HIPERTENSIHIPERTENSI

dr. Cholid T Tjahjono,MKes,SpJPdr. Cholid T Tjahjono,MKes,SpJPFakultas KedokteranFakultas Kedokteran

Universitas BrawijayaUniversitas BrawijayaMalangMalang

HipertensiDefinisi, klasifikasiPrevalensiKomplikasiFaktor kontribusi

Update pada VIIth report of the JNC Obat-obatan yang menurunkan

tekanan darah

Klasifikasi Tekanan DarahKlasifikasi Tekanan Darah

KlasifikasiKlasifikasi SBP (SBP (mmHgmmHg)) DBPDBP ((mmHgmmHg))____________________________________________________________________________________________________________

NormalNormal <120<120 andand <80<80

PrehypertensionPrehypertension 120–139120–139 or or 80–8980–89

HypertensionHypertension >140/90>140/90 Stage 1 HypertensionStage 1 Hypertension 140–159140–159 or or 90–9990–99

Stage 2 HypertensionStage 2 Hypertension >>160160 or or >>100100__________________________________________________________________________________________

Hipertensi esensialHipertensi esensial

Pada Pada 90–95% 90–95% kasus, penyebabnya kasus, penyebabnya tidak diketahui =tidak diketahui = Hipertensi esensialHipertensi esensial

Pengobatan simtomatik yaitu Pengobatan simtomatik yaitu menurunkan tekanan darah.menurunkan tekanan darah.

No real cure yet.No real cure yet.

Penyebab hipertensi Penyebab hipertensi sekunder yang bisa dikenalisekunder yang bisa dikenali

Sleep apnea Dipicu obat atau berhubungan dengan obat Penyakit ginjal kronik (Chronic kidney disease) Aldosteronisme primer Penyakit Renovaskular Chronic steroid therapy dan Cushing’s syndrome Pheochromocytoma Coarctation of the aorta (koarktasio aorta) Penyakit tiroid atau paratiroid

PrevalePrevalensinsi

Tinggi di Amerika Tinggi di Amerika : 50% : 50% orang orang dewasa,dewasa, 60% 60% kulit putihkulit putih, 71% of , 71% of African Americans, 61% Mexican African Americans, 61% Mexican Americans Americans diatas usia 60 tahundiatas usia 60 tahun

Lebih banyak pada laki-laki daripada Lebih banyak pada laki-laki daripada perempuan perempuan

Prevalensi tertinggi pada orang tua Prevalensi tertinggi pada orang tua perempuan perempuan African-AmericanAfrican-American

KomplikasiKomplikasi

Sistem kardiovaskular Sistem kardiovaskular CNSCNS (Central Nervous system) (Central Nervous system) Sistem ginjal (Sistem ginjal (Renal systemRenal system)) Kerusakan retina (Kerusakan retina (Retinal Retinal

damagedamage)) Penyakit arteri periferPenyakit arteri perifer

Target Organ DamageTarget Organ Damage Jantung (Heart)

Left ventricular hypertrophy Penyakit arteri koroner Infark miokardium Gagal jantung (Heart failure)

Otak (Brain) Stroke atau transient ischemic attacks

Penyakit ginjal kronik (Chronic kidney disease), gagal ginjal (kidney failure)

Retinopathy

Faktor kontribusiFaktor kontribusi

ObesitObesitasas StressStress Kurang olah ragaKurang olah raga Diet (excess dietary salt)Diet (excess dietary salt) Minum alkoholMinum alkohol MerokokMerokok

National Heart Lung Blood Institute National Heart Lung Blood Institute National High Blood Pressure National High Blood Pressure Education ProgramEducation Program

The Seventh Report of the The Seventh Report of the JJoint oint NNational ational CCommittee on Prevention, ommittee on Prevention, Detection, Evaluation, and Treatment Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7, 2003)of High Blood Pressure (JNC 7, 2003)

http://www.nhlbi.nih.gov/guidelines/hypertension/http://www.nhlbi.nih.gov/guidelines/hypertension/index.htmindex.htm

Mengapa perlu ada Guidelines untuk Hipertensi?50 juta orang dengan hipertensi di Amerika 10 tahun yang lalu – 1:4 secara keseluruhan, separuhnya berusia > 60Hanya 1 dari 2 orang yang mendapatkan pengobatan untuk menurunkan tek darah.Hanya 1 pada 4 orang berusia 18-74 tahun yang tek darahnya terkontrol <140/<90 di Amerika

Sasaran Baru tek darah

<140/<90 dan lebih rendah jika pasien toleran <130/<80 pada diabetics <130/<85 pada gagal jantung <130/<85 pada gagal ginjal <125/<75 pada gagal ginjal dengan proteinuria>1.0 g/24 jam

Penekanan pada Guidelines terkiniJNC, WHO/ISH, BHS,Canada, and More Strategi pengobatan yang agresif berdasarkan profil medik pasien

Mengobati mencapai sasaran

Based upon the average of > 2 properly measured readings at each of > 2 visits (at least 3 to 6 visits, spaced over a period of weeks to months)

Apply to adults on no antihypertensive medications and who are not acutely ill.

