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PENATALAKSANAAN HIPERTENSI

TERKINI :
FOKUS PADA JNC 8

WACHID PUTRANTO
Divisi Ginjal Hipertensi
Fakultas Kedokteran UNS/RS.Dr. Moewardi
Surakarta

Suatu keadaan klinis dimana tekanan darah


seseorang lebih tinggi daripada tekanan
darah normal
Epidemiologi :
Jumlah penderita hipertensi di seluruh dunia :
1 milyar
USA : 65 juta
Indonesia ? : belum ada data resmi
Conlin PR, Int J Clin Pract 2005; 59(2):214-24

Prevalensi Hipertensi

prevalence of hypertension (%)

70
60

SBP > 140 mm Hg


DBP > 90 mm Hg

64

65

70-79

80+

54

50

44

40
30
20

21
4

11

18-29

30-39

10
0
age (yrs)

40-49

50-59

60-69

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension complication
Eyes
retinopathy

Brain
stroke

Target Organ damage!!


Damages depend on:

Kidneys
renal failure

Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure

Peripheral arterial disease

How high of the blood


pressures

How long the


uncontrolled and
untreated high blood
presure

Blood Pressure Reduction Of 2 mmHg


Reduces The Risk Of CV Events by 710%
Meta-analysis of 61 prospective, observational studies

1 million adults
12.7 million person-years
2 mmHg
decrease in
mean SBP

7% reduction in risk
of ischaemic heart
disease mortality

10% reduction in risk


of stroke mortality

Lewington et al. Lancet 2002;360:190313

ASH/ISH

HYPERTENSION
GUIDELINES

CLASSIFICATION
HYPERTENSION
BP

BP

SBP

Optimal

<120

DBP
and

<80

SBP

DBP

Normal

<120 and

<80

High Normal

130-139

85-89

80-89

HT stg 1

140-159

90-99

Stg 1

120-139 or
140-159 or

90-99

HT stg 2

160-179

100-109

Stg 2

160 or

100

HT stg 3

180

110

ISH

140

<90

Normal
Pre HT

BP

SBP

Optimal

<120

and

<80

Normal

<130

and

<85

High Nml

130-139

or

85-89

HT stg 1

140-159 or

90-99

HT stg 2

160-179 or

100-109

HT stg 3

180

120-129and./or 80-84

and

DBP

or

110

JNC 8
No definition of HT

Topic
Methodology

JNC 7
Non systematic literature review by
expert committee including a range
of study design
Recommendation based on consensus

2014 Hypertension Guidelin

Critical questions and review criteria defined by expert


panel with input from methodology team
Initial systematic review by methodologist restricted to
RCT evidence
Subsequent review of RCT evidence and recommendations
by the panel according to a standardized protocol
Definitions
Defined hypertension and prehypertension Definision of hypertension and prehypertension not
addressed, but tresholds for pharmacologic treatment
were defined
Treatments
Separate treatmen goals defined for
Similar treatment goals defined for all hypertensive
Goals
uncomplicated hypertension and for
populations except when evidence review supports
subsets with various comorbid condition
different goals for a particular subpopulation
Lifestyle
Recommended lifestyle modifications
Lifestyle recommendations recommended by endorsing
Recommendation based on literature review and expert
the evidence based recommendations of the Lyfestyle
opinion
Work Group
Drug therapy
Recommended 5 classes to be considered
Recommended selection among 4 specific medications
as initial therapy for most patients without
classes ( ACEI or ARB, CCB or Diuretics) and doses based
compelling indication for another class
on RCT evidence
Specified particular antihypertensive
Recommended specific medication classes based on
medication classes for patients with
evidence review for racial, CKD, and diuretics sub group
compelling indication,ie,diabetes,CKD,heart Panel created a table of drugs and doses used in the
failure,myocardial infarction,stroke,high
outcome trials
CVD risk

Scope of topics

Review process
Prior to
Publication

Included a comprehensive table oral


Antihypertensive drugs including names
and usual dose ranges
Addressed multiple issues ( blood pressure
Evidence review of RCTS addressed a limited
measurements methods,patients evaluation
number of questions,those judge by the panel
components,secondary hypertension,
to be of highest priority
adherence to regimens,resistant hypertension,
and hypertension in special populations) based
on literature review and expert opinion
Reviewed by the National High Blood pressure
Reviewed by experts including those affiliated
Education Program Coordinating Committee,
with professional and public organizations and
a coalition of 39 major professional,public, and federal agencies; no official sponsorship by any
voluntary organizations and 7 federal agencies
organization should be inferred

The Process
Literature review 1/1/1966 12/31/2009

Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4) Kriteria inklusi/eksklusi.

