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HIPERTENSI

&
KESEHATAN
JANTUNG
Pusat Jantung Nasional Harapan Kita
UPF Prev-Rehabilitasi Medik
Jakarta

Definisi
Hiper : Berlebihan
Tensi : Tekanan/Tegangan
Hipertensi :
Gangguan sistem peredaran darah yang
menyebabkan kenaikan tekanan darah
diatas nilai normal.

Tekanan Darah
Terdiri dari 2 komponen :
1. Tekanan Sistolik : Tekanan tertinggi saat jantung
memompa (menguncup)
2. Tekanan Diastolik : Tekanan terendah saat jantung
istirahat (mengembang)
Mis : 120/80 ~ 120 : Sistolik
80 : Diastolik
1 Milyar penduduk dunia

Silent killer !!

Kapan disebut Hipertensi ?


Bila tekanan darah > 140/90 mmHg
dari 3 kali pemeriksaan terpisah
(jarak 1 2 minggu)
Diperiksa dalam keadaan
santai
Bila tinggi sekali tidak
perlu beberapa kali

Faktor Risiko Utama Penyakit Kardiovaskular


Hipertensi
Kegemukan
Kurang aktivitas fisik
Merokok
Peminum alkohol ( > 3 gelas perhari )
Dislipidemia ( Kolestrol tinggi )
Diet tinggi kandungan garam
Kencing manis DM
Obat-obatan ( mis : steroid )
Mikroalbuminuria
Usia ( wanita > 55 thn & pria > 45 tahun )
Riwayat keluarga : hipertensi , stroke

Penyebab
Hipertensi Primer
90% Tidak diketahui penyebabnya
Hipertensi Sekunder
10% Berhubungan dengan:
Kelainan Ginjal
Kelainan Hormonal
Kelainan Pembuluh Darah
Dll.. : - Kehamilan
- Alat kontrasepsi
- Rokok

Klasifikasi Hipertensi
Klasifikasi T.D

Sistolik

Diastolik

Normal

<120

dan

<80

Prehipertensi

120-139

atau

80-89

Hipertensi ST. 1

140-159

atau

90-99

Hipertensi ST. 2

>=160

atau

>=100
JNC VII 2003

Gejala Hipertensi
(-)
Rasa berat/sakit bagian belakang kepala
Sulit tidur
Mudah tersinggung
Diagnosispasti:
pasti Mengukur
: Mengukurtekanan
tekanandarah
darah!!!
Diagnosis

Gejala lain
(+ Penyakit lain)
Lemah
Penglihatan kabur
Sakit dada
Napas pendek
Mual/muntah
Berdebar

Mimisan
Gelisah/perubahan
mental
Kesadaran turun
Kelumpuhan

Komplikasi
Kerusakan berbagai organ tubuh
Jantung

LVH (serambi kiri jantung )


Angina - infark otot jantung
Revaskularisasi koroner
Gagal jantung

Komplikasi
Otak
Stroke
TIA
Ginjal
Penyakit ginjal kronis
Pembuluh darah perifer
Mata
Retinopati

Ginjal
Insufisiensi ginjal

Jantung
Hipertrofi ventrikel kiri

Hipertensi

Otak

Gagal jantung kronik


Infark miokard
Penyakit jantung
kongestif
Aritmia

Stroke

Pembuluh darah
Arteriosklerosis
Penyakit pembuluh darah perifer
Penyakit jantung koroner

Paradigma Perjalanan Penyakit Kardiovaskular

PVD

Infark miokard akut


plak tidak stabil

Hipertensi
Dislipidemia
Merokok
Diabetes , dll

Hipertrofi
ventrikel kiri

remodelling

STROKE

Disfungsi endotel
Gagal jantung
kongestif

Disfungsi endotel

Faktor risiko

Disfungsi diastolik

Disfungsi sistolik
ventrikel kiri

Penyakit jantung koroner


aterosklerosis

Disritmia
mati mendadak

Gagal jantung
tahap akhir
KEMATIAN

Hipertensi
Gagal ginjal
tahap akhir

Tekanan
glomerulus
Disfungsi mesangial
sitokin
Proteinuria
sklerosis & fibrosis

Penatalaksanaan
Perubahan gaya hidup

Gagal mencapai target tekanan darah

Medikamentosa : Obat
Tujuan : Mengurangi morbiditas dan mortalitas akibat penyakit
kardiovaskular dan ginjal

