PENYAKIT

PENYAKIT JANTUNG
JANTUNG HIPERTENSI
HIPERTENSI
Djanggan Sargowo

FAKULTAS KEDOKTERAN UNIVERSITAS WIJAYA KUSUMA SURABAYA

1

HYPERTENSION
Worldwide 1 billion people
USA 50 million people
Prevalence will be higher if
there are no effective
preventions

PJ HIPERTENSI
HIPERTENSI : Problem kardiovaskuler : Stroke, GPDO, PJK,
Aneurisma, Hipertensi krisis
Komplikasi : - Memperpendek usia; - Harapan hidup <<; - Biaya pengobatan >>

INSIDEN : Tahun - tahun >>

TGT : - Kesadaran masyarakat kesehatan
- Check up rutin
: 10 - 20% ( USA : 15 - 20%; JEPANG : 15 - 22%
Singapura : 14%; India : 15%; Philiphina : 10,8%
Indonesia : 15%)
Perlu survei yg luas pada masyarakat
- Case finding
- Problem kesehatan masyarakat
Pengobatan yang rasional : - Komplikasi dihindari
- Umur >>
- Kualitas hidup

FENOMENA GUNUNG ES
H. + Keluhan +
Pengobatan baik

H. + Komplikasi
H. + Keluhan +
Pengobatan tak baik

H. Tanpa keluhan
Border line
Nomiotensi

DEFINISI

Piekerning : Tek Darah : - Umur

- Sex
- Lingkungan
: Tek darah Prognosa
Penatalaksanaan
Kaplan : O < 45 th : 130/90 mm Hg
O > 45 th : 140/90 mm Hg
O- segala umur : 160/90 mm Hg
Hence

NYHA
: Tek darah > 140/90 mmHg
WHO (1993) : Tek darah > 140/90 mmHg
JNC (1997) : Tek darah > 140/80 mmHg
Kriteria : Diastole
96 - 100 Std I
100 - 109 Std II
110
Std III
5
Hipertensi sistolik : Tek sitole > 160 mmHg

1. Umur : >> umur Tek darah >>

Kriteria 160/90
Hipertensi Umur : Hipertensi
sistolik
2. Sex : Muda Pria > Wanita
> 45 tahun Pria = Wanita
3. BB

FAKTOR
PREDISPOSISI

: Gemuk Hipertensi
Hipertensi Gemuk
Hipertensi gemuk > BB ideal
Kenaikan 10 kg dari BB ideal >> tensi, 3 mmHg

4. Hiriditer : OT Anak
Anak dengan OT (+) 2 Anat OT (-)
5. Garam : NaCl Na air
6. Stress : Stress Hipotal Catekol >> Sympatis >>
Resistensi >>
7. Sosio ekonomis : - Kota > didesa
- Tegang, Makanan, Olah Raga
8. Lain-Lain : Rokok, Kopi, Alkohol

HYPERTENSION
Worldwide 1 billion people
USA 50 million people
Prevalence will be higher if
there are no effective
preventions

CVD Risk Factors

Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.

HYPERTENSION
In INDONESIA complex problems:

Etiology
Prevention
Early detection
Management
Monitoring
Socio economic
Education
Income
Etc.
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PENYEBAB

1. PRIMER (IDIOPATIK) = ESSENSIAL

- 80 -90 % Prevalensi Hipertensi

- Faktor : Usia, Sex, BB, Heriditas, Stress, Garam
- NaCl : 5 - 15 gr/hr Prevalensi > 15 - 20 %
- Simpatis >> Parasimpatis << (Neurogenik) COP >>
- Ginjal : Pengaturan air + garam
Renin angiotensin sistem
- Na >> Tek Darah >>
- Simpatis >> Tek Darah >>
- Atas dasar renin HE
1. HE Tinggi Renin : - Muda
- NOR Adrenalin >>
- COP >>
2. HE Normo Renin
3. HE Rendah Renin : - Tua
- Resistensi >>

10

2. Hipertensi Sekunder (H.S.)

10% Prevalensi Hipertensi
A. GINJAL : Parenchym : - GHA / GNC
- PHA / PNC
- Polikistik ginjal
- Kimmel Stiel-Wilson
- Peny Kollagen
- DM
- Tumor
- Batu
Vaskuler :
- Stenosis A. Renalis
- Nephro Sklerosis
- Fistula A - V
- Obstruksi : Tumor
B. HORMONAL : - Phaechromacytoma
- Cushing S.
C. COARCTATIO AORTA
D. KEHAMILAN : Eklampsi
E. KEL. SYARAF

