PENATALAKSANAAN HIPERTENSI

Prof Dr M. Yusuf Nasution, SpPD - KGH

Divisi Nefrologi Hipertensi Bagian Penyakit

Dalam FK. USU / RSHAM
Medan
 HT ?
WHO : ( DULU )

NORMONTENSI SISTOLIK 140 mm Hg

DIASTOLIK 90 mm Hg

BORDERLINE SISTOLIK : 141-159 mmHg

DIASTOLIK : 91-94 mmHg

HIPERTENSI SISTOLIK 160 mmHg

DIASTOLIK 95 mmHg

UMUR X
 Table 2.1 JNC Classification of blood pressure in adults age 18 years and
older
Category Systolic Diastolic
(mm hg) (mm/Hg)
Optimal < 120 and < 80
Normal < 130 and < 85
High normal 130 139 or 85 - 89
Hypertension
Stage I * 140 159 or 90 - 99
Stage II * 160 179 or 100 - 109
Stage III * 180 or 110
* Based on the average of two or more readings taken et each of two or more
visits after an initial screening
In addition to classifying stages of hypertension on the basis of average blood
pressure levels, clinicians should specify presence or absence of target organ
disease and additional risk factors. This specificity is important for risk
classification and decisions about intiation of medical theraphy.
Arch Intern Med. 1997; 157; 2413 - 2446
 PENGOBATAN HT

Tujuan
Menurunkan T.D.

Angka Morbiditas Angka Mortalitas <<

Resiko Komplikasi Target Organ

Bentuk Pengobatan HT

Non Farmaka
Farmaka
Penatalaksanaan Non farmaka
BB
Alkohol (-) Dapat Membantu
Aktifitas Fisik Penurunan TD
Garam

Rokok Stop
Lemak Faktor Resiko
DM Kendalikan
 Tabel 3.1 Lifestyle Modifications For Control Of Hypertension And / Or
Overall Cardiovascular Risk
- Weight loss, if overweight *
- Reductions of sodium intake to less than 100 mmol/day (2.4 of
sodium or approximately 6 g of sodium chloride) *
- Limiting alcohol intake to < 1 oz/day of ethanol (24 oz of beer, or 10 oz of
wine, or 2 oz of whiskey): approximately one half of these amounts for
women and thin people
- Cessation of smoking and reduction of dietary saturated fat and
cholesterol for overall cardiovasculer health; reduced fat intake also helps
reduce caloric intake important for control of weght and type 2 diabetes
- Maintain adquate dietary potassium, clcium, and magnesium intake
- Relaxation techniques biofeedback
- Vegetarian diets, fish oil

* These interventions have been found to be effective

Data on other interventions are not definitive (see text)
Modified from : Arch Intern Med . 1997;157;2413 - 2446
Table 4.1 JNC- IV Risk Strafication Of Hypertension To Guide Treatment Choices *

Blood pressure Stages Intial Theraphy

(mm Hg)
Risk Group A Risk Group A Risk Group A
(No risk factors; no (At least one risk factors, (TOD or evidence of
TOD / CVD) not including diabetes ; CVD and / or diabetes,
No TOD / CVD with / without other
risk factors)

Stage 0 (130 139/85 89) Lifestyle modification Lifestyle modification Medication

Stage 1 (140 159/90 99) Lifestyle modification Lifestyle modification Medication
(up to 6 months) (up to 3 4 months)
Stage 2 and 3 ( 160 / 100) Medication Medication Medication
Abbreviations : JNC VI, Joint National Committee on Ptevention, Detection, Evaluation and Treatment of High
Blood Pressure ; TOD, target organ disease; CVD, clinical cardiovascular disease; LVH, left ventricular hypertrophy

Lifestyle modification should be adjunctive theraphy for all patients recommended for pharmacologic
theraphy
For example, a patient with diabetes and a blood pressure of 142/94 mm Hg plus LVH shoul be classified as having
stage I hypertension with TOD (LVH) and with another major risk factor (diabetes). Patient would be stage I, risk
Group C; pharmacologic treatment should be initiated at the same time as lifestyle modifications.
For patients with multiple risk factors, clinicians should consider drugs as intial theraphy plus lifestyle
modifications.
Penatalaksaan farmakologik
Bila Non Farmaka tidak berhasil