9 Recommendations

A
B
C

D
E
N

Recommendation

Strength of
Recommendation

Recommendation 1
Populasi berusia
60 yrs,mulai
terapi
farmakologi SBP150 mmHg, DBP90 mmHg

Grade A
HYVET, Sys-Eur, SHEP, JATOS, VALISH,
CARDIO-SIS

Corollary Recommendation
Populasi usia 60 yrs, jika terapi farmakologi
mengakibatkan penurunan TD lebih rendah
(<140/90) dan pengobatan ditoleransi dengan
baik tanpa efek samping, teruskan pengobatan.
Usia ini TD <140 tidak lebih baik disbanding
140-160

Grade E

Recommendation 2
Populasi usia <60 yrs, terapi farmacologi bila
DBP90 mmHg . Target DBP<90 mmHg

Grade A (30-59 yrs)


Grade E (18-29 yrs)
HDFP, HT-Stroke Cooperative, MRC,
ANBP, VA cooperative

Recommendation

Strength of
Recommendation

Recommendation 3
Populasi usia <60 yrs, terapi farmacologi bila
SBP 140 mmHg.Target SBP<140 mmHg

Grade E

Recommendation 4
Populasi usia 18 yrs dengan CKD, terapi
farmacologi bila SBP 140 mmHg or DBP 90
mmHg . Target SBP <140 mmHg dan DBP <90
mmHg

Grade E
AASK, MDRD, REIN-2

Recommendation 5
Populasi usia 18 dengan DM, terapi
Grade E
farmacologi bila SBP 140 mmHg atau DBP 90
mmHg. Target SBP<140 and DBP <90
SHEP, Syst-Eur, UKPDS, ACCORD,
ADVANCE, HOT

Recommendation

Strength of
Recommendation

Recommendation 6
Pada populasi non black , termasuk dg DM,
initial anti HTN treatment : a thiazide type
diuretic, CCB, ACEI or ARB

Grade B
VA-cooperative, HDFP, SHEP

Recommendation 7
Populasi kulit hitam, termasuk dg DM, initial
anti HT: thiazide-type diuretic or CCB

Grade B ( No DM)
Grade C ( DM)
ALLHAT

Recommendation 8
Populasi usia 18 dg CKD dan HTN, initial (or
add on) anti HTN : ACEI or ARB utk
memperbaiki kidney outcomes. Tanpa melihat
ras atau status DM

Grade B
IDNT, AASK

Recommendation

Strength of
Recommendation

Recommendation 9
Tujuan treatment HTN adalah untik mencapai dan
mempertahankan target BP
Jika target BP tidak tercapai dlm 1 bl, naikkan dosis
atau tambahkan 2nd 1 obat dr rekomendasi 6
(thiazide-type diuretic, CCB, ACEI, or ARB)
Jika target BP tidak tercapai dg 2 obat, tambah dan
titrasi obat 3rd . Do not use an ACEI and an ARB
together
Jika target BP tidak dapat tercapai dg obat-obat pada
recommendasi 6 krn kontraindikasi atau butuh >3
obat, obat antiHT dari kelas lain bias digunakan.
Referral kepada hypertension specialist jika BP tidak
tercapai atau untuk management komplikasi.

Grade E

Strategies to Dose Antihypertensive Drugs


Strategies

Description

Details

Mulai 1 obat naikan sp


dosis
maksimum,kemudian
tambahkan obat ke-2

Jika target BP blm tercapai naikkan dosis


obat 1 sp dosis maksimum sblm
menambahkan obat ke-2 dan ke-3.

Mulai 1 obat kemudian


tambahkan obat ke-2
sblm dosis maksimum

Tambahkan obat ke-2 sblm obat 1


mencapai dosis maks.Jk Target BP blm
tercapai,tambahkan obat ke-3 dan
titrasi sp dosis maks.

Mulai dengan 2 obat


(separate or single
combination)

Mulai dg 2 obat
Bbrp committee merekomendasi:
2 obat SBP >160 dan/atau DBP
>100, atau SBP >20 mmHg diatas
target dan/atau DBP >10 mmHg
Jika target BP tdk tercapai (2 drugs),
tambahkan obat ke-3 dan titrasi.