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12

NATURAL HISTORY OF HYPERTENSION

Age

HEREDITY - ENVIRONMENT

Normotension

PRE - HYPERTENSION

0 - 30

EARLY HYPERTENSION

20 40

ESTABLISHED HYPERTENSION

30 50

UNCOMPLICATED

Accelerated
CARDIAC
Malignant Hypertrophy
course
Failure
Infarction

COMPLICATED

LARGE
VESSEL
Aneurysm
Dissection

CEREBRAL
Ischemia
Thrombosis
Hemorrhage

40

RENAL
Nephrosclerosis
Failure

13

The hypertension to heart failure continuum

Hypertension
Hypertension
Coronary risk
factors

Coronary
Coronaryartery
artery
disease
disease

Myocardial
Myocardial infarction
infarction

LV
LVhypertrophy
hypertrophy
LV dilation

Remodelling

Diastolic

LV dysfunction

LV damage
Systolic

Heart
Heartfailure
failure
Symptoms

Decreased tissue
perfusion

Increased
hospitalisations

Death

14

Hemodynamic overload
Hypertension

Myocardial Infarction

Hemodynamic Overload
Myocardial Remodeling
Myocardial Failure
15

Myocardial Remodeling
Systolic Overload
Hypertension
Aortic Stenosis

Diastolic Overload
Myocardial Infarction
Valvular Regurgitation

Concentric
Hypertrophy

Eccentric
Hypertrophy
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17

18

19

Factors Controlling LVH in

Hypertension
BLOOD PRESSURE

AGE

EXERCISE
GENDER
COEXISTENT
CARDIAC
DISORDERS

ADRENERGI
C
SYSTEM

LVH

WEIGHT

INSULIN, GROWTH,
THYROID HORMON
RENINANGIOTENSIN
SYSTEM

20

Impaired
LV filling

Myocardial
+ Ischemia
+ Infarction

Heart
failure

Sudden
death

LVH
Arrhythmia

Impaired
contractility
21

The Cardiovascular Continuum

MI
Loss of
muscle

CAD

Endothelial dysfunction
Microvascular Disease
Atherosclerosis
&
LVH
Risk factors
Hyperlipidemia
HTN
Diabetes
Smoking
Insulin resistance

Neurohormonal
activation

LV
Remodeling
Ventricular dilation
HF
End-stage Microvascular
& Heart Disease

Adapted with permission from Dzau V, Braunwald E. Am Heart J. 1991;121:1244-1263.

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Death

Classification of Hypertension
JNC V (1988)

Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Presure (JNC)

BP Range, mmHg

Category

BDP
< 85

Normal BP

85 89

High normal BP

90 104

Mild Hypertension

105 114

Moderate hypertension

> 115

Severe Hypertension

SBP, when
DBP < 90 mmHg
< 140

Normal BP

140 159

Borderline isolated systolic H.

> 160

Isolated systolic Hypertension

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24

WHO-ISH (1999)
Klasifikasi Derajat Tekanan Darah menurut WHO-ISH 1999
yang diadaptasi dari JNC VI 1997

1
2
3
4
5
6
7

Kategori

Sistolik
(mmHg)

Diastolik
(mmHg)

Optimal
Normal
Normal Tinggi
Hipertensi derajat 1 (ringan)
Subgrup : perbatasan
Hipertensi derajat 2 (sedang)
Hipertensi derajat 3 (berat)
Hipertensi Sistolik
(Isolated Systolic Hypertension)

120
130
130 - 139
140 - 159
140 - 149
160 - 179
180
140

80
85
85 - 89
90 - 99
90 - 94
100 - 109
110
90
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JNC VII
Blood Presure
(mmHg)
Normal

SBP

DBP

< 120

and

< 80

Prehypertension

120 139

or

80 89

Stage 1 H.

140 159

or

90 99

Stage 2 H.

> 160

or

> 100

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The Aims of Hypertension

Management
Decrease mortality and morbidity
Restore blood pressure to normal levels1
Maintain blood pressure at TD < 140/90
mmHg2
1. 1999 World Health Organisation-International Society of Hypertension Guidelines for the Management of
Hypertension.
2. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure

27

The Ideal of Antihypertension Drug

Decrease cardiac output
Decrease systemic peripheral resistense
Maintain the normal cardiac output
Maintain organ perfussion

28

Cardioprotective Effect of
Antihypertension Drugs
Prevents atherosclerosis

progression Prevents hearth

attacks
Prevent and regression of LVH
Does not increase risk factors
29

2.a. Management of treatment :

- Based on Risk Stratification
- We start with antihypertensive drugs:
Very High Risk
High Risk
Moderate Risk ( if BP didnt after
3 months non-pharmocology treatment)
Low Risk (if BP didnt after
3 - 12 months non-pharmocology treatment)

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Risk Stratification and Treatment (JNC-VI)

Risk Group B
(At Least 1 Risk
Risk Group A
Factor, Not Including
Blood Pressure Stages (No Risk Factors Diabetes; No
(mmHg)
No TOD/CCD)
TOD/CCD)

Risk Group C
(TOD/CCD and/or
Diabetes, With or
Without Other Risk
Factors)

High-normal
(130-139/89-89)

Lifestyle
modification

Drug therapy

Stage 1
(140-159/90-99)

Lifestyle
Lifestyle
modification
modification
(up to 12 months) (up to 6 months)

Drug therapy

Stages 2 and 3
(> 160/> 100)

Drug therapy

Drug therapy

Lifestyle
modification

Drug therapy

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
31 treatment.

