HIPERTENSI

dr. Cholid T Tjahjono,MKes,SpJP Fakultas Kedokteran Universitas Brawijaya Malang

 Hipertensi

Definisi, klasifikasi Prevalensi Komplikasi Faktor kontribusi

Update

pada VIIth report of the JNC

Obat-obatan

yang menurunkan tekanan darah

Klasifikasi Tekanan Darah

Klasifikasi
Normal Prehypertension Hypertension

SBP (mmHg)
<120 120139 and or

DBP (mmHg)
<80 8089

______________________________________________________

>140/90 Stage 1 Hypertension 140159 or

Stage 2 Hypertension

9099

>160 or >100 _____________________________________________

Hipertensi esensial
Pada 9095% kasus, penyebabnya tidak diketahui = Hipertensi esensial Pengobatan simtomatik yaitu menurunkan tekanan darah. No real cure yet.

Penyebab hipertensi sekunder 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 Cushings syndrome Pheochromocytoma Coarctation of the aorta (koarktasio aorta) Penyakit tiroid atau paratiroid

Prevalensi

Tinggi di Amerika : 50% orang dewasa, 60% kulit putih, 71% of African Americans, 61% Mexican Americans diatas usia 60 tahun
Lebih banyak pada laki-laki daripada perempuan Prevalensi tertinggi pada orang tua perempuan African-American

Komplikasi
Sistem kardiovaskular CNS (Central Nervous system) Sistem ginjal (Renal system) Kerusakan retina (Retinal damage) Penyakit arteri perifer

Target 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 kontribusi
Obesitas Stress Kurang olah raga Diet (excess dietary salt) Minum alkohol Merokok

National Heart Lung Blood Institute National High Blood Pressure Education Program
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7, 2003)
http://www.nhlbi.nih.gov/guidelines/hypertension/index.ht m

Mengapa perlu ada Guidelines untuk Hipertensi?

50 juta orang dengan hipertensi di Amerika 10 tahun yang lalu 1:4 secara keseluruhan, separuhnya berusia > 60 Hanya 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
toleran dan lebih rendah jika pasien

<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 terkini

JNC, WHO/ISH, BHS, Canada, and More

Strategi pengobatan yang agresif

berdasarkan profil medik pasien

Mengobati mencapai sasaran

Treatment Overview

Sasaran terapi Modifikasi gaya hidup Pengobatan farmakologik Algoritme untuk pengobatan hipertensi Klasifikasi dan tatalaksana tekanan darah pada dewasa Follow-up dan monitoring

Lifestyle Modifications (Modifikasi gayahidup)

Menurunkan berat badan sampai normal BMI (<25kg/m2): 5-20 mmHg/10kg loss
Rencana makan dengan DASH: 8-14 mmHg Reduksi garam diet : 2-8 mmHg

Meningkatkan aktivitas fisik : 4-9 mmHg

Reduksi konsumsi alkohol : 2- 4 mmHg

DASH Diet
Dietary
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

Approaches
to Stop

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

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 Indications

With Compelling Indications

Stage 1 Hypertension
(SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

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)

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

Renal function Blood volume Venous return Stroke volume Venous tone

Faktor-faktor yang mengendalikan the Mean Arterial Pressure

Muscular responsiveness Nervous control CNS factors Nervous control

Renal function
Renin release Angiontensin II formation

Myocardial contractility Heart rate

Intrinsic vascular responsiveness

Cardiac output
Mean arterial pressure

Peripheral resistance

Mean Arterial Pressure = Tekanan arteri rata-rata

MAP =
CO

CO
SV

PVR
myogenic tone vascular responsivenes nervous control vasoactive metabolites endothelial factors circulating hormones

= HR X
SNS

Blood volume Heart contactility Venous tone

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

Klasifikasi obat antihipertensi

Diuretik Obat yang mempengaruhi fungsi adrenergik Vasodilators Obat yang mempengaruhi Renin Angiotensin System (RAS)

BP Classification

SBP (mm HG)

DBP (mm HG)

Normal
Prehypertension

<120
120-139

and
or

<80
80-89

Stage 1 hypertension Stage 2 hypertension

140-159
160

or
or

90-99
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.