Perubahan gaya hidup


1. Memperbaiki gaya hidup
Pelihara agar berat badan dalam rentang normal
BMI : 18,5 - 24,9
2. Pengaturan pola makan
Perbanyak sayur & buah
Makanan rendah lemak kurangi makanan
berkolesterol/kalori naik
3. Kurangi konsumsi garam
4. Olahraga
Berolahraga teratur, minimal 30' perhari
Mis : Jalan, renang, bersepeda
5. Hindari minuman beralkohol
6. Berhenti merokok
7. Hindari stress dan emosi

Hubungan perubahan gaya hidup


dengan tekanan darah
Perubahan gaya hidup

Penurunan berat badan

Jumlah rata-rata penurunan


tekanan darah
520mmHg/10 kg BB

Perencanaan makan

814 mmHg

Diet rendah garam

28 mmHg

Aktivitas fisik

49 mmHg

Mengurangi konsumsi
alkohol

24 mmHg

Strategi Dasar Penurunan Tekanan Darah


DistribusiTD

Sesudah intervensi

Sebelum intervensi

penurunan
TD

Penurunan TD Sistol
(mmHg)
2
3
5

Pengurangan mortalitas (%)


Stroke
PJK
Total
6

14

Keuntungan menurunkan
tekanan darah
Persentasepenguranganinsidens
Stroke

3540%

Infarkmiokard

2025%

Gagaljantung

50%

PENGOBATAN DALAM RANGKA..


PENCEGAHAN PRIMER
PENCEGAHAN SEKUNDER

MEMERLUKAN KOMBINASI OBAT


DALAM WAKTU LAMABERTAHUN-TAHUN

KARENA ITU OBAT-OBAT HARUS YG DAPAT


DITOLERANSI DAN TERJANGKAU

Kapan minum obat ?


Bila tekanan darah > 160/100 mmHg
Terapi biasanya seumur hidup
Konsultasikan dengan dokter mengenai
obat hipertensi anda !!!

Target tekanan darah < 140/90 mmHg

Jangan lupa!!
Kontrol tekanan darah secara teratur dan minum
obat secara teratur
Tekanan darah hanya dapat diketahui dengan
mengukurnya dan bukan sekedar dengan keluhan
ataupun perasaan

K A S I H
T E R I M A

T H

Y O

...It is nice to be an important person but it is important to be a nice person...

Algorithm for Treatment of


Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)


(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling
Indications

With Compelling
Indications

Stage 1 Hypertension

Stage 2 Hypertension

(SBP 140159 or DBP 9099


mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.

(SBP >160 or DBP >100 mmHg)


2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)

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

Drug(s) for the compelling


indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.

Classification and Management


of BP for adults
Initial drug therapy

SBP*
mmHg

DBP*
mmHg

Lifestyle
modification

<120

and <80

Encourage

Prehypertension

120139

or 8089

Yes

No antihypertensive drug
indicated.

Stage 1
Hypertension

140159

or 9099

Yes

Thiazide-type diuretics for most.


May consider ACEI, ARB, BB,
CCB, or combination.

Stage 2
Hypertension

>160

or >100

Yes

Two-drug combination for most


(usually thiazide-type diuretic and
ACEI or ARB or BB or CCB).

BP classification
Normal

Without compelling indication

*Treatment determined by highest BP category.

Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

With compelling
indications

Drug(s) for compelling


indications.

Drug(s) for the compelling


indications.
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB) as
needed.