Prinsip pengobatan Hipertensi

HT. Sekunder Mengutamakan Kausal

HT. Essential TD Umur
Komplikasi
T.D diturunkan Obat Anti Hipertensi
Jangka Panjang Seumur hidup
Pemilihan Obat Anti Hipertensi

Aman
Efektifitas Tinggi
Efek Samping ()/ Toksisitas
Oral
Toleransi (-)
Ekonomis/Murah
Jangka Panjang
Pemberian Obat - obat Anti Hipertensi
Pilihan Utama :

Pendekatan Tradisional : Step Care Langkah I

B. Bloker Langkah II
Langkah I
Diuretik / Tiazide Langkah III

Berlanjut Kombinasi
Resistent Vasodilator
Sekarang Langkah I termasuk CA Antagonis
ACEI
Obat-oabt Langkah I : Tiazide
B. Blockers
Ca. Blockers
ACEI ( Blokers )
X Blocker
Obat Sentral
 Table 4.5 JNC VI AND WHO ISH RECOMMENDATIONS
FOR INITIAL ANTIHYPERTENSIVE THERAPHY

JVC VI WHO ISH

1. Diuretics or - blokers 9unless All available drugs classes suitable for initial
contraindicated in special situations) theraphy
Diuretics and - blockers Good data on
outcome
2. Specific indications * for : ACE inhibitors and CCBs Some outcome data
Angiotensin converting enzyme (ACE) Very limited data
inhibitors - blockers ARBS and - blockers
Angiotensin II receptor blockers (ARBs)
Diureties
Calcium channel blockers (CCBs)
3. Low dose combination theraphy appropriate

Abbreviation : WHO ISH, World Health Organization International Society of Hypertension.

* See Tables 15.2 and 15.3

 Diuretik Tiazide
Diberi pada :

Usia Tua
Kulit Hitam
Gagal Jantung Ringan
Cegah :
DM (Maturity Omset)
Hiperuricemia

Efek Samping :
Hipokalemi, Hiperuricemi
Hiperglikemi, Impotensi
Rash
Diskrashia Darah
 Cara Kerja

Kombinasi : Ekresi renal Sodium

Air Vol Darah Dan Kerja langsung
Otot polos Varkular PVR
 KEUNTUNGAN

Murah
Efektif
Mudah Dipakai
1x/hari
Absorbsi Diusus : Baik,Ekresi Ginjal
 . Blockers
Diberi Pada :

Usia muda
Angina (+)
Perokok (-)
MCI (+)
Anxious
 Cegah
Asma Peny. Periperal
Gagal Jantung Brittle IDDM
Blok Jantung

Efek Samping

Bronchospasm Fatigue
Bradikardi Vivid dream
Negatip Inotropik Hiperlipidemia
Tangan dan Kaki dingin Hiperglikemi
- Hiperuricemia
 CARA KERJA

Kompetitip Menghambat Kerja Katekholamin pada

B. Adrenoceptor dan yang lainnya,
Hambatan Masing-masing B1.Receptor (HR < Kontrakliti)
dan B2 Receptor (Vaskular dan otot polos Bronkhial).

Lainnya : Paling Utama Block B1 Receptor dan

kardio selektip.
 Absorbsi
Usus : Baik (terbanyak)
Liver
Ginjal
Dosis
Propanolol :
Mulai : 10 20 mg (2x/hari)
Maintenance : 80 mg (2x/hari)
Maksimum : 320 (2x/hari)

Metoprolol :
Mulai : 50 (2x/hari)
Maintenance : 100 (2x/hari)
Maksimum : 200 (2x/hari)
 Tablet 6.1 Some Commonly Used . Blockers For Treating Hypertension
Recommended Dosage
Generic (Trade) Name Range * Physiologic Effects Comments
Dose (mg) Frequency
Atenolol (Tenormin) 25 100 1 / day Cardiac output; Cardioselective
Plasma renin agents may also
Betaxolol (kerlone) 5 30 1 / day inhibit 2 -
activity;
blood pressure; receptors in hinger
Bisoprolol (Zebeta) 5 10 1 / day
doses (eg, all may
pulse rate aggravate asthma)
Metoprolol (Lopressor) 50 - 200 1 / day

