THE COMPARISON OF PERKI

2015 AND ESC 2018 GUIDELINE

OF HYPERTENSION
Oleh :
dr. Luh Putu Previyanti Dharma Putri
Pembimbing :
dr. Ida Bagus Rangga Wibhuti, Sp.JP (K)
INTRODUCTION
• Lowering blood pressure (BP) can substantially reduce premature
morbidity and mortality

• BP control rates remain poor world wide and are far from satisfactory

• Hypertension remains the major preventable cause of cardiovascular

disease (CVD) and all-cause death globally
 DEFINITION & CLASSIFICATION OF
HYPERTENSION
• Hypertension is defined as office SBP values >_140 mmHg and/or
diastolic BP (DBP) values >_90 mmHg.
SCORE
System
• The SCORE system estimates the 10 year risk of a first fatal
atherosclerotic event,in relation to age, sex, smoking habits,
total cholesterol level, and SBP.
• Applied not only to patients aged 40–65 yo but recently
adapted to patient >65 yo
• Classified to very high risk, high risk, moderate risk and low
risk (Tabel 5)
 HMO
D
• “hypertension-induced structural and/or functional changes in
major organs (i.e. the heart, brain, retina, kidney, and vasculature)”
• Consideration :
• Not all features of HMOD are included in the SCORE system
• The presence of HMOD is common and often goes undetected
• the presence of multiple HMODs in the same patient is also
common, and further increases CV risk
• Inclusion of HMOD assessment is important in patients with
hypertension (misclassified as having a lower level of risk by the
SCORE system)
PERKI
2015
ESC
2018
PERKI
2015
• Terapi farmakologi pada hipertensi dimulai bila pada pasien hipertensi
derajat 1 yang tidak mengalami penurunan tekanan darah setelah > 6
bulan menjalani pola hidup sehat dan pada pasien dengan hipertensi
derajat ≥ 2.
• Pada kasus high-normal BP tidak di rekomendasikan untuk inisiasi anti
hipertensi
ESC
2018
PERKI
2015
ESC 2018
Core drug treatment strategy for
uncomplicated hypertension
 REKOMENDASI
PERKI 2015
Pada pasien PJK yang mendapatkan obat anti
Rekomendasi hipertensi, rekomendasinya :
Terapi Hipertensi • Target SBP kurang dari sama dengan 130, jika
Pada dapat di toleransi, tetapi tidak kurang dari
Penyakit Jantung 120
• Pada pasien usia tua (>65 th), target SBP
Koroner antara 130-140
• Target DBP <80, tidak <70

• Pada pasien dengan riwayat MI, beta blocker

dan RAS blocker direkomendasikan sebagai
terapi
• Pada pasien dengan angina simptomatik,
beta blocker dan/atau CCB
direkomendasikan
ESC 2018
Hypertension and
CAD
 Drug treatment strategy for
hypertension and coronary artery disease
ESC 2018 : Hypertension and CKD
 Drug treatment strategy for
hypertension and chronic kidney disease
 REKOMENDASI
• Pada pasien hipertensi dengan penyakit jantung, target tekanan
darah sistolik adalah < 140 mmHg
• Diuretik, betablocker, ACEi, ARBs dan atau MRA merupakan
PERKI 2015 obat yang direkomendasikan pada pasien hipertensi dengan
gagal jantung untuk menurunkan mortalitas dan rehospitalisasi
Rekomendasi • Pada pasien gagal jantung dengan fraksi ejeksi yang masih baik,
Terapi Hipertensi tekanan darah sistolik perlu untuk diturunkan hingga < 140
mmHg
Pada Penyakit • Pengobatan yang bertujuan untuk memperbaiki gejala (diuretic
untuk kongesti, betablocker untuk menurunkan laju nadi, dll)
Jantung Non harus tetap diutamakan
Koroner • Pemberian ACEi atau ARBs ( dan betablocker dan MRA, bila
terdapat gagal jantung) harus dipertimbangkan sebagai terapi
antihipertensi pada pasien dengan risiko terjadinya AF atau
yang berulang

• Semua pasien dengan hipertrofi ventrikel kiri direkomendasikan

untuk mendapat terapi antihipertensi
• Pada pasien dengan hipertrofi ventrikel kiri, perlu
dipertimbangkan untuk memulai terapi dengan obat yang
terbukti dapat mengurangi hipertrofi ventrikel kiri, seperti ACEi,
ARBs dan CCB
 ESC 2018 :
Hypertension and HF /
LVH
Drug treatment strategy for
hypertension and HFrEF
 REKOMENDASI
PERKI 2015
Rekomendasi • Pada pasien hipertensi dengan fibrilasi atrial
harus dinilai kemungkinan terjadinya
Terapi tromboemboli, pertimbangkan pemberian
Hipertensi antikoagulan kecuali bila terdapat kontraindikasi
Pada
Atrial Fibrilasi • Pada pasien dengan kondisi ini yang di
rekomendasikan adalah Beta Blocker atau CCB
non-dihidropiridin
• Pemberian ARBs dan betablocker merupakan
terapi pilihan untuk pencegahan fibrilasi atrial
pada pasien hipertensi yang telah memiliki
gangguan organ jantung
ESC 2018 : Hypertension and AF
Drug treatment strategy for
hypertension and AF
 Resistant Hypertension

“Resistant to treatment when the recommended treatment

strategy fails to lower office SBP and DBP values to
<140 mmHg and/or <90 mmHg, respectively, and the
inadequate control of BP is confirmed by ABPM or HBPM in patients
whose adherence to therapy has been confirmed”
 Pseudo-Resistant Hypertension

