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BAGIAN

ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN
UNIVERSITAS KRISTEN INDONESIA
HIPERTENSI

Dr.dr. SAHALA PANGGABEAN, SpPD


Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE


Hypertension = Increased CO and/or Increaced PR

Preload Contractility Functional Structural


Constriction hypertrophy
Fluid Volume
Volume Redistribution
Sympathetic Renin- Cell Hyper
nervous over- Angiostensin Membran Insulinemia
Renal Decreased activity Excess Alteration
Sodium filtration
Retension surface

Stress Obesity

Excess Genetic Genetic Endothelium


Sodium Alteration Alteration derived
Intake factors
Classification of
Blood Pressure for Adults (JNC VI)
SBP DBP
Category (mm Hg)
(mm Hg)
Optimal < 120 And < 80
Normal <130 And < 85
High-normal 130-139 Or 85-89
Hypertension
Stage 1 140-159 Or 90-99
Stage 2 160-179 Or 100-109
Stage 3 180 Or 110

When SBP and DBP fall into different categories, use the higher
category
Classification and managemen of
blood pressure for adults (JNC VII)
INITIAL GRUG THERAPY

BP SBp* DBp* Lifestyle Without Compelling With Compelling


Classification mmHg mmHg MODIFICATION Indication indication
Normal <120 And <80 Encourage

No Antihypertension Drug(s) for comppelling


Prehypertension 120-139 Or 80-89 Yes
Drug indicated indication
Stage 1 140-159 Or 90-99 Yes Thiazide-type diuretics Drug(s) for the
Prehypertension for most. May consider compelling indications
ACEI,ARB,BB, CCB or Other antihypertensive
combination drugs (diuratics, ACEI,
ARB, BB, CCB) as
Stage 2 <160 Or <210 Yes Two drug combination
needed
Prehypertension for most (usually
Thiazide-type diuretics an
ACEI or ARB or BB or
CCB)

DBP* diagnostic blood pressure, SBP, systotic blood pressure


Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.
*
.
.
Recommendations for Followup
Based On Initial Measurements
Initial Blood Pressure
SBP DBP Followup Recommended

< 130 < 85 Recheck in 2 years


130-139 85-89 Recheck in year, give lifestyle advice
140-159 90-99 Confirm within 2 monts, give lifestyle advice
160-179 100-109 Evaluate/refer to care within 1 month
180 110 Evaluate/refer to care within 7 days
Evaluation Objectives

To identify know causes


To assess presence or absence of target
organ damage and cardiovascular disease
To identify other risk factors or disorders
that might guide treatment
Evaluation Components

Medical history
Physical examination
Routine laboratory tests
Optional tests
MEDICAL HISTORY
Duration and classification of
hypertension
Patient history of cardiovascular
disease
Family history
Symptoms suggesting causes of
hypertension
Lifestyle factors
Current and previous medications
Physical Examination

Blood pressure readings (two or more)


Verification in contralateral arm.
Height, weight, and waist circumference
Funduscopic examination
Examination of the neck, heart, lungs,
abdomen, and extremities
Neurological assessment
Laboratory Tests and Other
Diagnostic Procedure

Determine presence of target organ


damage and other risk factors
Seek specific causes of hypertension
Laboratory Tests Recommended
Before Initiating Therapy

Urinalysis
Complete blood count
Blood chemistry (potassium, sodium,
creatinine, and fasting glucose)
Lipid profile (total cholesterol and HDL
cholesterol)
12-lead electrocardiogram
Optional Tests and Procedures

Creatinine clearance Thyroid-Stimulating


Microalbuminuria hormone
24-hour urinary protein Plasma rennin
Serum calcium activity/urinary sodium
Serum uric acid determination
Fasting triglycerides Limited echocardiography
LDL cholesterol Ultrasonography
Glycosolated Measurement of ankle/arm
hemoglobin index
Examples of Identifiable
Causes of Hypertension
Renovascular disease Primary aldosteronism
Renal parenchymal disease Cushing syndrome
Polycystic kidneys Hyperparathyroidism
Aortic coarction Exogenous causes
Pheochromocytoma
Components of Cardiovascular
Risk in Patients With Hypertension

