HIPERTENSI

Dr. Refli Hasan, SpPD, SpJP(K) Dept. Cardiology and Vascular Medicine Fac. Medicine USU / Adam Malik Hospital

B P = CO x SVR
SV x HR
BP-blood pressure-tekanan darah. SVR-systemic vascular-resistance-tahanan perifer. SV-stroke volume-isi sekuncup. HR-heart rate-denyut jantung.

Framingham Study Blood pressure and Age

160 150 140 130 120 90 80 Diastolic BP 70 Systolic BP Women Men

Men Women

36 41 46 51 56 61 66 71 76 81 Years age
Kannel et al 1978

Definisi dan klasifikasi/kriteria menurut WHO, ISH, JNC.

HIPERTENSI
Tekanan darah sistolik lebih besar atau sama dengan 140 mmHg, dan / atau Tekanan darah diastolik lebih besar atau sama dengan 90 mmHg, atau Pasien dalam pengobatan anti hipertensi.

The JNC VI classification of blood pressure for adults 18 years old1

Category Systolic blood pressure (mmHg) <120 <130 130139 140159 160179 180 and and or or or or Diastolic blood pressure (mmHg) <80 <85 8589 9099 100109 110

Optimal2 Normal High normal

Hypertension3 Stage 1 Stage 2 Stage 3

1Not

taking antihypertensives and not acutely ill 2Optimal blood pressure with respect to cardiovascular risk is <120 mmHg systolic and <80 mmHg diastolic. 3Based on the average of two or more readings taken at each of two or more visits after an initial screening.
Based on JNC VI, National Institutes of Health, Nov. 1997

Definitions and classification of blood pressure levels (mmHg), 1999 WHO-ISH guidelines
Category Optimal Systolic < 120 Diastolic < 80

Normal
High-normal Grade 1 hypertension (mild)
Subgroup: borderline

<130
130-139 140-159
140-149

< 85
85-89 90-99
90-94

Grade 2 hypertension (moderate) Grade 3 hypertension (severe) Isolated systolic hypertension

Subgroup: borderline

160-179 > 180 > 140

140-149

100-109 > 110 < 90

< 90

When a patients systolic and diastolic blood pressures fall into different categories, the higher category should apply.
Guidelines Subcommittee. 1999. WHO-Intl Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999; 17:151-83.

JNC VII

Prevalence of Hypertension
Hypertension is one of the most frequent clinical discorders.
prevalence of hypertension (%)

70

60
50

SBP > 140 mm Hg DBP > 90 mm Hg

54 44

64

65

40
30

20
10 0
age (yrs) 4 11

21

18-29

30-39

40-49

50-59

60-69

70-79

80+

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

Secondary hypertension

Primary hypertension
No underlying cause

10 % 90 %

Renal Parenchymal Vascular Others Endocrine Neurogenic Miscellaneous Unknown

Fase Hipertensi

Early or Hyperkinetic hypertension

Clinical

signs : systolic blood pressure higher than normal, diastolic blood pressure normal. Pathophysiology : high cardiac output or tachycardia. Young adult patients.

Chronic or Established Hypertension

Clinical

signs : systolic and diastolic blood pressure elevated. Pathophysiogy : higher vascular resistance, but cardiac output normal or little lower than normal. Aortic compliance normal.

Isolated Systolic Hypertension (ISH)

Clinical

signs : high systolic blood pressure, diastolic blood pressure normal or low. Pathophysiology : Decreased aortic compliance caused by atherosclerotic in aortic and artery vascular system. Elderly patients

Crisis Hypertensive
Hypertensive emergency
Hypertensive encephalopathy. Acute aortic dissection. Pulmonary edema. Pheochromocytoma crisis. MAO inhibitor + tyramine interaction. Eclampsia.

Hypertensive urgency
Hypertension associated with CAD. Accelerated and malignant hypertension. Severe hypertension in the kidney transplant patient. Postoperative hypertension. Uncontrolled hypertension in the patient with emergency surgery.

Hemodynamic changes in Hypertension

Consequences of hypertension

Consequences

Left Ventricular Hypertrophy -angina -arrythmias -myocardial infarction -contributes to congestive heart failure

Consequences cont

Coronary Artery Disease -accelerated atherosclerosis -decrease in oxygen supply -in addition to high stystolic work load also contributes to risk of myocardial infarction

Consequences cont

Stroke -Hypertension induced strokes result from hemorragic (rupture of microaneurysms in cerebral vessels) or atherothrombotic (plaques in carotids or major cerebral arteries break off and embolize in smaller vessels conditions.)

