Classification of Blood

Pressure for Adults

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  or 110
 180
When SBP and DBP fall into different categories, use the higher category.

slide 2
 Types of hypertension
• Essential Hypertension
hypertension with no apparent cause 90-95%

• Secondary Hypertension
hypertension of known cause
• chronic renal diseases 2.5-5%
• Renovascular diseases 0.5-4%
• Oral contraceptive pills 0.2-1%
• Coarctation of the Aorta 0.1-1%
• Primary aldosteronism 0.1-0.5%
• Pheochromocytoma 0.1-0.2%
 Patho-physiology of Hypertension
• HTN develop gradually over a long period of time.
• The development of HTN requires the adjustment of
several compensatory mechanisms over time.
• Several hypothesis exists for the original
pathogenesis of HTN:
• Excess Na intake
• Renal Na retention
• RAS
• Stress & sympathetic over activity
• Peripheral resistance
• cell membrane and endothlial dysfunction
• Obesity
• insulin resistance
Garry P. Reams & John H. Bauer
 Faktor risiko kardiovaskuler
- Hipertensi
- Merokok
- Obesitas,
- Inaktifitas fisik,
- Dislipidemi,
- Diabetes mellitus,
- Mikroalbuminuri / laju infiltrasi glomerulus < 6 cc/mnt :
Laki-laki usia > 55 th, wanita usia > 65 th.
- Riwayat keluarga dengan riwayat kardiovaskuler dini :
Laki-laki < 50 th, wanita < 65 th.
 kerusakan organ sasaran

- Jantung : LVH
Angina pectoris, Infark miokard
Revaskularisasi coroner

Gagal jantung.

- Otak : stroke atau TIA

- CKD : Penyakit arteri perifer.
- Retinopati.
 Vascular Complications
Komplikasi pada pembuluh darah
• Arterioscelorosis
–  wall:lumen ratio
– remodeling
• Atherosclerosis
– Plaque
• Fibrous cap
• necrotic center
• Fibrinoid necrosis.
• Aortic dissection.
 Retinal complications
• Hypertensive Venous
tapering
retinopathy Increased light
reflexes from
Blurred
arterioles
optic disc

Punctate
hard
exudate

Normal hemorrhage

KW : I - IV
 Cardiac complications
Left ventricular myocardium Coronary vascular bed
(myocardial factor) (coronary factor)

Hypertrophy Dilatation CAD Coronary

Microangiopathy

Decrease in contractility
Abnormal increase in c. resistance

Impairement in LV Impairment of O2 availability

fuction
Coronary insufficiency, MI
Heart failure Heart failure
The left ventricle is markedly thickened in this patient
with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.
 Anti-Hypertensive Drugs
Sites of Action
Blood Cardiac Total
Pressure = Output X Peripheral
Resistance
b-Blockers ACE Inhibitors
AT1 Blockers
a-Blockers
a2-Agonists
CCBs* CCBs
DA1 Agonists
Diuretics Diuretics
Sympatholytics
Vasodilators

* = non-dihydropyridine CCBs
 Petunjuk pemilihan obat pd compelling indications
Obat-obat yg direkomendasikan
Kondisi Risiko
tinggi dgn
Diuretik Penyekat Penghambat Alfa Penghambat Antagonis
compeling
Reseptor ACE Blocker Kalsium Aldosteron
indications
b
Gagal jantung
    

Pasca Infark
Miokard   

Risiko tinggi
peny. Koroner    

DM
   

Peny. Ginjal
kronik  

Pencegahan
stroke
berulang  
DEFINITION :
 HYPERTENSIVE CRISIS
A severe elevation in BP, generally a SBP > 220 mm Hg and / or
DBP > 120 mm Hg. (JNC-VII, 2007 }
 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.
 HYPERTENSIVE URGENCIES
Severe elevations in BP without evidence of target organ
deterioration.
 HYPERTENSIVE CRISIS
DBP >120 mmHg

URGENCY EMERGENCY
 BP within hours < 24 hours  BP within minutes < 1 hours
(PARENTERAL / ORAL) (PARENTERAL)

- Accelerated malignant hypertension

- Hypertensive encephalopathy
- Intracerebral/Subarachnoid hemorrhage
- Acute aortic dissection
- Acute left ventricular failure
- Acute myocardial infarction
- Acute glomerulonephritis
- Eclampsia
KAPLAN NM . Lancet 344:1335,1994
End-Organ Damage Associated Hypertensive Emergencies

End-Organ Damage Type No of Cases (%)

Cerebral Infarction 26 (24.5)
Intracerebral or sub-arachnoid
5 (4.5)
hemorrhage
Hypertensive encephalopathy 18 (16.3)
Acute pulmonary edema 24 (22.5)
Acute congestive heart failure 15 (14.3)
Acute myocardial infarction or unstable
13 (12.0)
angina pectoris
Eclampsia 5 (4.5)
Aortic dissection 2 (2.0)

Zampaglione, et al. AHA ; 27 (1) : 144

MANAGEMENT OF HYPERTENSIVE EMERGENCIES
JNC-VI RECOMMENDATION

• Reduce Mean Arterial BP no More than 25 %

over 2 hours then Reduce to 160 / 100 mm Hg
within 2-6 hours.

• Avoid excessive falls in Blood Pressure

• Titrate with Intravenous antihypertensives.

• Guideline of treatment based on concensus
expert.
Intravenous Drugs for Hypertensive
Emergencies Available in Indonesia

Vasodilators
• Clonidine
• Nitroglicerin
• Sodium Nitropruside
Ca-Antagonist
• Diltiazem Hydrochloride
 COMMONLY USED DRUG IN
HYPERTENSIVE EMERGENCY

DILTIAZEM I.V. (HERBESSER)

 Useful for hypertensive emergency and urgency.
 Acts as calcium slow-channel blockers.
 Dose-dependent :
• Predictable onset of action
• Rapidly reduced BP.
• No rebound on withdrawn
 Adverse effect : bradycardia, hypotension, headache, flushing.
 Has antiischemic and antiarrhythmic effect (class-IV)
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