FARMAKOTERAPI HIPERTENSI

HIPERTENSI :
Adalah kenaikan TD arteri yg tetap (JNC-7 = Joint National Committee)

KLASIFIKASI TEK DARAH JNC-7

KLASIFIKASI SISTOL(mmHg) DIASTOL (mmHg)

Normal <120 Prehypertension 120139

and or

<80 8089

Stage 1 Hypertension Stage 2 Hypertension

140159
>160

or
or

9099
>100

Bila TDD < 90 mmHg & TDS 140 mmHg = isolated systole HT
Bila TDD/TDS > 180/120 mmHg Crisis Hypertenson

Definitions
HPT emergency(crisis): Is characterized by a severe elevation in BP, complicated by evidence of impending or progressive target/end organ dysfunction VS
HPT urgency: is a severe elevation in BP without progressive target organ dysfunction

NB these definitions do not specify absolute BP levels

PATOFISIOLOGI HT
A.Hipertensi esensial (HT primer)= HT Idiopatik, yg blm jelas penyebabnya.Dipengaruhi usia, kelamin, merokok, kholesterol, BB B.Hipertensi sekunder. Dipengaruhi oleh obat, penyakit ginjal, penyakit endokrin (DM, tiroid , Cushing)

Hypertension

Hypertension
Tingkat tekanan darah adalah fungsi dari cardiac output dikalikan dengan resistensi perifer (perlawanan dalam pembuluh darah ke aliran darah) Dasar hemodinamik hipertensi MAP = CO x TPR
MAP=mean arteria pressure; CO=cardiac output; TPR=total resistence perifer

Prevalence of Hypertension by Age

Age
18-29 30-39 40-49 50-59 60-69 70-79 80+

% Hypertensive
4 11 21 44 54 64 65

MANFAAT MENURUNKAN TD
Stroke incidence 3540%
Myocardial infarction 2025% Heart failure
50%

Tanda-Tanda Klinik HT
1.Pusing paroksismal 2.Berkeringat 3.Takikardia 4.Palpitasi

Organ yg terkena HT :
Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Untreated

Arteriosclerosis Heart

hypertension can result in:

--Kidney damage --Stroke --Blindness

Attack Enlarged heart

FAKTOR RESIKO HT
Faktor resiko mayor Hipertensi Merokok Obesitas (BMI 30) Immobilitas Dislipidemia Diabetes mellitus Mikroalbuminuria atau perkiraan GFR<60 ml/min Umur (>55 tahun untuk laki-laki, >65 tahun untuk perempuan) Riwayat keluarga untuk penyakit kardiovaskular prematur (laki-laki < 55 tahun atau perempuan < 65 tahun)

TERAPI :
NON FARMAKOLOGI FARMAKOLOGI

TUJUAN TERAPI HT :
1.Reduce CVD and renal morbidity and mortality. 2.Treat to BP <140/90 mmHg (Umum) or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. 3.Achieve SBP goal especially in persons >50 years of age.

PENCEGAHAN & TERAPI 1.Bagi yg obese, turunkan BB 2.Diet garam ( 2.4g/hr) 3.Kurangi konsumsi lemak 4.Tidak merokok, kurangi kopi & alkohol 5.Istirahat cukup 6.Olahraga teratur.

Tx NON-FARMAKOLOGI

Tx FARMAKOLOGI
A.ACE-1 / ACE-2 (ARB) / ALFA1BLOCKER B.BETA-BLOCKERS C.CA-ANTAGONISTS D.DIURETICS

A B C D

Terapi Kombinasi
Rasional kombinasi obat antihipertensi: Ada 6 alasan mengapa pengobatan kombinasi pada hipertensi dianjurkan:
1. 2. 3. 4. 5.

Mempunyai efek aditif Mempunyai efek sinergisme Mempunyai sifat saling mengisi Penurunan efek samping masing-masing obat Mempunyai cara kerja yang saling mengisi pada organ target tertentu 6. Adanya fixed dose combination akan meningkatkan kepatuhan pasien (adherence)

ANTIHIPERTENSI DI PUSKESMAS
1.Propanolol / Bisoprolol 2.Nifedipin / Adalat OROS / Amlodipin 3.Captopril / Lisinopril 4.HCT / Spironolakton 5.Reserpin

Fixed-dose combination yang paling efektif adalah sebagai berikut:

1. Penghambat enzim konversi angiotensin (ACEI) dengan diuretik 2. Penyekat reseptor angiotensin II (ARB) dengan diuretik 3. Penyekat beta dengan diuretik 4. Diuretik dengan agen penahan kalium 5. Penghambat enzim konversi angiotensin (ACEI) dengan antagonis kalsium 6. Agonis -2 dengan diuretik 7. Penyekat -1 dengan diuretic

ALGORITMA Tx HT
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.