Major Risk Factors :


Smoking
Dyslipidemia
Diabetes mellitus
Age older than 60 years
Sex (men or postmenopausal women)
Family history of cardiovascular disease
Clinical Risk Factors for Stratification
Of Patients With Hypertension

Heart diseases
Stroke or transient ischemic attack
Nephropathy
Peripheral arterial disease
Retinopathy
Risk Stratification

Risk Group A No risk factors


No target organ disease/clinical cardiovascular disease

Risk Group B At least one risk factor, not including diabetes


No target organ disease/clinical cardiovascular disease

Risk Group C Target organ disease /clinical cardiovascular disease and/or


diabetes.
With or without other risk factors
Treatment Strategies and
Risk Stratification
Blood Pressure
Stages (mmHg) Risk Group A Risk Group B Risk Group C
High-normal Lifestyle modification Lifestyle modification Drug therapy
(130-139/85-89) Lifestyle modification

Stage 1 Lifestyle modification Lifestyle modification Drug therapy


(140-159/90-99) (up to 12 months) (up to 6 months)** Lifestyle modification

Stages 2 and 3 Drug therapy Drug therapy Drug therapy


(160/ 100) Lifestyle modification Lifestyle modification Lifestyle modification

Or those with heart failure, renal insufficiency, or diabetes


For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification
Primary Prevention

Primary prevention offers an opportunity to interrupt


the costly cycle of managing hypertension
A population wide approach can reduce morbidity and
mortality
Most patients with hypertension do not sufficiently
change their lifestyle or adhere to drug therapy enough
to achieve control.
Blood pressure rise with age is not inevitable
Lifestyle modifications have been shown to lower
blood pressure
Goal of Hypertension
Prevention and Management

To reduce morbidity and mortality by the least


intrusive means possible. This may be
accomplished by
- Achieving and maintaining SBP < 140 Hg
and DBP < 90 mm Hg.
- Controlling other cardiovascular risk factors.
Lifestyle Modifications

For Prevention and For Overall and


Management Cardiovascular Health
Lose weight if overweight Maintain adequate intake of
calcium and magnesium
Limit alcohol intake
Stop Smoking
Increase aerobic physical activity
Reduce dietary saturated fat and
Reduce sodium intake cholesterol
Maintain adequate intake of
Potassium
Pharmacologic Treatment

Decreases cardiovascular morbidity and mortality


based on randomised controlled trials
Protects against stroke, coronary events, heart
failure, progression of renal disease, progression
to more severe hypertension, and all-cause
mortality
Special Considerations
In Selecting Drug Therapy

Demographics
Coexisting diseases and Therapies
Quality of life
Physiological and biochemical measurements
Drug interactions
Economic considerations
Drug Therapy

A low dose of initial drug should be used slowly


titrating upward.
Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least 50% of
peak effect remaining at end of 24 hours
Combination therapies may provide additional
efficacy with fewer adverse effects
Classes of
Antihypertensive Drugs
ACE inhibitors
Adrenergic inhibitors
Angiotensin II receptor blockers
Calcium antagonists
Direct vasodilators
Diuretics
Combination Therapies

adrenergic blockers and diuretics


ACE inhibitors and diuretics
Angiotensin II receptor antagonists and diuiretics
Calcium antagonists and ACE inhibitors
Other combinations
Followup
Follow up within 1 to 2 months after initiating therapy
Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
Consider reducing dose and number of agents after 1
year at or below goal.
Causes for inadequate
Response to drug Therapy
Pseudo resistance
Non adherence to therapy
Volume overload
Drug-related causes
Associated conditions
Identifiable cause of hypertension
Hypertensive Emergencies
And Urgencies
Emergencies require immediate blood
pressure reduction to prevent or limit
target organ damage
Urgencies benefit from reducing blood
pressure within a few hours
Elevated blood pressure alone rarely
requires emergency therapy
Fast-acting drugs are available.
Drugs Avaiblable for
Hypertensive Emergencies
Vasodilators Adrenergic Inhibitors
Nitroprusside Labetalol
Nicardipine Esmolol
Fenoldopam Phentolamine
Nitroglycerin
Enalaprilat
Hydralazine
Algorithm for Treatment of Hypertension
(JNC VI)