Nadolol (Corgard) 20 240 1 / day

Propranolol (Inderal) 40 240 2 or 3 / day

Propranolol LA (Inderal LA) 80 160 1 / day

 - Blockers With ISA
Acebutolol (Sectral) 200 - 2 / day Lees effect on
800 heart rate and
vasculer and
Carteolol (Cartrol) 2.5 1 / day
bronchial
5.0
smooth muscle
Panbutolol (Levatol) 20 1 / day
Pindolol (Visken) 10 2 / day
40
As in the other tables, not all available
medications are listed. Dosages may also
differ from the manufacturers
Cardioselective
ISA = intrinsic sympathomimetic action
(slight 2 receptor stimulation )
 Table 7.1 Combined 1And -Blockers In The Treatment Of Hypertension
Recommended Dosage Range
Generic (Trade) Dose (mg) Frequency Physiologic Comments
Name Effects
Carvedilol (Coreg) 6.25 25 1 or 2 / day Cardiac output Beneficial effects in
and renal blood heart failure; may
flow maintained, decrease myocardial
blood pressure demage post
decreased, myocardial infarction
antioxidant
effects

Labetalol 200 500 or 2 / day Cardiac output Probably more

(Normodyne, 600 effective in blacks
Trandate) Plasma renin than other -
activity, Blockers ; may cause
postural effects;
blood pressure,
tiration should be
some decrease in
based on standing
pulse rate
blood pressures
 Calcium Antagonist
Diberi pada :
Asthma
Angina (+)
Peny. Periperal Vascular

Cegah :
Verapamil, Diltiazem + Block Jantung
Hati-hati dengan Digoxin, B.Blockers.

Efek Samping :
Flushing
Sakit Kepala
Swelling Ankle
Hiperplasia Gusi/Gigi
 Cara Kerja

Menghambat Transport ion Ca melalui sel.Membrane.

Penting untuk kerja pontensial dan kontraksi otot.
Menurunkan T.D. dengan Vasodilatasi.

Jenis Beda
Nifedipine Cardiac Conducting Tissue
Verapamil (memperlambat hantaran
Diltiazem Atrionodal)
Cardiac Muscle
(mengurangi Kontraktiliti)
P.D. Otot Polos (Vasodilatasi
Perifer)
Dosis
Nifedipin : 10 20 mg 3-4x/hari
Verapamil : 160 mg 3 x/hari
ACEI
Cara Kerja :

Berperan Converting Angiotensin I.

Angiotensin II ( Vasokonstriktor +
Merangsang Sekresi Aldosteron).
Breakdown Bradykinin (Vasodilator) .

T.D PVR
Mencegah Reabsorbsi Sodium oleh :
Aldosteron.
Diberi :
Gagal Jantung (Hati-hati Diuretik)
Peny. Peripheral Vascular

Hati hati :

GG T.U Diuretic Potassium Sparring

(Spironolactone )
NSAID
Cegah :
Stenosis A. Renalis Bilateral
Efek Samping :
Gangguan Pengecapan
Batuk
Hipertensi pada Vol deplesi
Rashes
Neutropenia
Proteinuri
Angioneurotic Oedema

Captopril
Jenis Enalapril
Dll
Dosis & Cara pemakaian
Orang Tua Captopril : 2 x 12,5 mg/h
Enalapril : 1 x 2,5 5 mg/h
GG
Diuretik

Dosis dinaikkan gradual

Fungsi Ginjal Normal

150 mg/h Captopril

40 mg/h Enalapril
Obat obat Lain : Blocker
Prazosin
Cara kerja
Antagonis
Merangsang Vascular 1 receptor
Dilatasi Arteri & Vena
PVR Takhikardi (-)

Dosis dan cara pemakaian

Dosis mula :
Rendah Sinkope (+)
0,5 mg malam hari mau tidur
Naikkan pelan-pelan s/d maksimum 30 mg, 2-3x/hr
Indikasi :
Asthma
Peny. Peripheral Vascular
Gagal Jantung

