TUTORIAL HIPERTENSI

2 3.
The cuff must be level with the The column of mercury
heart. If arm circumference must be vertical. Inflate to
1. exceeds 35 cm, a large cuff must occlude the pulse. Deflate
The patient should be be used. Place stethescope at 2 to 3 mm/sec. Measure
relax and the arm must be diaphragm over brachial artery systolic ( first sound) and
supported.. Ensure no thight diastolic (disappearance)
clothing constricts the arm to nearest 2 mmHg

Technique of blood pressure measurement recommended by the British Hypertension Society

Hypertension in the elderly
Blood Pressure should always be taken in the:
* supine or seated position
* standing position immediately and 5 minutes after the
assumption of upright position ( also during treatment)
 Pseudohypertension
 Auscultary gap. The auscultary gap will not be missed if the cuff
is inflated above 250 mmHg and deflated slowly, since the
gap usually occurs between 170 and 230 mmHg.

 Blood pressure variability

Change in systolic and diastolic blood pressure with age

160 SBP
Blood Pressure (mmHg)

140

120

100

DBP
80

60
Age (years)
15-24 25-34 35-44 45-54 55-64 65-74 75-84

Galarza et al. Hypertension, 1997

 Hypertension
Lifestyles, Fitness
and Rehabilitation

• How can I tell if I have High

Blood Pressure?
– Usually NO SYMPTOMS!
– “The Silent Killer”
– May have:
• Headache
• Blurry vision
• Chest Pain
• Frequent urination at night
 Hypertension
Lifestyles, Fitness
and Rehabilitation

• Blood Pressure Measurement

– Sphygmomanometer
– Systolic pressure= pressure when 1st sound is
heard
– “Diastolic pressure= pressure when last sound
is heard
• Blood Pressure Cuff Size
– Small – children and small adults
– Average
– Large – overweight and large adults
 Reduced
Excess Na Nephron Genetic Endothelium
intake Numbers Stress Alterations Obesity derived factors

Decreased
Renal Na Sympathetic RAS Cell-membrane Hyper
filtration
retention Over activity Excess alterations insulinemia
surface

 Fluid Venous
Volume constriction

Functional Structural
 Preload  Contractibility
constriction hypertrophy

Blood pressure=Cardiac Output X Peripheral

HTN and/or Resistance
 Stroke or TIA

Sequelae of
Hypertension
Heart diseases Nephropathy,
Proteinuria, CrCl↑

Retinopathy Peripheral arterial Disease

(atherosclerotic plaque
iliac,carotid, femoral artery,
aorta)
 The Cardiovascular Continuum:
Targeting Mechanisms and Mediators

Maladaptive Cardiovascular Remodeling

Endothelial
Target Organ
Dysfunction
Tissue Injury Pathological Damage
(MI, Stroke) Remodeling
Vascular Disease Target Organ
Dysfunction (CHF,
Renal)
Vascular
dysfunction End-stage
Organ Failure
Risk factors:
Diabetes
Hypertension Death

Adapted from Dzau V, Braunwald E. Am Heart J. 1991 Gibbons 1999

 The JNC VII classification of blood
pressure for adults 18 years old
Category Systolic blood Diastolic blood
pressure (mmHg) pressure (mmHg)

Normal <120 and <80

Prehypertension 120–139 or 80–89
Hypertension3
Stage 1 140–159 or 90–99
Stage 2 ≥ 160 or ≥ 100

Based on JNC VII, National Institutes of Health, Nov. 2003

ESH / ESC 2013 CLASSIFICATION
 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.

Stratification of Risk of HT Patients
ESH/ESC 2007
 Laboratory investigations

Routine tests:

• Hemoglobin and hematocrit

• Fasting plasma glucose
• Fasting serum triglycerides
• Serum total cholesterol, LDL-cholesterol, HDL-cholesterol
• Serum creatinine, potassium, uric acid

• Urinalysis (complemented by microalbuminuria dipstick test and

microscopic examination)
• Estimated creatinine clearance (Cockroft-Gault formula) or glomerular
filtration rate (MDRD formula)
• Electrocardiogram (ECG)
• Thorax X-ray
 Laboratory investigations

Recommended tests

• Echocardiogram
• Carotid ultrasound
• Quantitative proteinuria (if dipstick test positive)
• Ankle-brachial BP index
• Fundoscopy
• Glucose tolerance test (if fasting plasma glucose > 5,6 mmol/l
(102 mg/dL)
• Home and 24h ambulatory BP monitoring
• Pulse wave velocity measurement (where available)
 Lifestyle Modification
Modification Approximate SBP reduction
(range)

Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol 2–4 mmHg
consumption
 Lifestyle Modifications
For Prevention For Overall and
and Management Cardiovascular Health

• Lose weight if • Maintain adequate

overweight intake of calcium and
• Limit alcohol intake magnesium
• Increase aerobic • Stop smoking
physical activity
• Reduce dietary saturated
• Reduce sodium intake fat and cholesterol
• Maintain adequate
intake of potassium
Positive Indications of Major Antihypertensive Drugs
Beta-
CCB ARB/ACEI Diuretics blocker
LVH ● ●
Heart Failure ● ● ●
Af （prevention） ●
Tachycardia ● ●
Angina Pectoris ● ●
Post-MI ● ●
Proteinuria ●
Renal Insufficiency ● ●
Cerebrovascular
Disease (Chronic Phase)
● ● ●