Lifestyle Modification

JNC 8

JNC 7

G
U
I
D
E
L
I
N
E
C
0
M
P
A
R
I
S
O
N
GOAL BP
INITIAL TX

Guideline
2014 HT
Guideline

ESH/ESC

Population

Goal BP

Initial drugs

General 60 y

<150/90

General <60 y
DM

<140/90
<140/90

CKD

<140/90

Non Black: thiazide type diuretic, ACEI,


ARB or ARB
Black: thiazide type-diuretic or CCB
Thiazide type diuretic, ACEI, ARB or
CCB
ACEI or ARB

CHEP

General (non
elderly)
General elderly
<80 y
General 80 y
DM
CKD (no
proteinemia)
CKD +
proteinemia

<140/90

Bocker, diuretic, CCB, ACEI, ARB

<150/90
<150/90
<140/85
<140/90

ACEI or ARB
ACEI or ARB

<130/90

General <80 y

<140/90

General >80 y
DM

<150/90
<130/80

CKD

<140/90

Thiazide, Blocker (<60y), ACEI (nonblack) or


ARB
Add CVD risk: ACEI or ARB
No CVD risk: ACEI/ARB/Thiazide/DHPCCB
ACEI or ARB

Guideline

Population

Goal BP

Initial drugs

ADA

DM

<140/80

ACEI or ARB

KDIGO

DM and CKD
alb exc <30
mg/d
DM and CKD
alb exc >30
mg/d

140/90

ACEI or ARB

NICE

General <80 y
General 80 y

<140/90
<150/90

<55 y; ACEI or ARB


55 y or black; CCB

ISHIB

Black, lower risk


TOD or CVD risk

<135/85
<130/80

Diuretic or CCB

JNC 7

General
CKD
DM

<140/90
<130/80
<130/80

130/80

ACEI or ARB

Important Variables For HTN Recommendations


BP

NICE

ESC/ESH

ASH/ISH AHA/AC
C/CDC

Definition
HTN

140/90
and
daytime
ABPM
135/85

140/90

140/90

Drug th/ in
low risk
pts after
non pharm
th/
Blocker
as 1st line

160/100 140/90
or daytime
ABPM
150/95

No

Yes

140/90

No

140/90

140/90

No

JNC 7

JNC 8

Pre HT 120-139
or 80-89
Stg 1 HT
140-159 or 9099
Stg 2 HT
160 or 100

Not
addressed

140/90

<60 y,
140/90
60 y,
150/90

No

No

NICE

ESH/ESC

ASH/ISH

AHA/ACC
/CDC

JNC 7

JNC 8

Diuretic

Chorthalidone
(CTD)
Indapamide (IND)

Thiazides
(THZ),
CTD
ND

THZ
CTD
IND

THZ

THZ

THZ
CTD
IDP

Initiate
th/ with
2 drugs

Not
mentioned

Pts w/
markedly
elevated BP

160/90

160/100

160/100

Not
mentioned

<140/90

<160/90
(<60 y)

BP
target

<140/90
80 y,
<150/90

<140/90
<140/90
Elderly <80 80 y,
SBP 140<150/90
150, in fit
pts SBP
<140
Elderly 80
y SBP 140150

<140/90

60 y,
<150/90

Under JNC 8, in all cases, targets BP should be reached within


a month of starting treatment either by increasing the dose or
by using a combination drugs
In patients 60 yrs who do not have DM or CKD, the goal BP
level is <150/90 mm Hg

In pts 18 - 59 yrs without major comorbidities target BP


<140/90, and in patient 60 yrs without DM, CKD, or both, the
new goal BP is <150/90 mm Hg

JNC 8 panel recommended thiazide-type diuretics as initial


therapy for most patients (include newly diagnosed HTN)

JNC 8 also recommend lifestyle interventions include use of the


DASH eating plan, weight loss, reduction in sodium intake to
<2.4 gr/day, and at least 30 minutes of aerobic activity most
days of the week
Under the JNC 8 guidelines, patients would receive a dosage
adjustment and combinations of the 4 first-line & later line
therapies ACEI/ARB, CCB, and thiazide-type diuretic
The JNC 8 does not recommend -blockers and -blockers as 1st
therapy due to 1 trial that showed a higher rate of CV events
with use of B compared with use of an ARB, and another trial
in which B resulted in inferior CV outcomes compared with use
of a diuretic

When initiating therapy, patients of African descent


without CKD should use CCBs and thiazides instead of ACE
inhibitors

ACE inhibitors and ARBs should not be used in the same


patient simultaneously