HYPERTENSION

SEPTRIYANTO DIRGANTARA, M.Si., Apt

Batasan Hipertensi
1. Bila tekanan sistolik >= 140 mmHg, dan
atau tekanan diastolik >= 90 mmHg,
atau sedang mendapat obat
antihipertensi.

2. Dilakukan dua kali atau lebih

pengukuran pada dua kali atau lebih
kunjungan.
Blood Pressure Classification
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Hypertension

Stage 2 >160 or >100

Hypertension
WHO/ISH 2003.
ESC/ESH 2003 .
 Classification of blood pressure levels of the
British Hypertension Society

Category Systolic blood pressure Diastolic blood pressure

(mmHg) (mmHg)

Optimal <120 <80

Normal <130 <85
High-normal 130–139 85–89

Hypertension
Grade 1 (mild) 140–159 90–99
Grade 2 (moderate) 160–179 100–109
Grade 3 (severe) 180 110

Isolated Systolic Hypertension

Grade 1 140 - 159 <90
Grade 2 >160 <90

Brit Med J 2004 328:634-40.

AUSTRALIA 2003
 BP Measurement Techniques
Method Brief Description

In-office Two readings, 5 minutes apart,

sitting in chair. Confirm elevated
reading in contralateral arm.
Ambulatory BP Indicated for evaluation of “white-
monitoring coat” HTN. Absence of 10–20% BP
decrease during sleep may indicate
increased CVD risk.
Self-measurement Provides information on response
to therapy. May help improve
adherence to therapy and evaluate
“white-coat” HTN.

JNC 7 2003
 Office BP Measurement
 Use auscultatory method with a properly calibrated and validated
instrument.
 Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
 Appropriate-sized cuff should be used to ensure accuracy.
 At least two measurements should be made.
 Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.

JNC 7 2003
How to measure blood pressure accurately

 ……… sphygmomanometer
 Patient should be seated and relaxed, preferably for several
minutes prior to the measurement and in a quiet room.
 Appropriate cuff size.
 Average the readings. If the firsty two readings differ by more than 10
mmHg systolic or 6 mmHg diastolic or if the initial readings are high,
take several readings after five minutes of quiet rest, until consecutive
readings do not vary by greater than these amounts.
 Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
…………………..
Australia, 2004
 Box 2 Procedures for blood pressure measurement

When measuring blood pressure, care should be taken to

 ……….. to sit for several minutes in a quiet room before
beginning blood pressure measurements.

 Take at least two measurements spaced by 1-2 min, ………….

 Use a standard bladder ……. but have a larger and a smaller

bladder available for fat and thin arms, respectively.

 Have the cuff at the heart level, whatever the position of the
patient.
 Use phase I and V …………….

 Measure blood pressure in both arms at first visit to detect

possible differences ……………………..

 Measure blood pressure 1 and 5 min after assumption of

the standing position in elderly subjects, diabetic
patients,……………..

 Measure heart rate by pulse palpation (30 s) after the

second measurement in the sitting position.
HIPERTENSI

Tekanan Darah :

• Rata-rata dari  2 kali pemeriksaan

• Pengukuran pada waktu yang berbeda
• Pengukuran pada waktu duduk

12
 TD  kekuatan darah ketika melewati
dinding arteri
 Jenis Hipertensi
Hipertensi Resisten
Hipertensi Emergensi
Hipertensi Urgensi
 Berdasarkan Penyebab
Hipertensi Primer  idiopatik 90-95%
Hipertensi Skunder  Sistemik
Prevalensi Hipertensi 

USA 50 Juta dari total

Penduduk
( 1 dari 4 orang
dewasa)

Indonesia Baliem 0,65%

Sukabumi 28,6%
Etiology

 Primary hypertension
 95% of all cases
 Secondary hypertension
 5% of all cases
 Chronic renal disease – most common
 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.

 Identifiable
Causes of Hypertension
 Sleep apnea
 Drug-induced or related causes
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy and Cushing’s syndrome
 Pheochromocytoma
 Coarctation of the aorta
 Thyroid or parathyroid disease
 Target Organ Damage
 Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
 Categories of hypertensive
end-organ damage

Origin Category
Large arteries Loss of compliance
(Dissecting) aneurysm
Peripheral occlusive arterial disease

Kidney Nephrosclerosis

Birkenhäger and de Leeuw (1992)

OBAT ANTIHIPERTENSI
Hipertensi & Kerusakan Organ Target

21
 Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
 Treatment
Overview
 Goals of therapy
 Lifestyle modification
 Pharmacologic treatment
• Algorithm for treatment of hypertension
 Classification and management of BP for adults
 Followup and monitoring
 Goals of Therapy

 Reduce CVD and renal morbidity and mortality.