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

Initial drug choices

Without compelling indications With compelling indications

Stage 1 Hypertension
(SBP 140159 or DBP 9099 mm HG) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.0

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).

Drug(s) for compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

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.

Definition1 >140/90 mm HG by clinic measurement >130/80 mm HG by home or ambulatory measurement

True Hypertension

Synonym Isolated office hypertension2

White-Coat Hypertension

Definition Hypertensive by clinic (office) measurement and normotensive by home and ambulatory measurement3

Synonyms White-coat normotension; reverse white-coat hypertension; undetected ambulatory hypertension2 Definition Normotensive by clinic measurement and hypertensive by home and ambulatory measurement1

Masked Hypertension

1. National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003. 2. Pickering TG, et al. Hypertension. 2002;40:795-796. 3. Staessen JA, et al. Blood Press Monit. 2001;6:355-370.

 Suspected

white-coat hypertension Drug-resistant hypertension Hypotensive symptoms with medications Episodic hypertension Autonomic dysfunction

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

Office blood pressure >140/90 mm HG in low-risk patients (no target organ disease) >130/80 mm HG in high-risk patients (target organ disease, diabetes) Self-monitored BP <130/80 mm HG Perform ambulatory BP monitoring 24-hour BP <130/80 mm HG 24-hour BP 130/80 mm HG Self-monitored BP 130/80 mm HG

Initiate antihypertensive therapy Follow up with non-drug therapy on a 612 month basis Repeat ambulatory BP measurement every 1-2 years Perform ambulatory blood-pressure monitoring 24-hour BP <130/80 mm HG 24 hour BP 130/80 mm HG Change antihypertensive therapy to improve control (target <130/80 mm HG) Follow up with ABPM every 2 years Adapted from White WB. N Engl J Med. 2003;348:2377-2378.

TREATED

Maintain present therapy Follow up with an ABPM every two years

 Accounts

for BP variations over time Diagnosis of white-coat hypertension and masked hypertension Allows for evaluation of consistency of drug effect over dosing periods 24 hours More reproducible than clinic BP

Mancia G, et al. J Hypertens. 1997;15(Suppl 2):S43-S50.

hBP3
Impaired release of renin due to NSAIDs, beta-blockers, cyclosporine, tacrolimus, diabetes, or advanced age

Angiotensin I

Renin

Angiotensin II ACE inhibitors1

Angiotensin-receptor blockers1 Angiotensin receptor Adrenal gland

Impaired aldosterone metabolism due to adrenal disease, heparin, or ketoconazole

Distal convoluted tubule Afferent arteriole Juxtaglomerular cells Apical membrane KAldosterone K+ Na+ Collecting duct

Aldosterone

Glomerular capsule Proximal tubule

Aldosteronereceptor blockers: spironolactone and eplerenone4 Aldosteronereceptor

Renin inhibitors2

Lumen
Na-

Sodium-channel blockers: amiloride, triamterene, trimethoprim, and pentamidine

Collecting duct (principal cell)

1. Palmer BF. N Engl J Med. 2004;351:585-592. 2. Maibaum J, et al. Expert Opin Ther Patients. 2003;13:589-603. S-YS, et al. Prescriber. 2004;5:33-46. 4. Givertz MM. Circulation. 2005;111:1012-1018.

3. Ooi

ACE inhibition

Angiotensin receptor blockade

GISSI-3 ISIS-4
Coronary thrombosis Myocardial ischemia Myocardial Infarction

AIRE SAVE SOLVD-Prevention TRACE

LV Dysfunction Arrhythmia

CHARM-Preserved OPTIMAAL VALIANT

HOPE EUROPA

CAD

Remodeling

Atherosclerosis LVH

Ventricular dilation

SOLVD-Treat
Heart failure

ALLHAT ANBP2 ASCOT INVEST

Hypertension End-stage heart disease

CHARM-Added CHARM-Alternative ELITE II Val-HeFT

CONSENSUS

LIFE VALUE

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