Definition
HYPERTENSIVE CRISIS
is determined :
- by the rate of BP-rise, rather than actual BP,
- by vascular and organ status.
Form : HYPERTENSIVE EMERGENCY
( Life threatening, uncontrolled hypertension
with acute end-organ damage )
HYPERTENSIVE URGENCY
( Severe but not live threatening )

DEFINITION :
HYPERTENSIVE CRISIS
A severe elevation in BP, generally a SBP > 220 mm Hg and / or
DBP > 120 mm Hg. (JNC-VII, 2004)

1. HYPERTENSIVE EMERGENCIES
Severe elevation in BP complicated by acute target organ
dysfunction, such as coronary ischemia, stroke, intracerebral
hemorrhage, pulmonary edema, or acute renal failure.

2. HYPERTENSIVE URGENCIES
Severe elevations in BP without evidence of target organ
deterioration.

Colhum DA. Oparil S, New Engl. J. Med, 323 : 1177, 1990

Risk factor :
Characteristics that related to Increasing
Risk Become Sick / Illness
Cardiovascular Risk Factor :
Characteristics that related to increasing
Risk become Cardiovascular Disease/
Abnormality

RISK FACTORS OF CORONARY


HEART DISEASE
The Framingham Heart Study, 1948 : the
prevalence of CHD is associated with the
following modifiable or immutable risk factors :
- Advanced aged
- Tobacco use
- Male gender
- Hypertension
- Family history of CHD
- Diabetes mellitus
- Hypercholesterolemia
- Sedentary lifestyel
- Low levels of HDL cholesterol

ATHEROGENESIS
Risk Factors
Smoking
Hypertension
Hyperlipidemia
Others (diabetes, coagulation
abnormalities,
hemocysteinemia,etc)

Fatty streak

Risk Factors for Atherothrombosis


Hypercoagulable states
Homocysteinemia

Life-style (e.g, smoking,


diet, lack of exercise)

Hyperlipidemia

Hypertension
Gender

Diabetes

Infection?

Obesity
Genetics

Age

Atherotrombotic Manifestations
(MI, Ischemic stroke, Vascular death
American Heart Association, Heart and Stroke facts: 1997 Statistical supplement;
Wolf Stroke 1990;21 (SUPPL 2):II-4II-6;Laurila et al. arterioscle TrombVasc bio 1997;17:2910-2913;Grau et
al. Stroke 1997;26;1724-1729; Graham et al JAMA 1997;277: 1775-1781;Brigden Postgrad
Med;101(5);249-262

MAJOR RISK FACTORS FOR CHD


The NCEP Adult (treatment panel identifies Positive Risk Factors (RF)
for CHD
Risk Factors
Family history of early CHD

parent or sibling <55 years of age if male, <65 years of age if female
Age :
male >45 years
Female >55 years or premature menopause without estrogen replacement
therapy (ERT)
Hypertensive (BP > 140/90 mmHg or taking antihypertensive medication)
Curent smoker
Type 2 diabetes
Low HDL-cholesterol (<35 mg/dl)
Negative Risk factor
If HDL-C is >60 mg/dl substract one risk factor

Non traditional Risk factors


Alcohol (moderate consumsumption)
Alcohol raises HDL, stimulates fibrinolysis, reduces fibrinogen levels,
and inhibits aggregation of platelets
Antioxidants
Studies have generally shown reduced CHD risk in individuals
consuming foods high in antioxidant vitamins;
Fibrinogen
Factors associated with elevated fibrinogen include cigarette smoking,
sedentary lifestyle, and high triglyceride levels. Fibric acid
derivatives, estrogen administration, cigarette smoking cessation,
and aerobic reduce fibrinogen levels.

Homocysteine
Deficiencies in folate intake and reduced serum levels elevated
homocystein
Levels. Folate therapy shown to reduce homocysteine levels and improve
Endothelial function. Some hyperhomocysteinemic patients with other
enzyme abnormalities require pyridoxine or vitamin b12
Infectious agents
Local arterial infection (include Chlamydia pneumonia, Helicobacter
pylori, Cytomegalovirus and other herpes virus) cause coronary
atherosclerosis and postangioplasty restenosis.
Causative mechanism include endothelial injury, local inflammation,
smooth muscle proliferation with p53 inactivation, and autoimmunity

Coronary Heart Disease Risk Factors


AHA scientific position

Non modifiable major risk factors :


Increasing age : About four out of five people who die of
CHD are 65 or older. At older age, women who has heart
attacks are more likely than men to die from them within
a few weeks.
Male sex (gender) : Men have greater risk of heart attack
than women, and they have attacks earlier in life. Even
after menopause when womans death rate from heart
diseases increass, it is not as great as mens.