 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients

with diabetes or chronic kidney disease.

 Achieve SBP goal especially in persons >50 years of age.

Sign and Symptoms
 Essential HTN is usually
- asymptomatic
- undetected for many years
- headache, BP elevated systolic
beyond 200 mmHg or BP rising
rapidly (can occur in malignant
HTN)
Symptomatic associated with
malignant HTN
 Headache
 Blurred vision
 Chest pain
 Breathlessness
 Nausea, vomiting
 Anxiety, confusion, coma
 Seizures
 Consequences of Malignant HTN
End Organ Complications

Aorta Aortic disection

Brain Hipertensive encepahlopathy
Cerebral Infarction or Haemmorharge
Heart Cardiac failure
Myocardial ischemic or infarction

Kidney Renal failure

Haematuria
Gastrointestinal Anorexia,nausea,vomiting,abdominal
pain
Placenta Eclampsia
Other Micro-angiopathic haemolytic anemia
 Consequences of hypertension

 Cardiac disease
Left ventricular failure
Angina
Myocardial infarction

 Cerebrovascular disease
Transient ischemic attacks
Stroke
Multi-infarct dementia
Hypertensive encephalopathy
Consequences of hypertension

 Vascular disease
Aortic aneurysm
Occlusive peripheral vascular disease
Arterial dissection

 Others
Progressive renal failure
Hypertensive retinopathy
Risk of Hypertension

 Advancing age
 Positive family history of premature
cardiovascular disease
 Smoking
 Hypercholesterolemia
Hypertension is thought to account for :
- One–half of all deaths due to stroke
- Up to one quarter of coronary heart
disease deaths
Isolated Systolic hypertension increase
the risk of :
 stroke and coronary heart disease by
about 40%
 cardiovascular death by about 50%
 heart failure by about 50%
Aetiology of hypertension
 Essential hypertension
(primer/idiopathic hypertension
remain uncertain
(genetic and environmental factors
contribute to development of
hypertension)

 Secondary hypertension
Secondary hypertension

 Renal parenchymal disease, causes :

- the glomerulonephritides
- diabetic nephropathy
- analgesic nephropathy
- adult polycystic kidney disease
 Renal artery stenosis
 Primary hyperaldosteronism
 Phaeochromocytoma
Secondary hypertension
 Aortic coarctation
 Cushing’s syndrome
 Drug induced hypertension
- the oral contraception pill
- steroids
- NSAID
- immunosuppressive
- sympathomimetics
- anabolic steroids
- erythropoieti n
- monoamin oxidase inhibitors
 Thyrotoxicosis
 Rare monogenic syndrome
Clinical assesment of hypertension
 Sign and symptoms
 Pointers to secondary hypertension
 Features of malignant hypertension
 End organ damage
 Hypertensive nephropathy
 Left ventricular hypertrophy
 Hypertensive retinopathy
 Grades of hypertension retinopathy
Grade Features
I Mild narrowing or sclerosis of the retinal
arteriole, no symptoms,
Good general health
II Venous compression at artriovenous
crossing (A-V nipping) no symptoms,
good general health
III Retinal oedema, cotton wool spots,
hemmorhages, often symptoms
IV All above
Papiloedema,Symptomatic
Cardiac and renal function often
impaired, reduced survival
Treatment
 Non Pharmacotherapy
(lifestyle modification)
 Pharmacotherapy
Pengobatan

Tujuan:

ANGKA KESAKITAN
KERUSAKAN ORGAN TARGET
ANGKA KEMATIAN
 Sasaran Pengelolaan
Menilai gaya hidup dan identifikasi faktor
risiko kardiovaskular lain atau gangguan
yang menyertai yang dapat
mempengaruhi prognosis & pengobatan
Mengetahui penyebab tekanan darah
yang tinggi
Menilai adanya kerusakan organ dan
penyakit kardiovaskular

40
Strategi Penatalaksanaan Hipertensi
JNC:
 Preventif
 Deteksi
 Evaluasi
 Pengobatan
JNC VI, 1997
Preventif
 Untuk mencegah atau memperlambat terjadinya
Hipertensi

 Merupakan solusi jangka panjang masalah hipertensi

 Mencegah terjadi komplikasi

 Dapat menghentikan atau mengurangi biaya

pengobatan dan komplikasi

NHBPEP Working Group Report on Primary Prevention of Hypertension

Preventif

 Upaya preventif primer:

Terhadap individu yang potensial
hipertensi:
TD normal tinggi
Riwayat keluarga hipertensi
Obesitas
Konsumsi tinggi garam
Kurang aktifitas
Konsumsi tinggi alkohol