Efek Samping :

Sinkop Dosis I
Sedasi, Retensi Cairan
Mulut kering
 Methyl Dopa
Cara kerja :
Tak Seluruhnya diketahui
Kerja pada SSP Sympathetic
Outflow

Dosis dan Cara Pemakaian

Dosis besar E.S Muncul Segera (1 gr/h )
Anjuran Dosis : 250 500 mg 3x/h.
GG (+) Dosis (Eksresi melalui ginjal)

Indikasi :
Cegah :
Asthma
Gagal Jantung Depresi
Claudicatio Peny. Hati
DM
Efek Samping

Hepatitis
Anemia Hemolitik
Sedasi
Mulut kering
Impotensi
Table 9.1 Central Agonists

Recommended
Generic (Trade) Dosage Range * Adverse Physiologi Comments
Name Dose Frequency Reactions Effects
(mg)
Colonidine 0.1 0.8 2 / day Dry mounth, Stimulate central Clonidine patch is
(Catapres) drow siness, 2 receptors that replaced once a
headache, inhibit efferent week. None of these
fatigue, sympathetic agents should be
depression activity blood withdrawn abruptly
pressure ; because of rebound
Clonidine 0.1 0.2 1 / week hypertension
peripheral
(Catapres TTS
(patch) resistance ; no
significant effect
Guanabenz 4 16 2 / day on heart rate,
(Wytensin) CO, renal blood
flow or GFR
Guanfacine ) 13 1 / day
Tenex)
Methldopa 250 2 / day Possible
(Aldomet) 1000 immune
reactions
Abbreviations : CO, cardiac output; GFR, glomerular filtration rate
 Tabel 1 SPECIFIC INDICATIONS AND CONTRAINDICATIONS
FOR PARTICULAR ANTIHYPERTENSIVE DRUGS *
Clinical Situation May Have Favorable Effects Requires Contraindicated
Careful Follow
Up
Cardiovascular
Angina pectoris - Blockers, calcium channel - Direct vasodilators
blockers
Bradycardial/heart block, - - - Blockers, labetalol,
sick sinus sybdrome verapamil, diltiazem

Cardiac failure systolic Diuretics, ACE inhibitors, AB Some - Blockers, calcium

dysfunction receptor blockres, 1- -
Blockers (carvedilol), some -
Blockers
Hypertrophic - Blockers,ditiazem, verapamil,
cardiomyopathy with 1 - - Blockers
diastolic dysfunction
(carvedilol)
Hyperdynamic circulation - Blockers
(rapid heart rate)
channel blockers
Diuretics ACE inhibitors, 1
blockers, hydralazine,
minoxidil, AB receptor
antagonists
- Direct vasodilators

Peripheral vascular - - Blockers -

occlusive disease
After mycardial infarction
Renal
Bilateral renal arterial disease
or severe stenosis of artery to
solitary kidney
Renal insufficiency; carly
(serum creatinine 1.5 2.5
mg/dl)
Advanced (serum creatinin
2.5 3.0 mg/dl)
Depression
Diabetes mellitus type 2
(insulin dependent)
Diabetes mellitus type 2
(with or without proteinemia)
Liver disease
Vascular headache (migraine)
* Not all indications or contraindications are listed. See also Tables 15.3 and 15.4
Non ISA - - Blockers, ACE Direct vasodilators
inhibitors (selected patients),
verapmil, or diltiazen
- - ACE inhibitors, AB receptor
antagonists
- - Potassium sparing agents,
postassium supplements
Loop diuretics ACE inhibitors, diuretics, AB Potassium sparing agents,
receptor blokers postassium supplements
- 2 Agonists Reserpine
ACE inhibitors (or possibly AB - Blockers -
receptor blockres) with a
diuretics
ACE inhibitors (or possibly AB Use with caution in patients -
receptor blockers) usually with with serum creatinine > 3
a diuretic, - Blockers / mg/dl
diuretic
- Labetalol Methylopa
- Blockers, - -
nondihydropyridine CCBs