Target Organ Damage in Hypertension

Organ System
Heart
-Left

Manifestations
ventricular hypertrophy -Heart failure -Myocardial ischemia and infarction Stroke
-Aortic

Cerebrovascular Aorta and peripheral vascular Kidney Retina

aneurysm and/or dissection -Arteriosclerosis

-Nephrosclerosis -Renal

failure

-Arterial

narrowing -Hemorrhages, exudates, papilledema

TARGET ORGAN DAMAGE

Rekomendasi pengobatan hipertensi Pemilihan obat anti hipertensi berkaitan dengan kerusakan target organ, penyakit kardiovaskuler dan ada/tidak ada DM.

RULE OF HALVES

Only HALF of all hypertensive patients are AWARE

Only HALF of those aware are TREATED Only HALF of those treated have their BP CONTROLLED

= 50% x 50% x 50%

Classes of antihypertensive agents

Diuretics

Vasodilators

thiazides and related agents loop diuretics K+-sparing diuretics

arterial dilators arterial and venous dilators

Sympatholytic drugs

Ca2+ channel blockers ACE inhibitors Angiotensin II receptor antagonists

centrally acting agents adrenergic neurone-blocking agents adrenergic antagonists 1 adrenergic antagonists multiple-action neurohormonal antagonists

Goodman and Gilman (1996)

Guidelines for Selecting Drug Treatment of Hypertension Class of Drug Compelling Possible Compelling Possible
indication indication Diabetes contraindication Gout Diuretic Heart failure Elderly patients Systolic hypertension Angina After myocardial infarct Tachyarrhytmias Heart failure Left ventricular dysfunction After myocardial infarct Diabetic nephropathy Angina Elderly patients Systolic hypertension Prostatic hypertrophy Peripheral vascular disease Glucose intolerance Dyslipidaemia Heart failure Pregnancy Bilateral renal artery stenosis Hyperkalaemia

contraindication Dyslipidaemia Sexually active males Dyslipidaemia Athletes and physically patients Peripheral vascular disease

Beta Blockers

Heart failure Pregnancy Diabetes

Asthma and COPD Heart block a

ACE inhibitors

Pregnancy Hyperkalaemia Bilateral renal artery stenosis Heart block b

Calcium antagonists Alfa Blockers

Congestive heart

Orthostatic hypotension

Angiotensine II antagonists

ACE inhibitors cough

Ideal Hypertension Agent :

Once Daily

Smooth anti HT effect Well tolerated, minimal SE Beneficial CV effect independent of BP lowering

Intl Forum on Angiotensin Receptor Antagonism, Monte Carlo 1999

GOALS OF TREATMENT
Is to achieve the maximum reduction in the total risk of Cardiovascular morbidity and mortality
Reduce CVD and renal morbidity and mortality. Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years of age.

JNC VI - NEW BP GOALS

<140/<90 and lower if tolerated <130/<85 in diabetics (types 1 &2) <130/<85 in cardiac failure <130/<85 in renal failure

<125/<75 in renal failure with proteinuria > 1.0 gm/24 hr

WHO-ISH new BP Goals

< 140/90 in elderly < 130/85 in young, middle-aged < 130/85 in diabetic
Adapted from JNC VI.1997

JNC VI

ALGORITHM FOR THE TREATMENT OF HYPERTENSION

Begin or Continue Lifestyle Modification Not at Goal Blood Pressure (< 140/90 mm Hg) Lower goals for patients with diabetes or renal disease

Initial Drugs Choices* Uncomplicated Hypertension Compelling Indication Diuretics Diabetes mellitus (type 1) with proteinuria Beta-blockers * ACE Inhibitors Heart failure Specific indications for the * ACE inhibitors Following Drugs * Diuretics ACE inhibitors Isolated systolic hypertension (older persons) Angiotensine II receptors blockers * diuretics preferred Alpha - blockers * Long acting dihydropyridine Alpha-beta-blockers * calcium antagonists Beta-blockers Myocardial infaction Calcium Antagonists * Beta-blockers (non ISA) Diuretics * ACE inhibitors (with systolic dysfunction)
* Start with a low dose of a long acting once daily drug, and titrate dose * Low-dose combinations may be appropriate

JNC 7 Report on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Initial Drug Therapy Systolic Diastolic BP BP Without Compelling With Compelling Lifestyle BP Classification mm Hg mm Hg Modification Indication Indications Normal <120 and <80 Encourage

Prehypertension

120139 or 8089

Yes

No antihypertensive drug indicated

Drug(s) for compelling indications

Stage 1 hypertension

140159 or 9099

Yes

Stage 2 hypertension

>160

or >100

Yes

Thiazide-type Drug(s) for the diuretics for most. May consider ACEi, compelling ARB, BB, CCB, or indications combination Other Two-drug combination for most antihypertensive (usually thiazide-type drugs (diuretics, diuretic and ACEi or ACEi, ARB, BB, ARB or BB or CCB) CCB) as needed

ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1-receptor blocker; BB, beta-blocker; CCB, calcium channel blocker. Chobanian AV et al. JAMA. 2003;289:2560-2572.

