalsium • Mempunyai waktu paruh 35-48 jam • T/P Ratio >50% • Dosis sekali sehari • Menurunkan tekanan darah secara gradual .

which is hydrolyzed to its active metabolite.41:515-527. J Hypertens 2001. J Clin Pharmacol 2001. Laeis P.Pharmacokinetics: Olmesartan • Olmesartan medoxomil is a prodrug.6% • Time to Cmax ~2 hours • t1/2 ~10-15 hours • Dual elimination: – 40% renal – 60% hepatobiliary Schwocho LR. olmesartan • Absolute bioavailability 25.19(Suppl 1):S21-S32 . et al. et al.

Pharmacokinetics: Summary (cont.41:515-527. J Hypertens 2001.19(Suppl 1):S33-S40 . et al. Laeis P.) • Not metabolized by cytochrome P450 system. von Bergmann K. et al.19(Suppl 1):S21-S32. J Clin Pharmacol 2001. et al. interactions with drugs metabolized by CYP450 unlikely • Can be administered with or without food • No dosage adjustment necessary for the elderly or in patients with renal or hepatic impairment – BUT not recommended for patients with severe renal or hepatic impairment Schwocho LR. J Hypertens 2001.

058 (NS) 0. et al.005 0.19 n=20 1.036 5 p vs olmesartan Change from predose to 24 hours in mean PRA (ng/mL/h) 4 3.028 0. Presented at ASH 2006.0001 0.004 0. plasma renin activity Valsartan 320 mg Jones M.78 1.Olmesartan may give more prolonged AT1 blockade than irbesartan or valsartan p vs placebo <0.002 0.16 3 2 1 0 0 Placebo Olmesartan 40 Irbesartan 300 mg mg Valsartan 160 mg 1.84 PRA. Abstract P-195 .

et al. BP.2 ** -10.05 ** p0.0 -8. blood pressure Oparil S. J Clin Hypertens 2001.9 ** -9.8 * * p0.Results at Week 2 (cont.3:283-291 .005 n=588 SeSBP.) Change in SeSBP Losartan 50 mg/d Valsartan 80 mg/d Olmesartan 20 mg/d 0 -2 Change in BP (mmHg) Irbesartan 150 mg/d -4 -6 -8 -10 -12 -14 -13. seated systolic blood pressure.

0005 -11.3:283-291. BP. et al. blood pressure Oparil S.21(Suppl 2):S43-S46 .2 ** -7.9 ** -9.5 40% 46% 16% SeDBP. J Clin Hypertens 2001.9 * -12 * p<0. J Hypertens 2003.05 ** p<0. seated diastolic blood pressure.Results at Week 8 Change in SeDBP Losartan 50 mg/d Valsartan 80 mg/d n=588 Irbesartan 150 mg/d 0 Olmesartan 20 mg/d Change in BP (mmHg) -4 -8 -8. Brunner HR.

Clin Ther 1998.blockers CCBs ACE inhibitors ARBs ACE. angiotensin-converting enzyme. calcium-channel blocker.20:671-681 . ARB. et al. CCB.007 vs ACE inhibitors 64 * 58 50 43 38 10 0 Diuretics Beta. angiotensin II receptor blocker Bloom BS.Compliance at 1 year with antihypertensive treatment 70 Compliance at 1 year (%) 60 50 40 30 20 * p<0.

• • • • • • • • • ACEI + CCB Less peripheral oedema Less cough Potentiation of the BP lowering effect Greater reduction of CV events Greater organ protection Antiinflamatory vasc effect Anti atherogenic properties Anti diabetogeniceffects Neutral effects on lipid profile and uric acid .

Olah raga teratur .Take home messages • Kenalilah tekanan darah anda • Kendalikanlah dengan : – Mengkonsumsi obat sesuai anjuran dokter – Rajin berkonsultasi pada dokter – Mengurangi asupan garam – Mengendalikan berat badan – Berhenti merokok .

all patients should adopt appropriate lifestyle modifications • A low dose of a diuretic should be considered as the first choice of therapy for the majority of patients without a compelling indication for another class of drug 2003 WHO/ISH Statement on Hypertension. J Hypertens 2003.Summary • Regardless of the blood pressure level.21:1983-1992 .

21:1011-1053 . and cost and risk profile • Long-acting drugs that provide once-daily.Summary • • • • Specific drug classes may differ in their effects Main benefits are due to BP lowering Drugs are not equal in adverse-event profiles Major drug classes are suitable for initiation and maintenance of therapy • Choice of drug will be influenced by patient experience and preference. blood pressure ESH/ESC Guidelines 2003. J Hypertens 2003. 24-hour efficacy are preferable BP.

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