If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension.

Treatment OverviewTreatment Overview

Sasaran terapi Modifikasi gaya hidup Pengobatan farmakologik Algoritme untuk pengobatan

hipertensi Klasifikasi dan tatalaksana tekanan

darah pada dewasa Follow-up dan monitoring

Lifestyle ModificationsLifestyle Modifications(Modifikasi gayahidup)(Modifikasi gayahidup)

Menurunkan berat badan sampai Menurunkan berat badan sampai normal normal BMI (<25kg/mBMI (<25kg/m22): 5-20 mmHg/10kg loss): 5-20 mmHg/10kg loss

Rencana makan dengan Rencana makan dengan DASHDASH:: 8-14 8-14 mmHgmmHg

Reduksi garam diet Reduksi garam diet : 2-8 mmHg: 2-8 mmHg Meningkatkan aktivitas fisik Meningkatkan aktivitas fisik : 4-9 mmHg: 4-9 mmHg Reduksi konsumsi alkohol :Reduksi konsumsi alkohol : 2- 4 mmHg 2- 4 mmHg

DASH Diet

Dietary

Approaches

to

Stop

Hypertension

• Menekankan: buah, sayuran, makanan rendah lemak, dan mengurangi garam

•Termasuk whole grains, poultry, ikan, nuts

• Mengurangi jumlah daging merah, gula dan total kolesterol dan saturated fat

Sacks FM et al: NEJM 344;3-10, 2001

Algorithm for Treatment of Algorithm for Treatment of HypertensionHypertension

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140–159 or DBP 90–99

mmHg) Thiazide-type diuretics for most.

May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling Indications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

Renalfunction

Bloodvolume

Venoustone

Venousreturn

Heartrate

Nervouscontrol

Muscularresponsiveness

Myocardialcontractility

Strokevolume

Cardiacoutput

CNSfactors Renin

release

Angiontensin II formation

Intrinsic vascularresponsiveness

Peripheralresistance

Nervouscontrol

Renalfunction

Mean arterialpressure

Faktor-faktor yang mengendalikan

the Mean Arterial Pressure

Mean Arterial PressureMean Arterial Pressure= Tekanan arteri rata-rata= Tekanan arteri rata-rata

MAP = MAP = COCO

CO = HR X SVCO = HR X SV

SNSSNS Blood Blood volumevolume

Heart Heart contactilitycontactility Venous toneVenous tone

X X PVRPVRmyogenic tonemyogenic tonevascular vascular

responsivenesresponsivenesnervous controlnervous control

vasoactive vasoactive metabolitesmetabolites

endothelial factorsendothelial factorscirculating circulating

hormoneshormonesCO= Cardiac output; PVR: peripheral vascular resistance; HR=heart rate;SV: stroke volume; SNS: sympathetic nervous system

Klasifikasi obat antihipertensiKlasifikasi obat antihipertensi

DiuretiDiuretikk Obat yang mempengaruhi Obat yang mempengaruhi

fungsi adrenergikfungsi adrenergik VasodilatorsVasodilators Obat yang mempengaruhi Obat yang mempengaruhi

RRenin enin AAngiotensin ngiotensin SSystem ystem (RAS)(RAS)

The cardiovascular risk profile of the patient

Coexisting disorders Target organ damage Interactions with other drugs used for

concomitant conditions Tolerability of the drug Cost of the drug

Reduce cardiac output-adrenergic blockers• Ca2+ Channel blockers

Dilate resistance vessels• Ca2+ Channel blockers• Renin-angiotensin system blockers1 adrenoceptor blockers• Nitrates

Reduce vascular volume• Diuretics• Direct vasodilators

β BLOCKERS

Calsium Antagonist+

α BLOCKERS

HYDRALAZINE

SymphateticActivity

Cardiac Output

Renin

PERIPHERAL VASCULAR

RESISTENCE

ThiazidsACE-iARBs

Renin inhibitors

Condition Preferred drugs Other drugs that can be used

Drugs to be avoided

Asthma CCBs -blockers/ARB/Diuretics/ACE-i

-blockers

Diabetes mellitus

-blockers/ACE-i/ ARB

CCBs Diuretics/-blockers

High cholesterol levels

-blockers ACE-i/ARB/ CCB -blockers/Diuretics

Elderly patients

CCBs -blockers/ACE-i/ARB/- blockers

BPH - blockers -blockers/ ACE-i/ ARB/ Diuretics/ CCBs

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB,

CCB) as needed

With Compelling Indications

Stage 2 Hypertension

(SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually

thiazide-type diuretic and ACEI or ARB or BB or

CCB)

Stage 1 Hypertension

(SBP 140–159 or DBP 90–99 mmHg)

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or

combination

Without Compelling Indications

Not at Goal BP

Optimize dosages or add additional drugs

until goal BP is achieved.Consider consultation with

hypertension specialist.