DM/ MetS ●
Elderly Patients ● ● ●
 2007 ESH- ESC Guidelines for the Management of Arterial Hypertension

Initiation of Antihypertensive Treatment

Blood Pressure (mmHg)
Other Risk Factors Normal High Normal Grade 1 HT Grade 2 HT Grade 3 HT
OD or disease SBP 120-129 SBP 130-139 SBP 140-159 SBP 160-179 SBP ≥ 180
or DBP 80-84 or DBP 85-89 or DBP 90-99 or DBP 100-109 or DBP ≥ 110

No BP No BP Lifestyle changes Lifestyle changes Immediate drug

No other risk factors for several months for several WEEKS treatment and
intervention intervention Then
Then drug lifestyle changes
treatment if drug treatment
preferred by the if BP uncontrlled
patient and
resources available
Lifestyle Lifestyle Lifestyle changes Lifestyle changes Immediate drug
1-2 risk factors changes changes for several WEEKS for several WEEKS treatment and
Then drug treatment Then drug treatment lifestyle changes
if BP uncontrlled if BP uncontrlled
3 or more risk factors, Lifestyle changes Lifestyle changes & Drug treatment Drug treatment Immediate drug
consider and and treatment and
MS or OD lifestyle changes lifestyle changes lifestyle changes
drug treatment
Lifestyle changes Drug treatment and
diabetes lifestyle changes

Drug treatment Immediate drug Immediate drug Immediate drug Immediate drug
Estabilished CV or and treatment and treatment and treatment and treatment and
Renal disease lifestyle changes lifestyle changes lifestyle changes lifestyle changes lifestyle changes
 Mild BP elevation
Choose between Marked BP elevation
Low/ moderate CV risk
ESH Conventional BP target
High/ very high CV risk
Lower BP target

ESC
2007 Single agent at low Two-drug combination at
dose low dose

If goal BP not
achieved
Previous Switch to different Previous Add a third
agent at full agent at low dose combination at drug at low
dose full dose
dose

Monotherapy vs combination therapy strategies

 Mild BP elevation
Choose between Marked BP elevation
Low/ moderate CV risk
ESH Conventional BP target
High/ very high CV risk
Lower BP target

ESC
Single agent at Two-drug combination
2007 low dose at low dose

If goal BP not achieved

Previous agent Switch to different

at full dose agent at low dose Previous combination Add a third drug at
at full dose low dose

If goal BP not achieved

Two-to three-drug Full dose Three-drug combination

combination monotherapy at effective doses

Monotherapy vs combination therapy strategies

 Hypertension
Lifestyles, Fitness
and Rehabilitation

• Ten Commandments for Blood

Pressure Control
1
– Know your blood pressure
• Have it checked regularly
2
– Know what your weight should be
• Keep it at that level or below
3
– Don’t use excessive salt in cooking or
at meals
• Avoid salty foods
 Hypertension
Lifestyles, Fitness
and Rehabilitation

• Ten Commandments for Blood

Pressure Control
4
– Eat a low-fat diet
• According to AHA regulations
5
– Don’t smoke cigarettes
• Or use tobacco products
6
– Take your medicine exactly as
prescribed
• Don’t run out of pills even for a single day
 Hypertension
Lifestyles, Fitness
and Rehabilitation

• Ten Commandments for Blood

Pressure Control
7
– Keep your appointments with the doctor
8– Follow your doctors advice about

exercise
9
– Make certain family members have their
blood pressure checked regularly
10
– Live a normal life in every other way!
 HIPERTENSI KRISIS

PENINGKATAN TDS > 180 SECARA PROGRESIF

URGENCY EMERGENCY

(-) TARGET ORGAN (+) TARGET ORGAN

Hypertensive Crises!
When a patient's blood pressure escalates to
dangerous levels, quick action is necessary. You'll
need to assess for—and try to prevent—damage to
the brain, heart, kidneys, and other organs and
initiate treatment quickly. You'll also have to monitor
drug therapy closely so that BP is decreased neither
too slowly nor too rapidly.
4th Asian-Pacific Congress of Hypertension
June 1-4, 2005, Millennium Seoul Hilton, Seoul, Korea
 The Concept of 200
180
Hypertensive Crisis 160
An abrupt rise in BP
140
 120
over 220/120 mmHg, 100
but lower levels are
also possible.

 JNC 7: Severe 120

elevations in BP (> 110
180/120 mmHg) 100
90
80
a situation that requires immediate
70
reduction in blood pressure (BP)

Kaplan: Clinical Hypertension 2002

4th Asian-Pacific Congress of Hypertension
June 1-4, 2005, Millennium Seoul Hilton, Seoul, Korea
 Parenteral Drugs for Treatment of Hypertensive
Emergencies - Vasodilators -

Drugs Onset of action Duration of action

Nicardipine * 5 min 1 hr
Sodium Nitropruside immediate 1-2 min
Fenoldopam < 5 min 30 min
Nitroglycerin * 2-5 min 2-3 min
Enalaprilat 15-30 min 6 hr
Hydralazine 10-20 min 4-6 hr
Diltiazem * 5 min 30 min
Trimetaphan 5-10 min 10 min
* Available in Indonesia
4th Asian-Pacific Congress of Hypertension
June 1-4, 2005, Millennium Seoul Hilton, Seoul, Korea