• Poor adherence to prescribed medicines

• White-coat phenomenon
• Poor office BP measurement technique
• Marked brachial artery calcification
• Clinician inertia
• Other causes of resistant hypertension
• Lifestyle factors, Obstructive sleep apnoea,
undetected secondary hypertension, advanced HMOD
(CKD)
Characteristic of Resistant Hypertension
 Diagnostic approach to resistant
hypertension
• The patient’s history : lifestyle characteristics, alcohol and
dietary sodium intake, interfering drugs or substances, and
sleep history.
• The nature and dosing of the antihypertensive treatment.
• A physical examination: focus on determining the presence of
HMOD and signs of secondary hypertension
• Confirmation of treatment resistance by out-of-office BP
measurements (i.e.ABPM or HBPM).
• Laboratory tests : electrolyte (hypokalaemia), associated risk
factors (diabetes), organ damage (advanced renal
dysfunction),and secondary hypertension.
• Confirmation of adherence to BP-lowering therapy.
Management of Resistant Hypertension
 Secondary hypertension

• Secondary hypertension is hypertension due to an identifiable cause,

which may be treatable with an intervention specific to the cause.
• The prevalence of secondary hypertension is reported to be 5–15% of
people with hypertension
Characteristic Patients with suspicion of
Secondary hypertension
Common Causes of Secondary hypertension
Incidence and typical causes of secondary hypertension according to age
 Hypertension urgencies and
emergencies
Hypertension emergencies : “situations in which severe hypertension (grade
3) is associated with acute HMOD,  life threatening and requires immediate
but careful intervention to lower BP”

Typical presentations of a hypertension emergency :

• Patients with malignant hypertension (HT stage 3 with one of : flame
haemorrhages and/or papilloedema, disseminated intravascular
coagulation, encephalopathy, AHF, and acute deterioration in renal
function).
• Patients with severe hypertension associated with other clinical conditions
(aortic dissection, IMA, AHF)
• Patients with sudden severe hypertension due to phaeochromocytoma
• Pregnant women with severe hypertension or preeclampsia
 3. Hypertension urgencies and emergencies
The most common emergency symptoms will depend of the organs
affected :
- Headache
- Visual disturbances
- Chest pain
- Dyspnoea
- Dizziness, and other neurological deficits

“Hypertension urgency” :
Severe hypertension in patients presenting to the emergency
department in whom there is no clinical evidence of acute HMOD
Diagnostic workup for patients with a suspected
hypertension emergency
Target BP reduction in HT emergencies
White-coat and Masked hypertension
 Hypertension in Younger Adults (<50 y.o)

• There is a greater likelihood of detecting secondary hypertension in

younger patients (<50 years)
• Long-term epidemiological studies have demonstrated a clear
relationship between BP and longer-term risk of CV events and
mortality in young adults with a BP >130/80 mmHg.
• All younger adults with grade 2 or more severe hypertension should
be offered lifestyle advice and drug treatment
• Earlier treatment can prevent more severe hypertension and the
development of HMOD
• In younger patients with hypertension treated with BP-lowering
medication, office BP should be reduced to ≤130/80 mmHg if
treatment is well tolerated
 Hypertension Older Patients (>65 y.o)

• The prevalence of hypertension increases with

age,with a prevalence of ~60% over the age of 60
years and ~75% over the age of 75years.
• Inappropiate approach : “potential poor tolerability,
and even harmful effects of BP-lowering interventions
in people in whom mechanisms preserving BP
homeostasis and vital organ perfusion may be more
frequently impaired”
 Hypertension Older Patients (>65 y.o)

• “antihypertensive treatment substantially reduces CV

morbidity and CV and all-cause mortality”
• older patients are more likely to have comorbidities such
as renal impairment, atherosclerotic vascular disease, and
postural hypotension, which may be worsened by BP-
lowering drugs
• better adherence to antihypertensive treatment was
associated with a reduced risk of CV events and mortality,
even when age was >85 years
 Hypertension Older Patients (>65 y.o)

• Recommendation :
• Target 130-139 mmHg and <80 mmHg (if tolerated), SBP
<130mmHg should be avoided.
• Should use the lowest available dose
• Loop diuretic and alpha-blocker should be avoided, unless there
are concomitant disease
• Frequent evaluation of renal function
• Assesment risk of orthostatic hypotension
Hypertension and Pregnancy
Hypertension and
DM
Hypertension and CKD
Hypertension and Cerebrovascular
Ds
Hypertension and Vascular
Disease
Perioperative management of
hypertension
 Statins and lipid-lowering
drugs
• Patients with hypertension also with type 2
diabetes or metabolic syndrome  atherogenic
dyslipidaemia
• Very high CV risk  LDL <70mg/dL or a reductionof
≥50% if the baseline LDL-C is between 70 and 135
mg/dL.
• High CV risk  LDL <100mg/dL or a reduction of
≥50% if thebaseline LDL-C is between 100 and 200
mg/dL.
• Previous stroke  LDL-C <100 mg/dL
 Antiplatelet & anticoagulant therapy

• Hypertension predisposes to a prothrombotic state,

LEAD, heart failure, or AF  thromboembolism
• Aspirin did not reduce stroke or CV events compared
with placebo in primary prevention patients with
elevated BP and no previous CVD.
• Secondary prevention : absolute reduction in vascular
events of 4.1% compared with placebo.
• ‘flag up’ patients at particularly high risk (e.g. HAS-
BLED ≥3) for more regular review and follow-up
 Antiplatelet & anticoagulant
therapy
• Benefit has not been demonstrated for anticoagulation therapy, alone
or in combination with aspirin, in patients with hypertension in the
absence of other indications requiring anticoagulants
THANK YOU