Heredity (including race)


African Americans have more severe
hypertension than Caucasians and a higher risk
of heart disease. Heart disease risk is also
higher among Mexican Americans, American
Indians, native Hawaiians and some Asian
Americans. Most people with a strong family
history of heart disease have one or more other
risk factors.

The Major risk factors that can be modified, treated


or controlled
Tobacco smoke. Smokers risk of heart attack is >2 that
of nonsmokers. Cigarette smoking is the biggest risk
factor for sudden cardiac death. Smokers have 2 4
times the risk of non smokers. Cigarette smoking also
acts with other risk factors to greatly increase the risk for
CHD.

High Blood Cholesterol. Elevated blood cholesterol


rises the risk of CHD. A cholesterol level is also affected
by age, sex, heredity, and diet.

High blood pressure. High blood pressure increases


hearts workload, causing the heart to enlarge and
weaken. It also increases your risk of stroke, heart
attack, kidney failure and congestive heart failure.
Physical inactivity. An inactive lifestyle is a risk factor for
CHD. Regular, moderate-to-vigorous physical activity
helps prevent heart and blood vessel disease. Exercise
helps controlling blood cholesterol, diabetes, and obesity,
as well as help lowering the blood pressure

Obesity and overweight. Excess weight increases the


strain on the heart. It also raises blood pressure and
blood cholesterol and Triglyceride levels, and lowers
HDL levels.
Diabetes mellitus. Diabetes increases your risk of
developing cardiovascular disease. Even when glucose
levels are under control, diabetes greatly increases the
risk of heart disease and stroke. About two third of
people with diabetes die of some form of heart or blood
vessel disease.

Other factors contribute to heart disease risk


Individual response to stress may be a contributing
factor. Some scientis have noted a relationship between
coronary heart disease risk and stress in a persons life,
their health behaviours and socioeconomic status.
Sex hormones play a role in heart disease. Men have
more heart attacts than women do before women reach
the age of menopause. If menopause is caused by
surgery removing the uterus and ovaries, the risk of
heart attack rises sharply.

Hormones also affect blood cholesterol. Female


hormones tend to raise HDL cholesterol and
lower total blood cholesterol. Male hormones do
the opposite.
If you have had a natural or surgical menopause,
you may be considering estrogen replacement
therapy(ERT) or hormone replacement therapy
(HRT). ERT and HRT may increase your risk of
some diseases and heath conditions.

The Cardiovascular Continuum:


Targeting Mechanisms and Mediators
Mild
Endothelial
Dysfunction

Sever
e

Vascular disease
Vascular
dysfunction

Target Organ
Damage

Tissue injury Pathological


remodeling
(MI, stroke)

ACEI

Target organ dysfunction


(HF, renal)
-

ARB
Risk factors:
diabetes
hypertension

Angiotensin II

Adapted 2003 from Dzau V, Braunwald E. Am Heart J. 1991; Gibbons

National Heart, Lung, and Blood Institute


National High Blood Pressure Education Program

U.S. Department of
Health and Human
Services

National Institutes
of Health

National Heart, Lung,


and Blood Institute

The Seventh
Report of the
Joint National
Committee on
Prevention,
Detection,
Evaluation, and
Treatment of
High Blood
Pressure (JNC 7)

CVD Risk Factors


Hypertension*
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.

Chain of events leading to endstage


heart disease
Myocardial
infarction
Coronary
thrombosis
Myocardial
ischaemia

Stroke

Arrhythmia &
loss of muscle
Silent
Angina
Hibernation

CAD

Atherosclerosis
LVH
Risk factors
(CHOL, BP, DM, smoking)
platelets, fibrinogen

Sudden death

Remodelling
Ventricular
dilatation
Congestive
heart failure
End stage
heart
disease