Rasionalisasi Terapi

Hipertensi

Dr. Suryono,SpJP.FIHA

Bagian-SMF Kardiologi & Kedokteran Vaskular

FK UNEJ / RSD dr. Soebandi
JEMBER
 Definisi Hipertensi (JNC VII)
 Klasifikasi tekanan darah pada seseorang berumur 18 dan lebih

Systolic Diastolic
Category (mm Hg) (mm Hg)
Normal <120 dan <80
Pre Hipertensi 120-139 atau 80-89
Hipertensi
Stage 1 140-159 atau 90-99
Stage 2 > 160 atau >100
 Prevalensi dari Hipertensi
Hipertensi salah satu dari penyakit yang sering dijumpai di klinik

70
SBP > 140 mm Hg
prevalence of hypertension (%)

64 65
60 DBP > 90 mm Hg
50 54
44
40

30
21
20
4 11
10

0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Hypertension Prevalence and
Treatment:
North America and Europe
Prevalence of Hypertension Patients on Therapy
US
55 Canada
100 Italy
50
90 Sweden
45 England
80 Spain
40
70 Finland
% 35 % 60 Germany
30
50
25
40
20
30
15
20
10
10
5
0
0
Country Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
New Criteria (WHO-ISH 1999) ≥ 140 / 90 mmHg

22 % of American adults 18 to 70 years of age have hypertension

20 % of Indonesian adults have hypertension

Hypertensive patients Hypertensive patients

who are treated who are treated
but uncontrolled and controlled

16%
23%

19% 42%

Patients who are aware

but remain untreated Hypertensive patients
and uncontrolled who are unaware

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

 Presentasi pasien hipertensi
yang terkontrol
< 140/90 mmHg < 160/95 mmHg
USA Canada Finland Spain Australia
16 20.5 20 19
27

England France Germany Scotland India

6 9
24 22.5 17.5

> 65 years

USA: JNC VI. Arch Intern Med 1997 Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998
Adapted from G. Mancia / L. Ruilope
 Diagnosis of Hypertension

Hypertension is defined as:

- BP  140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit
Caused of Hipertension :
I. Primer / essential / idiopathic
II. Sekunder :
A. Renal
B. Endocrine
C. Coartation of the aorta
D. Pregnancy induced hypertension
E. Neurological disorder
F. Drug and other abused substancen
PATOPHYSIOLOGY
The factors affecting cardiac output:
- sodium intake, renal function, &
mineralocorticoids
- the inotropic effects occur via extracellular
fluid volume augmentation
- an increase in heart rate and contractility

Peripheral vascular resistance is dependent

upon the sympathetic nervous system,
humoral factors, and local autoregulation

(Sharma,
2003)
 Neurohormonal control of blood pressure

Blood pressure = Cardiac output (CO) x Peripheral resistance (PR)

Hypertension = Increased CO and/or Increased PR

Vasoconstriction
 Preload  Contractility
 Fluid volume

 Fluid volume
Sympathetic Renin-
nervous angiotensin-
Renal sodium system aldosterone
retention system

Excess Genetic
sodium factors
intake
(Adapted from Kaplan, 1994)
Acute neurohormonal effects on blood
pressure homeostasis
Perfusion

 RAA  SNS

 Heart rate and cardiac output

 Sodium and water retention

 Blood pressure
 The Renin-Angiotensin System
Alternate Pathway

Circulating Local
Liver Tissue
Angiotensinogen
Non Renin pathways
- t-PA
Renin inhibitors Renin - Cathepsin G
- Tonin

Angiotensin I
Non-ACE pathways
ACE inhibitor Converting enzyme - Chymase
- CAGE
- Cathepsin G

Angiotensin II

Angiotensin
AII receptor blockers
receptors
 Effects of Angiotensin II at AT1 and AT2
Receptors

AT1 AT2
Blocked by ARB s
- Vasoconstriction - Vasodilation
- Aldosterone release - Antiproliferation
- Oxidative stress - Apoptosis
- Vasopressin release - Antidiuresis/antinatriuresis
- SNS activation - Bradykinin production
- Inhibits renin release - NO release
- Renal Na+ and H2O reabsorption
- Cell growth and proliferation

Siragy H. Am J Cardiol. 1999;84:3S–8S.

 Technique of blood pressure measurement
recommended by the British Hypertension Society
1.
Several time, rest 5
minutes before
2.
The patient should be
relaxed and the arm must be
supported. Ensure no tight
clothing constricts the arm
3.
The cuff must be level with the
heart. If the circumference
exceeds 33cm, a large cuff must
be used (2/3 of arm). Place
stethoscope diaphram over
brachial artery
(From British Hypertension Society 1985)
4.
The column of mercury
must be vertical. Inflate to
occlude the pulse (>30
mmHg). Deflate at 2-3
mm/s. measure systolic
( first sound / Korotkoff I )
& diastolic
(disappearence /
Korotkoff IV or V ) to
nearest 2 mmHg
 Recommended Technique
for Measuring Blood Pressure

Standardized technique:

• Have the patient rest for 5 minutes

• Use an appropriate cuff size
• Use a mercury manometer or a recently
calibrated electronic device
 Recommended Technique
for Measuring Blood Pressure (cont.)