Begin or Continue Lifestyle Modification

Not at Goal Blood Pressure

Initial Drug Choices

Not at Goal Blood Pressure

Notresponse or Inadequate response


Trpublesome side effect But well tolerated

Subtitute drug, from Add agent from


Different class Different class

Not at Goal Blood Pressure

Continue adding agents from other classes


Consider referral to a hypertension specialist
Algorithm for Treatment of
Hypertension (continued)

Begin or Continue Lifestyle Modifications

Lose weight Maintain potassium


Limit alcohol Maintain calsium and magnesium
Increase physical activity Stop Smoking
Reduce sodium Reduce saturated fat cholesterol

Not at Goal Blood Pressure


Algorithm for Treatment of
Hypertension (continued)

Not at Goal Blood Pressure


Initial Drug Choices
Uncomplicated Specific Indications
Compelling Indications

- Start at low dose and titrate upward


- Low-dose combinations may be appropriate

Not at Goal Blood Pressure


Algorithm for Treatment of
Hypertension (continued)

Not at Goal Blood Pressure


Initial Drug Choices *

Uncomplicated
* Diuretics
* -blockers

Based on randomizet controlled trials


Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices *
Compelling Indications
* Heart failure
- ACE inhibitors
- Diuretics
* Mycardial infarction
- -blockrs (non-ISA)
- ACE inhibitors (with systolic dysfunction)
* Diabetes Mellitus (Type 1) with proteinuria
- ACE inhibitors
* Isolated systolic hypertension (older persons)
- Diuretics preffered
- Long-acting dihydropyridine calcium antagonists

* Based on randomizet controlled trials


Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices *
Specific indications for the following drugs :
- ACE inhibitors
- Angiotensin II receptors blockrs
- - blockrs
- - -blockrs
- -blockrs
- Calcium antagonists
- Diuretics

* Based on randomizet controlled trials


Lifestyle Modifications
(JNC VII)
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patiens with diabetes or chronic kidney disease

Initial Drug Choices

Without Compelling With Compelling Indication


Indication

Stage 1 Stage 2 Drug(S) for the


compelling indications
Hypertension Hypertension (se table *
(SBP 140-159 or DBP (SBP >=160 or DBP
90-99 mmHg >=100 mmHg
Other antihypertensive
drugs ( diuretics, ACEI,
Thiazide -type diuretc To-drug combination for ARB, BB, CCB) as
for most. May consider most (usually thiazide - needed
ACEI, ARB, BB, CCB, type diuretic and ACEI
or combination 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

DBP, diastolic blood pressure, SBP, systolic blood pressure


Drug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin
receptor blocker; BB= beta-blocker; CCB= calcium channel blocker.
Specific Drug Indications

Some antihypertensive drugs may have


favourable affects on co-morbid conditions :

Angina Heart failure


- -blockers - Carvedilol
- Calcium antagonists - Losartan
Atrial tachycardia and Myocardial infarction
fibrillation - Diltiazem
- -blockers - Verapamil
- Nondihydropyridine Calcium antagonists
Specific Indications (continued)

Some antihypertensive drugs may have favourable affects


on co-morbid conditions :
Cyclorsporine-induced Prostatism (benign prostatic
hypertension hyperplasia)
- Calcium antagonists - -blockers
Diabetes mellitus (1 and 2) Renal insufficiency (caution
with proteinuria in renovascular hypertensio
- ACE Inhibitos (preferred) and creatinine > 3 mg/dl [>
265. mol/L])
- Calcium antagonists
Diabetes mellitus (type 2) - ACE inhibitors
- Low-dose diuretics
Dyslipidemia
- -blockers
Specific Indications (continued)
Essential tremor
- Non-cardioselective -blockers
Hyperthyroidism
- -blockers
Migraine
- Non-cardioselective -blockers
- Non-dihydropyridine calcium antagonists
Osteoporosis
- Thiazides
Peri-operative hypertension
- -blockers