R A A S

Renin
Angistensin I
ACE

Angistensin II
Vasokonstriksi

Aldosteron
Na
Vol

Tek Darah
Aktivasi RAA
COP

Angiotensi I
Angiotensi II
Afterload

Vasokonstruksi

Preload

Aldosteron

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PENATALAKSANAAN (WHO)
1. HIPERTENSI : 1. Non Farmakologik
- Diet
- OR
- Stress (-)
- Rokok (-)
2. Fakmakologik
Stepped care WHO I, II, III, IV.
2. KOMPLIKASI :
LVF : Kontraksi : Inotropik
Preload : Diuretik
Afterload : - Vasodelator
- Ace inhobitor
PJK : - Suplai O2 : - Vasodelator
Nitrat, Acenning
- Ca antagonis
- Demand O2 : Blocker

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HIPERTENSION, AWARENESS,
TREATMENT, AND CONTROL RATES
1970 - 1975

1975 - 1980 1980 - 1985

1985 - 1990

Aware (%)

51

64

73

84

Treated (%)

36

34

56

73

Control (%)

16

20

34

55

34

35

Lifestyle Modifications to
Prevent and Manage Hypertension
Reduce weight

Moderate consumption of:

alcohol
sodium
saturated fat
cholesterol

Maintain adequate intake of dietary:

Increase
physical
activity

potassium
calcium
magnesium

(JNC VI. Arch Intern Med. 1997)

Avoid tobacco
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1999 WHO-ISH Guidelines for Initiation

of Anti-Hypertensive Treatment
The six classes of antihypertensive agents
listed in the new WHO/ISH guidelines:

Diuretics
Beta-blockers
ACE Inhibitors

Calcium antagonists
Alpha-blockers
Angiotensin II Receptor Blockers

Guidelines Subcommitte 1999 WHO-Intl Society of Hypertension. Guidelines for

Management of Hypertension. J Hypertens 1999;17:151-83

37

JNC
JNCVII
VII
2003
2003

Classification and Management

of BP for adults

Lifestyle
BP
SBP* DBP*
classification mmHg mmHg modification

JAMA.2003;289

Initial drug therapy

Without compelling
indication

With compelling
indications

Normal

<120

and
<80

Encourage

Prehypertens
ion

120
139

or 80
89

Yes

No antihypertensive
drug indicated.

Stage 1
Hypertension

140
159

or 90
99

Yes

Stage 2
Hypertension

>160

or >100

Yes

Thiazide-type diuretics
for most. May consider Drug(s) for the
ACEI, ARB, BB, CCB, compelling
or combination.
indications.
Other
Two-drug combination antihypertensive
drugs (diuretics,
for most (usually
ACEI, ARB, BB,
thiazide-type diuretic
CCB) as needed.
and ACEI or ARB or
38
BB or CCB).

Drug(s) for
compelling
indications.

JNC
JNCVII
VII
2003
2003

Compelling indications

Heart Failure
Post Myocardial Infarction
High Coronary Art. Disease Risk
Diabetes
Chronic Kidney Disease
Recurrent Stroke Prevention
JAMA.2003;289

39

INDICATIONS FOR INDIVIDUAL DRUG CLASSES

Compelling
indications
Heart failure
Post-MI
High coronary
disease risk
Diabetes
Chronic
kidney disease
Stroke
prevention

Diuretic -blocker

ACE
inhibitor

ARB

The JNC VII Report. JAMA 2003;289:2560-2572

40

CCB

Development of Antihypertensive Drugs

Reserpin (1949)

1950
HCT (1958)

1960

Diuretics

Verapamil (1963)
Furosemide (1964)
Propanolol (1965)

Beta blockers

1970
CCBs
1-blockers
ACE-inhibitors

Nifedipin (1975)
Prazosin (1977)

1980

Captopril (1981)

1990

Losartan (1995)
Valsartan

AT1-antagonists

2000

41

Treatment Algorithm for Adults with Systolic-Diastolic

Hypertension without another compelling indication
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Thiazide