• Position cuff appropriately

• Increase pressure rapidly
• Support arm with antecubital fossa or heart
level
• To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
• Place stethoscope over the brachial artery
 Recommended Technique
for Measuring Blood Pressure (cont.)

• Drop pressure by 2 mmHg / beat:

- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
• Take 2 blood pressure measurements, 1
minute apart
Pengukuran tekanan darah ambulatory
(ABPM)

Indikasi
1. Adanya variasi tekanan darah yang besar
2. Office hypertension
3.Dicurigai adanya episode hipotensi
4. Hipertensi yang resisten terhadap
pengobatan
 Symptoms

• Headache
• Dizziness
• Fatigue
• Pounding of the heart
• Symptoms of complications : heart failure,
chest pain, claudication, vision
Riwayat Klinik (Ax):

• Lama, tingkat TD
• Adanya Penyakit penyerta
• Faktor risiko
• obat-obatan
• Faktor pribadi,psikososial dan
lingkungan.
 Pemeriksaan Fisik :

• Pemeriksaan fisik & TD yang teliti

• TB, BB, & BMI
• Sistim kardiovaskuler
• Paru
• abdomen.
• Fundus optikus & sistim syaraf
(mengetahui kerusakan serebro-vaskuler).
Pemeriksaan penunjang

• Laboratorium
• EKG & Foto polos dada
• Ekhokardiografi
• Ultrasonografi vaskuler
• Ultrasonografi renal Angiografi
 Komplikasi Hipertensi

Eyes Brain Kerusakan Target Organ!!

retinopathy stroke

Kerusakan yang disebabkan

Heart oleh hipertensi tergantung :
ischaemic heart disease
Kidneys left ventricular hypertrophy • Besarnya peningkatan
renal failure heart failure tekanan darah
• Lamanya kondisi tekanan
darah yang tidak
Peripheral arterial disease
terdiagnosis dan tidak
diobati
 Hypertension :
The Disease Continuum
Early Paradigm

Natural History of CVD Progression

Elevated BP Target Organ Damage

More Recent Paradigm

Vascular Dysfunction Elevated BP Target Organ Damage

A Proposed Future Paradigm

Endothelial Vascular Elevated BP Target Organ

Dysfunction Dysfunction Damage Angina
? LVH Pectoris
Renal MI Stroke
Damage
Risiko Infark Miokard dan Stroke

15

10
5-year risk (%)

MI Stroke

0 100 200 300

Systolic blood pressure (mm Hg)

Brown, M.J., Lancet 2000;355:653-4

Cumulative Incidence of CHF : Normotensives
and Stage 1 and 2 Hypertensives
20
Stage 2+ hypertension

15
CHF
Cumulative Stage 1+ hypertension
Incidence 10
(%)
5
Normal BP
0
5 10 15
Years From Baseline Exam

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.

Data from Levy D et al. JAMA. 1996;275:1557-1562.
Effects of blood pressure on the risk
of cardiovascular disease
Average annual incidence rate per 10.000
100
90 CHD
80
70
60
50
40 Stroke
30
CHF
20
10
0
<100 120 140 180 >180
Systolic blood pressure (mmHg)
Source : Framingham study (after Gorlin)
 Total Mortality and Continuous
Ambulatory Blood Pressure
Systolic Blood Pressure Diastolic Blood Pressure
7 5
6
events/100 pt/yrs

4
5
4 3

3 2
2
1
1
mm Hg mm Hg

< 140 140-159 160-179 180-199 200+ < 80 80-89 90-99 100-109 110+

Assessment of the 24-hour blood pressure load is

a good clinical method to identify high-risk patients

Khattar, R.S. et al. Circulation 1999; 100:1071-4

 NON-Farmakologis
 Farmakologis
 Non Pharmacologic
( lifestyle modification )
Modification Approximate SBP
reduction (range)
Weight reduction 5–20 mmHg/10 kg 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
 Dahulu : stepped care therapy

 Kini : individualized therapy

Taylored therapy
 Therapy of Hypertension
( pharmacologic )

– Goal of treatment
• Improved endothel function
• Decreased systemic vascular resistance
• Maintain cardiac output & blood suply to organ
– Life long therapy
– Bad compliance  failed of therapy
 Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