Stratification of Risk to Quantify Prognosis

Blood Pressure (mmHg) Grade 1 Other Risk Factors & Disease History I no other risk factors
(mild hypertension)

Grade 2
(moderate hypertension)

Grade 3
(severe hypertension)

SBP 140-159 or DBP 90-99 LOW RISK MED RISK HIGH RISK VERY HIGH RISK

SBP 160-179 or DBP 100-109 MED RISK MED RISK HIGH RISK VERY HIGH RISK

SBP > 180 or DBP > 110 HIGH RISK VERY HIGH RISK VERY HIGH RISK VERY HIGH RISK

II 1-2 risk factors

III 3 or more risk factors or TOD or diabetes

IV ACC

TOD = Target Organ Damage

Guidelines Subcommittee. 1999. WHO-Intl Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999;17:151-83

Initiation of Treatment
SBP 140-180 mmHg or DBP 90-110 mmHg on several occasions (Grades 1 & 2 hypertension) Assess other risk factors, TOD and CCD

Initate Lifestyle Measures

Stratify Absolute Risk

Very High Begin drug treatment

High Begin drug treatment

Medium Monitor BP and other risk factors for 3 - 6 months

Low Monitor BP and other risk factors for 6 - 12 months

SBP > 140 or DBP > 90 Begin drug treatment

1. TOD 2. ACC

SBP < 140 or DBP < 90 Continue to monitor

SBP > 140 or DBP > 90 Begin drug treatment

SBP < 140 or DBP < 90 Continue to monitor

- Taeget Organ Damage (precious WHO Stage 2 hypertension) [6] - Associated Clinical Condition including clinical cardiovascular disease and renal disease (previous WHO Stage 3 hypertension) [6]

The lifestyle modifications

Lose weight if overweight. Limit alcohol intake to no more than 1-2 drinks per day (equivalent to approximately 15-30 mL ethanol per day). Increase aerobic physical activity to 30 - 45 minutes on most days. Reduce sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride per day). Maintain adequate intake of dietary potassium (approximately 90 mmol per day). Inadequate intake may increase blood pressure. Maintain adequate intake of dietary calcium and magnesium for general health. Inadequate intake may increase blood pressure. Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health.

Hypertensive Heart Diseases

Target Organ Damage in Hypertension

Organ System
Heart
-Left

Manifestations
ventricular hypertrophy -Heart failure -Myocardial ischemia and infarction Stroke
-Aortic

Cerebrovascular Aorta and peripheral vascular Kidney Retina

aneurysm and/or dissection -Arteriosclerosis

-Nephrosclerosis -Renal

failure

-Arterial

narrowing -Hemorrhages, exudates, papilledema

ECG of a 47-year-old man with a long-standing history of uncontrolled hypertension showing left atrial enlargement and left ventricular hypertrophy.

ECG of a 46-year-old man with long-standing hypertension showing left atrial abnormality and left ventricular hypertrophy with strain.

Two-dimensional echocardiogram of a 70-year-old woman (parasternal long axis view) showing concentric left ventricular hypertrophy.

Short axis view : concentric left ventricular hypertrophic

Gross specimen of the heart with concentric left ventricular hypertrophy.

Guidelines for Selecting Drug Treatment of Hypertension Class of Drug Compelling Possible Compelling Possible
indication indication Diabetes contraindication Gout Diuretic Heart failure Elderly patients Systolic hypertension Angina After myocardial infarct Tachyarrhytmias Heart failure Left ventricular dysfunction After myocardial infarct Diabetic nephropathy Angina Elderly patients Systolic hypertension Prostatic hypertrophy Peripheral vascular disease Glucose intolerance Dyslipidaemia Heart failure Pregnancy Bilateral renal artery stenosis Hyperkalaemia

contraindication Dyslipidaemia Sexually active males Dyslipidaemia Athletes and physically patients Peripheral vascular disease

Beta Blockers

Heart failure Pregnancy Diabetes

Asthma and COPD Heart block a

ACE inhibitors

Pregnancy Hyperkalaemia Bilateral renal artery stenosis Heart block b

Calcium antagonists Alfa Blockers

Congestive heart

Orthostatic hypotension

Angiotensine II antagonists

ACE inhibitors cough

THANK YOU