ACE-I

ARB

Betablocker

Long-acting
DHP-CCB

Alpha-blocker
as initial
monotherapy

2003 Canadian Hypertension Education Program Recommendations.

42

The Renin-Angiotensin System

Alternate Pathway

Local

Circulating

Tissue

Liver

Angiotensinogen
Renin inhibitors

Renin

Non Renin pathways

- t-PA
- Cathepsin G
- Tonin

Angiotensin I
ACE inhibitor

Converting enzyme

Non-ACE pathways
- Chymase
- CAGE
- Cathepsin G

Angiotensin II
AII receptor blockers

Angiotensin
receptors
43

ACE INHIBITOR (ACEI)

Indikasi Spesifik dari ACEI

Hipertensi ringan, sedang, berat

Hipertensi disertai hipertropi ventrikel kiri
Gagal jantung kiri
Miokard infark disertai remodeling
Diabetes disertai mikroalbuminuria
Hipertensi disertai
Penyakit vaskuler perifer
Penyakit jalan nafas obstruktif menahun
Depresi
44

ACTIVATION AND BLOCKADE OF

NEUROHUMORAL SYSTEM IN CHF
RAA System

SNS System

Angiotensin II

Noradrenalin

ACE-I

-Blocker

Hypertrophy, apoptosis, ischemia,

arrhythmia, remodelling, fibrosis

45

46

WHERE -BLOCKERS WORK

Sudden
Sudden
death
death
Angina
Angina
Ventricular
Ventricular
arrhythmias
arrhythmias

Hypertension
Hypertension
Coronary
Coronary
artery
artery
disease
disease

Diabetes
Diabetes

Hyperlipidemia
Hyperlipidemia
Hypertrophic
Hypertrophic
cardiomyopathy
cardiomyopathy

Myocardial
Myocardial
infarction
infarction

Cardiac
Cardiac
rupture
rupture

LV
LV
dysfunction
dysfunction

Atrial
Atrial
fibrillation
fibrillation

Mechanical
Mechanical
death
death47

Heart
Heart
failure
failure

Pump
Pump
failure
failure

Antihypertensive

Anti-ischemic

-blocking
-blocking
agents
agents
Antiarrythmic

Treatment for heart failure

48

Not all -BLOCKERS are the same !

NON
SELECTIVE
ISA -

ISA +

Nadolol

Pindolol

Propanolol
Penbutolol

SELECTIVE
ISA -

ISA +

Atenolol Acebutolol
Esmolol

Labetolol
Bucindolol
Carvedilol

Celiporlol

Timolol Alprenolol

Metoprolol

Sotalol Oxprenolol

Bisoprolol
Bisoprolol
Betaxolol

Non-selective with
alfa-blocking activity

49

Treatment Algorithm for Adults with Systolic-Diastolic

Hypertension without another compelling indication
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Thiazide

ACE-I

ARB

Betablocker

Long-acting
DHP-CCB

Alpha-blocker
as initial
monotherapy

2003 Canadian Hypertension Education Program Recommendations.

50

EFFEK KARDIOPROTEKTIF CALSIUM ANTAGONIST

MENURUNKAN KEBUTUHAN OKSIGEN MIOKARDIUM
Menurunkan Tekanan Darah
Menurunkan Denyut Jantung
MENEKAN KERUSAKAN SEL MIOKARDIUM AKIBAT
INFLIKS ION CA++ YANG BERLEBIHAN KE DALAM SEL
Menekan peningkatan ion Ca++ di dalam sel miokardium
Menekan penurunan ATP & CP di dalam sel miokardium
MENINGKATKAN PENYEDIAAN OKSIGEN MIOKARDIUM
Menghilangkan spasme koroner
Meningkatkan aliran darah sub-endokardium
Menurunkan denyut jantung
(memperpanjang periode diastolik)
Menekan sklerosis koroner
EFEK : Anti Aritmia

51

Combination Drugs of
Hypertension
Diuretics

ACE Inhibitor (ARB)

- blocker

C.C. Blocker

52

PERCENTAGE OF PATIENTS WHO

NEEDED COMBINATION THERAPY
COOPE
INSIGHT
MRC1
NORDIL
STOP1
Syst-Eur
Average
0

10

20

30

40
50
60
70
% OF PATIENTS

80

90

53

100

POSSIBLE COMBINATIONS OF DIFFERENT

CLASSES OF ANTIHYPERTENSIVE AGENTS
DIURETICS

BETHA
BLOCKERS

AT1- RECEPTOR
BLOCKERS

ALFA
BLOCKERS

CALCIUM
ANTAGONISTS
ACE
INHIBITORS

54

Efective drug combinations

Diuretic and -blocker
Diuretic and ACE Inhibitor or AIIRA
Calcium antagonist (dihydropyridine)
and -blocker.
Calcium antagonist and ACE inhibitor.
-Blocker and -blocker

55

Thank
You

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