MORTALITAS / MORBIDITAS TETAP TINGGI
failed of therapy
• Tenaga medis
• Asuransi
• Pemegang kebijakan
• Penderita
– bad compliance
 Minimal BP Goal of Therapy
Recommendations (SBP/DBP mmHg)
Patient Type JNC VI
Uncomplicated HTN < 140/90
Hypertension with < 130/85
diabetes mellitus < 130/80*
Heart failure < 130/85
Hypertension with < 125/75
renal impairment†
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
†
Proteinuria > 1 g/24h.
(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive
Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)
Recomendation
 Algorithm for Treatment of Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 (SBP >160 or DBP >100 mmHg) indications
mmHg) 2-drug combination for most Other antihypertensive drugs
Thiazide-type diuretics for most. (usually thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
May consider ACEI, ARB, BB, CCB, ACEI, or ARB, or BB, or CCB) as needed.

or combination.

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.
 Compelling Indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
Heart failure THIAZ, BB, ACEI, ARB, ACC/AHA Heart Failure
ALDO ANT Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES
Postmyocardial BB, ACEI, ALDO ANT ACC/AHA Post-MI
infarction Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
High CAD risk THIAZ, BB, ACE, CCB ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE
 Compelling Indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis

Diabetes THIAZ, BB, ACE, ARB, NKF-ADA Guideline,

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

Recurrent stroke THIAZ, ACEI PROGRESS

prevention
 Diuretics

AT1 receptor
-blockers blockers

Calcium
1-blockers
antagonists

ACE inhibitors
Possible combinations of different classes of antihypertensive agents.
The most rational combinations are represented as thick lines. ACE,
angiotensin-converting enzyme; AT1, angiotensin II type 1.
 Terapi Kombinasi
• Potensiasi
• Sinergisme
• Saling melengkapi
• Mengurangi efek samping
• Fix kombinasi ---- mening kepatuhan
THANK YOU
TERIMA KASIH
MATUR NUWUN

SAKALANGKONG
KASO’ON

Mba Marijan
Pengukuran Tekanan Darah :
• Karena adanya variasi yang besar TD, diagnosis hipertensi harus
berdasarkan beberapa kali pengukuran yang diambil pada beberapa
kesempatan (waktu) yang terpisah.
• TD biasanya diukur secara tak langsung dengan sphygmo-manometer air
raksa atau alat noninvasif lainnya pada posisi duduk atau telentang.
• sebelum pengukuran penderita istirahat 5 menit diruangan yang tenang
• ukuran manset lebar 12-13 cm serta panjang 35 cm, ukuran lebih kecil pada
anak-anak dan lebih besar pada penderita gemuk (ukuran sekitar 2/3
lengan)
• diperiksa pada fosa kubiti dengan cuff setinggi jantung (ruang antar iga IV)
• TD dapat diukur pada keadaan duduk atau telentang, pada JNC VII
dianjurkan pada posisi duduk
 Pengukuran Tekanan Darah :
• TD dinaikkan sampai 30 mmHg (4.0 kPa) diatas tekanan sistolik
(palpasi), kemudian diturunkan 2 mmHg/detik (0,3 kPa/detik) dan
dimonitor dgn stetoskop diatas a brakhialis.
• tekanan sistolik ialah tekanan pada saat terdengar suara Korotkoff I
sedangkan tekanan diastolik pada saat Korotkoff V menghilang. Bila
suara tetap terdengar, dipakai patokan Korotkoff IV (muffling
sound).
• pada pengukuran pertama dianjurkan pada kedua lengan terutama
bila terdapat penyakit pembuluh darah perifer.
• kadang perlu pengukuran pada posisi duduk/telentang dan berdiri
untuk mengetahui ada tidaknya hipotensi postural terutama pada
orang tua, diabetes mellitus dan keadaan lain yang menimbulkan hal
tersebut (pemberian penyekat alfa).
 Risk Stratification and Treatment
(JNC-VI)
Risk Group B Risk Group C
(At Least 1 Risk (TOD/CCD and/or
Risk Group A Factor, Not Including Diabetes, With or
Blood Pressure Stages (No Risk Factors Diabetes; No Without Other Risk
(mmHg) No TOD/CCD)† TOD/CCD) Factors)
High-normal Lifestyle Lifestyle Drug therapy§
(130-139/89-89) modification modification
Stage 1 Lifestyle Lifestyle Drug therapy
(140-159/90-99) modification modification‡
(up to 12 months) (up to 6 months)
Stages 2 and 3 Drug therapy Drug therapy Drug therapy
(> 160/> 100)

For example, a patient with diabetes and a blood pressure of 142/94 mmHg plus left ventricular
hypertrophy should be classified as having stage 1 hypertension with target organ disease (left
ventricular hypertrophy) and with another major risk factor (diabetes). This patient would be categorized
as Stage 1, Risk Group C, and recommended for immediate initiation of pharmacologic treatment.