 Diharapkan prevalensi Hipertensi turun

Intervensi Preventif Primer
Terbukti Efektif
Efektif terbatas

 Turunkan BB  Manajemen Stres

 Kurangi Garam  Kalium
 Kurangi Alkohol  Minyak Ikan (Fish oil)
 Olah Raga  Kalsium
 Magnesium
 Serat
 Cegak makronutrien
Deteksi
 Dilakukan di fasilitas kesehatan
dengan alat ukur yang standar dan
cara yang benar
 Pasien diberitahu tentang makna
TDnya
 Pasien dianjurkan melakukan
pemeriksaan periodik sesuai dengan
TD pertama

 Diharapkan ditemukan kasus tahap

awal
Evaluasi
 Mencari penyebab hipertensi
(sekunder)

 Memeriksa adanya kerusakan organ

target dan penyakit lain

 Mencari faktor risiko

 Mengetahui respon pengobatan, efek

samping dan kepatuhan pasien
 WHO-ISH Guidelines for Management
of Hypertension: Stratification of
Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1 Grade 2 Grade 3
Mild Moderate Severe
hypertension hypertension hypertension
Other risk factors and SBP 140–159 SBP 160–179 SBP  180
disease history or DBP 90–99 or DBP 100–109 or DBP  110
I No other risk factors Low risk Med risk High risk
II 1–2 risk factors Med risk Med risk Very high risk
III 3 or more risk factors High risk High risk Very high risk
or TOD or diabetes
IV ACC Very high risk Very high risk Very high risk

TOD = Target-organ damage Guidelines subcommittee. WHO-ISH

ACC = Associated clinical conditions Guidelines. J Hypertens 1999;17:151-183.
BP TARGETS:

WITHOUT COMPLICATION : <140/80 mmHg

DIABETES : < 130/80 mmHg

CKD : < 130/80 mmHg

PROTEINURIA > 1 g/d : <125/75 mmHg

 Lifestyle Modification
Modification Approximate SBP
reduction
(range)
Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH 8–14 mmHg

eating plan
Dietary sodium 2–8 mmHg
reduction
Physical activity 4–9 mmHg
Moderation of 2–4 mmHg
alcoholconsumption
Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four or five times per week

I Intensity - Moderate

T Time - 45-60 minutes

Type Dynamic exercise

- Walking
T - Cycling
- Non-competitive swimming

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
Treatment of Hypertension
 Diuretic
 ACE-Inh
 ARB
 Beta blocker
 Alpha blocker
 Direct renin inhibitor
Treatment Algorithm for Adults with Systolic-
Diastolic Hypertension without another
compelling indication

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Long-acting Beta-
Thiazide ACE-I ARB
DHP-CCB blocker

Alpha-blocker
as initial
monotherapy
Indications for
Pharmacotherapy
 Strongly consider prescription if:
 Average DBP equal or over 90 mmHg and:
Hypertensive Target-organ damage (or CVD) or
Independant cardiovascular risk factors
 Elevated systolic BP
 Cigarette smoking
 Abnormal lipid profile
 Strong family history of premature CV disease
 Truncal obesity
 Sedentary Lifestyle

– Average DBP equal or over 80 mmHg and

diabetes
 Diuretics

-blockers AT1 receptor

blockers

α-blockers Ca Antagonist

ACE Inhibitors

2003 Guidelines for Management of Hypertension, J of Hypertension 2003

C.I. : Verapamil + ßBlocker ESH-ESC 2003

JNC 7: Management of Hypertension by
Blood Pressure Classification
Initial Drug Therapy
Lifestyle Without Compelling With Compelling
BP Classification Modification Indication Indication

Normal Encourage
<120/80 mm Hg

Prehypertension Yes No drug indicated Drug(s) for the compelling

120-139/80-89 mm Hg indications

Stage 1 hypertension Yes Thiazide-type diuretics Drug(s) for the compelling

140-159/90-99 mm Hg for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Stage 2 hypertension Yes 2-drug combination for most
≥160/100 mm Hg (usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;
CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed
 Compelling Indications for
Individual Drug Classes
Compelling Initial Therapy Clinical Trial
Indication Options Basis

Diabetes THIAZ, BB, ACE, NKF-ADA

ARB, CCB Guideline, UKPDS,
ALLHAT
NKF Guideline,
Chronic kidney ACEI, ARB Captopril Trial,
disease RENAAL, IDNT,
REIN, AASK

Recurrent stroke THIAZ, ACEI PROGRESS

prevention
JNC 7 2003