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Hypertension

Hypertension

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Clinical Guideline of Hypertension
Clinical Guideline of Hypertension

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Published by: docbay on Jan 21, 2010
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HYPERTENSION

Worldwide  1 billion people USA  50 million people Prevalence will be higher if there are no effective preventions

ETIOLOGY OF Hypertension
Rudnie, Danilson & Sinclair (5.448 P.Hy) Essential hypertension Renal disease Coarctasion of Aorta Primary Aldosteronism Cushings syndrome Prehormacytoma Oral Contraceptive induced : 92,1 – 95,3 % : 3,4 – 6,3 % : 0 - 0,2 % : 0 - 0,3 % : 0,1 - 0,2 % : 0 - 0,2 % : 0,2 - 1 %

CVD Risk Factors
          Hypertensions* Cigarette smoking Obesity* (BMI ≥ 30 kg/m2) Physical Inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR < 60 ml/min Age ( older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65)

*Components of the metabolic syndrome

NATURAL HISTORY OF HYPERTENSION
HEREDITY – ENVIRONMENT PRE – HYPERTENSION

Normotension

EARLY HYPERTENSION

ESTABLISHED HYPERTENSION

UNCOMPLICATED

COMPLICATED

Accelerated Malignant course

CARDIAC Hypertrophy Failure Infraction

LARGE VESSEL Aneurysm Dissection

CEREBRAL Ischemia Thrombosis Hemorrhage

RENAL Nephrosclerosis Failure

HYPERTENSION
In INDONESIA  complex problems :  Etiology  Prevention  Early detection  Management  Monitoring  Socio – economic  Education  Income  Etc.

Control of Blood Pressure
Blood pressure Hypertension = = Cardiac output Increased CO x and/or Peripheral resistance Increased PR

↑ Preload ↑ Fluid volume

↑ Contractility ↑ Heart rate Sympathetic Nervous system

Vasoconstriction

Renal sodium retention

Reninanglotensinaldosterone system

Excess Sodium Intake

Genetic factors

Kaplan (1994)

HYPERTENSION
THE LATEST GUIDELINES :
The Seventh Report of the JOINT NATIONAL COMMITTEE On Prevention, Detection, Evaluation, and Treatment Of High Blood Pressure (JNC VII) (May, 2003)

2003 Guidelines for the management of hypertension From European Society of Hypertension – European Society of Cardiology (ESH – ESC 2003) (June, 2003)

JNC VII
NEW GUIDELINES IN JNC VII : 1. Classification and Management of Blood Pressure for Adults 2. Patien Evaluation 3. Treatment

JNC VII
Blood Pressure (mmHg) Normal Prehypertension Stage 1 H. Stage 2 H. SBP < 120 120 – 139 140 – 159 ≥ 160 and or or or DBP < 80 80 – 89 90 – 99 ≥ 100

The Aims of Hypertension Management
 Decrease mortality and morbidity  Restore blood pressure to normal levels1  Maintain blood pressure at TD < 140 /90 mmHg2

The Ideal of Antihypertension Drug

• • • •

Decrease cardiac output Decrease systemic peripheral resistense Maintain the normal cardiac output Maintain organ perfussion

Cardioprotective Effect of Antihypertension Drugs
• Prevents atherosclerosis progression→ Prevents hearth attacks • Prevent and regression of LVH • Does not increase risk factors

Management of treatment :
– Based on Risk Stratification – We start with antihypertensive drugs : Very High Risk High Risk Moderate Risk (if BP didn’t ↓ after 3 months non-pharmacology treatment) Low Risk (if BP didn’t ↓ after 3 – 12 months non – pharmacology treatment)

Stratification of Risk to Quantify Prognosis
Other risk factors & disease history Grade I (mild HT) SBP 140 – 159 / DBP 90 - 99 Grade 2 (moderate HT) SBP 160 – 179 / DBP 100 - 109 Grade 3 (severe HT) SBP ≥ 180 / DBP ≥ 100

I. No other risk factors II. 1 – 2 risk factors III. 3 or more risk factors or TOD or Diabetes mellitus IV. ACC

Low risk Med risk High risk

Med risk Med risk High risk

High risk V High risk V High risk

V High risk

V High risk

V High risk

BLOOD PRESSURE TARGET
(WHO-ISH, 1999)

→ 140 / 190 →130 / 85 (Diabetes Melitus, young adult) →130 / 80 (Proteinuria) →125 / 75 (Proteinuria > 1 gram/day)

1999 who-ish Guidelines for Initiation of Anti-Hypertensive Treatment
The six classes of antihypertensive agents listed in the new WHO/ISH guidelines :
 Diuretics  Beta-blockers  ACE Inhibitors ▪ Calcium antagonists ▪ Alpha-blockers ▪ Angiotensin II Receptor Blockers

Lifestyle Modifications to Prevent and Manage Hypertension
• Reduce weight • Moderate consumption of: • alcohol • sodium • saturated fat • cholesterol • Maintain adequate intake of dietary : • potassium • calcium • magnesium

Increase physical activity

 Avoid tobacco

Compelling indications
Heart Failure Post Myocardial Infraction High Coronary Art.Disease Risk Diabetes Chronic Kidney Disease Recurrent Stroke Prevention

INDICATIONS FOR INDIVIDUAL DRUG CLASSES
Compelling Indication Heart failure Post-MI High coronary disease risk Diabetes Chronic kidney disease Stroke Prevention ● ● ● Diuretic ß-blocker ● ● ● ● ● ACE Inhibitor ● ● ● ● ● ● ● ● ● ARB ● CCB

Algorithm for Treatment of Hypertension
Lifestyle Modification s Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling
Stage 1 Hypertension (SBP 140-160 or DBP 90-99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, Or combination. Stage 2 Hypertension (SBP ≥160 or DBP ≥100 mmHg) 2-drug combination for most. (Usually thiazide-type diuretic And ACEI or ARB or BB or CCB)

Compelling Indications
Drug(S) for the compelling indications Other antihypertensive Drugs (diuretics, ACEI, ARB BB, CCB) as needed.

Not at Goal Blood Pressure
Optimeze dosages or add additional drugs until goal pressure is achived. Consider consultation with hypertension specialist

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