JNC 7 Medication Algorithm

Class of drugs

Main side-effects Contraindications/ Special Precautions

Diuretics (e.g. HCT)

Electrolyte imbalance, level of total and C-LDL,, glucose levels, UC, ↓C-HDL

Hypersensitivity, Anuria

-blockers (e.g. atenolol)

Impotence, Bradycardia, fatique

Hypersensitivity, Bradycardia, Conduction disturbances, Diabetes, Asthma, Severe cardiac failure

Class of drugs Main side-effects Contraindications/ Special Precautions

CCB (e.g. Amlodipine, Diltiazem)

Pedal edema, Headache

Non-DHP CCBs (e.g diltiazem)– Hypersensitivity, Bradycardia, Conduction disturbances, CHF, LV dysfunction. DHP CCBs–Hypersensitivity

-blockers (e.g. Doxazosin)

Postural hypotension Hypersensitivity

ACE-inhibitors (e.g. Lisinopril)

Cough, Hypertension, Angioneurotic edema

Hypersensitivity, Pregnancy, Bilateral renal artery stenosis

A-II RB Headache, Dizziness Hypersensitivity, Pregnancy,Bilateral renal artery stenosis

BPClassification

SBP(mm HG)

DBP(mm HG)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension 160 or 100

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

Not at goal blood pressure (<140/90 mm HG) (<130/80 mm HG for those with diabetes or chronic kidney disease)

Initial drug choices

Drug(s) for compelling indications

Other antihypertensivedrugs (diuretics, ACEI,

ARB, BB, CCB) as needed.

With compelling indications

Lifestyle modifications

Stage 2 Hypertension(SBP >160 or DBP >100 mm

HG) 2-drug combination for most (usually thiazide-type diuretic

and ACEI, or ARB, or BB, or CCB).

Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mm

HG) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB,

or combination.0

Without compelling

indications

Not at goal blood pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

Acute life-threatening increase in BP Hypertensive urgency: severe

hypertension (usually SBP > 180 and DBP > 120 mmHg) without acute target organ damage (TOD)

Hypertensive emergency : severe HTN + TOD

Untreated essential hypertension Sudden withdrawal / non-adherence to

antihypertensive drug therapy Increase in sympathetic tone (stress,

drugs) Renovascular hypertension, renal

parenchymal diseases, pheochromocytoma, or primary hyperaldosteronism.

Pressure damages vascular endothelium Platelets and fibrin activate

Encephalopathy AMI (acute myocardial infarction)/USA

(Unstable angina) Nephropathy Aortic dissection (Diseksi aorta) LV failure (gagal ventrikel kiri)/cardiac

decompensation (gagal jantung) Eclampsia

Medical history (Riwayat medik) Physical examination (Pemeriksaan fisik) Laboratory evaluation (evaluasi

laboratorium)• serum• urine

Profil pengobatan Riwayat pemakaian obat Fundoscopy EKG, CXR (chest X ray= foto thoraks), head

CT (CT scan kepala), echocardiography

Urinalysis: protein, RBC (red blood cells), casts

Cardiac enzymes- CKMB, troponins Electrolytes, BUN (blood urea nirogen) ,

creatinine Toxicology screen EKG, echo, angiography, X-ray Thyroid, cortisol, BG (blood gas analysis) LFTs (liver function tests)

Time frame - consider risk level BP goal

• Urgency: gradual; DBP to 110 in 24-48 hours

• Emergency: MAP < 20 to 25% in 1 to 2 hours

Drug selection Route

Widening neurologic deficits Retinal ischemia: blindness Acute myocardial infarction Deteriorating renal function

End-stageheart

disease

Heartfailure

ACE inhibitionAngiotensin receptor blockade

GISSI-3ISIS-4

AIRESAVESOLVD-PreventionTRACECHARM-PreservedOPTIMAALVALIANT

SOLVD-TreatCHARM-AddedCHARM-AlternativeELITE IIVal-HeFT

CONSENSUS

HOPEEUROPA

ALLHATANBP2ASCOTINVESTLIFEVALUE

Adapted from: Dzau V, et al. Am Heart J. 1991;121:1244-1263.

Ventriculardilation

Remodeling

LVDysfunctionArrhythmia

MyocardialInfarctionCoronary

thrombosis

Myocardialischemia

CAD

Athero-sclerosisLVH

Hypertension

45