 JNC 7 (cont) Diuretics first Addition of a second drug from a different class > 2 drugs (combo good) >160/100-start with 2 drugs (diuretic/BB, diuretic/ACEI, diuretic/ARB, diuretic/CCB) Multiple drugs if CAD, DM, Renal disease Monotherapy response rate 40-50% Multiple meds response rate 75-80% Racial differences in response disappear with multiple drugs

Logical Combinations
Diuretic b-blocker CCB ACE inhibitor a-blocker

Diuretic
b-blocker CCB ACE inhibitor a-blocker

* Verapamil + beta-blocker = absolute contra-indication

Kieran McGlade Nov

Department of General Practice QUB

British Hypertension Society Guidelines 2000 Compelling and possible indications and contrindications for the major classes of antihypertensive drugs INDICATIONS
CLASSS OF DRUG a-blockers Angiotensin converting enzyme (ACE) inhibitors POSSIBLE Prostatism Heart failure Left ventricular dysfunction Cough induced by ACE inhibitor Myocardial infarction Angina Heart failure Dyslipidaemia Peripheral vascular disease Asthma or COPD Heart block

CONTRAINDICATIONS
COMPELLING
Dyslipidaemia Chronic renal disease * Type II diabetic nephropathy Heart failure Intolerance of other antihypertensive drugs Heart failure POSSIBLE Postural Hypotension Renal impairment * Peripheral vascular disease Peripheral vascular disease COMPELLING Unrinary incontinence Pregnancy Renovascular disease Pregnancy Renovascular disease

Angiotensin II receptor antagonists

b-blockers

Calcium antagonists (dihydropyridine)

Isolated systolic hypertension (ISH) in elderly patients

Angina Elderly patients Myocardial infarction _

Calcium antagonists (rate limiting) Thiazides

Angina Elderly patients including ISH

Combination with b-blockade Dyslipidaemia

Heart block Heart failure Gout

* ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and British Hypertension Society Guidelines 2000
specialist advice are needed when there is established and significant renal impairment Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association If ACE inhibitor indicated f b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure with renovascular disease.

Kieran McGlade Nov 2001

Department of General Practice QUB

KLASIFIKASI & MANAGEMEN HT PADA DEWASA

Lifestyle BP SBP* DBP* modificati classification mmHg mmHg on Normal Prehypertens ion Stage 1 Hypertension <120 120 139 140 159 and <80 or 80 89 or 90 99 Encourage Yes No antihypertensive drug indicated. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for compelling indications.

Initial drug therapy

Without compelling indication

With compelling indications

Yes

Stage 2 Hypertension

>160

or >100

Yes

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

OBAT-OBAT LAIN YG SERING DIGUNAKAN UTK Px HT ANTIPLATELET LIPID LOWERING OBAT DIABETES NEUROPROTEKTAN ANTIARITMIA DLL-NYA

HATI-HATI MENGGUNAKAN :
Presription Drugs: NSAIDs, including Coxibs Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants (ephedrin, PPA, Pseudoefedrin) Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Monoamine oxidase inhibitors (MAOIs) Other: Licorice root Stimulants including cocaine, amfetamin (Ecstasy, Sabu2) Garam Excessive alcohol use

CONTOH KASUS RESEP

Dr.Jantung
R/.Tanapres 10 mg XXX S.1-0-0 R/.Bisoprolol 5 mg XXX S.0-0-1 R/.Letonal 25 mg XXX S.1-0-0 R/.Analsik XV S.3dd 1 Pro : Tn. LK

Dr.Jantung

R/.Cedocard 5 mg 90 S. 3 dd 1 R/.Concor 2.5 mg 30 S. 1-0-0 R/.Rhinofed XV S. 1-1-0 R/.OBH Combi 1 fl S. 3 dd C R/.Xanax 0.5 mg 30 S.0-0-1 Pro : Ny.Zakky