HIPERTENSI

MAIMUN SYUKRI

Blood Pressure Classification

BP
Classification

SBP
mmHg

Normal

<120

DBP
mmHg
and

<80

Prehypertension 120139

or

8089

Stage 1
Hypertension

140159

or

9099

Stage 2
Hypertension

>160

or

>100

WHO/ISH 2003.

ESC/ESH 2003 .

Classification of blood pressure levels of the

British Hypertension Society
Category

Optimal
Normal
High-normal

Systolic blood pressure

(mmHg)
<120
<130
130139

Diastolic blood pressure

(mmHg)
<80
<85
8589

Hypertension
Grade 1 (mild)
140159
Grade 2 (moderate) 160179
Grade 3 (severe)
180

9099
100109
110

Isolated Systolic Hypertension

Grade 1
140 - 159
Grade 2
>160

<90
<90
Brit Med J 2004 328:634-40.

AUSTRALIA 2003

BP Measurement Techniques
Method

Brief Description

In-office

Two readings, 5 minutes apart,

sitting in chair. Confirm elevated
reading in contralateral arm.

Ambulatory BP
monitoring

Indicated for evaluation of whitecoat HTN. Absence of 1020% BP

decrease during sleep may indicate
increased CVD risk.
Provides information on response
to therapy. May help improve
adherence to therapy and evaluate
white-coat HTN.

Self-measurement

JNC 7 2003

Office BP Measurement
Use auscultatory method with a properly calibrated and validated
instrument.
Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made.
Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.
JNC 7 2003

How to measure blood pressure accurately

sphygmomanometer
Patient should be seated and relaxed, preferably for several
minutes prior to the measurement and in a quiet room.
Appropriate cuff size.
Average the readings. If the firsty two readings differ by more than 10
mmHg systolic or 6 mmHg diastolic or if the initial readings are high, take
several readings after five minutes of quiet rest, until consecutive
readings do not vary by greater than these amounts.
Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
..
Australia, 2004

Box 2 Procedures for blood pressure measurement

When measuring blood pressure, care should be taken to

.. to sit for several minutes in a quiet room before

beginning blood pressure measurements.

Take at least two measurements spaced by 1-2 min, .

Use a standard bladder . but have a larger and a smaller

bladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of the
patient.
Use phase I and V .

Measure blood pressure in both arms at first visit to detect

possible differences ..

Measure blood pressure 1 and 5 min after assumption of the

standing position in elderly subjects, diabetic patients,
..

Measure heart rate by pulse palpation (30 s) after the

second measurement in the sitting position.

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.

Identifiable
Causes of Hypertension
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

Target Organ Damage

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

Laboratory Tests
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
Optional tests
Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved

Treatment
Overview
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Classification and management of BP for adults
Followup and monitoring

Goals of Therapy
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.

Sign and Symptoms

Essential HTN is usually

- asymptomatic
- undetected for many years
- headache, BP elevated systolic
beyond 200 mmHg or BP rising
rapidly (can occur in malignant
HTN)

Symptomatic associated with

malignant HTN

Headache
Blurred vision
Chest pain
Breathlessness
Nausea, vomiting
Anxiety, confusion, coma
Seizures

Consequences of Malignant HTN

End Organ

Complications

Aorta

Aortic disection

Brain

Hipertensive encepahlopathy
Cerebral Infarction or Haemmorharge

Heart

Cardiac failure
Myocardial ischemic or infarction

Kidney

Renal failure
Haematuria

Gastrointestinal

Anorexia,nausea,vomiting,abdominal
pain

Placenta

Eclampsia

Other

Micro-angiopathic haemolytic anemia

Consequences of hypertension

Cardiac disease
Left ventriclar failure
Angina
Myocardial infarction

Cerebrovascular disease
Transient ischemic attacks
Stroke
Multi-infarct dementia
Hypertensive encephalopathy

Consequences of hypertension

Vascular disease
Aortic aneurysm
Occlusive peripheral vascular disease
Arterial dissection

Others
Progressive renal failure
Hypertensive retinopathy

Risk of Hypertension

Advancing age
Positive family history of premature
cardiovascular disease
Smoking
Hypercholesterolemia

Hypertension is thought to account for :

- Onehalf of all deaths due to stroke
- Up to one quarter of coronary heart
disease deaths

Isolated Systolic hypertension increase

the risk of :

stroke and coronary heart disease by

about 40%

cardiovascular death by about 50%

heart failure by about 50%

Aetiology of hypertension

Essential hypertension
(primer/idiopathic hypertension
remain uncertain
(genetic and environmental factors
contribute to development of
hypertension)

Secondary hypertension

Secondary hypertension

Renal parenchymal disease, causes :

- the glomerulonephritides
- diabetic nephropathy
- analgesic nephropathy
- adult polycystic kidney disease
Renal artery stenosis
Primary hyperaldosteronism
Phaeochromocytoma

Secondary hypertension

Aortic coarctation
Cushings syndrome
Drug induced hypertension
- the oral contraception pill

- steroids
- NSAID
- immunosuppressive
- sympathomimetics
- anabolic steroids
- erythropoieti n
- monoamin oxidase inhibitors
Thyrotoxicosis
Rare monogenic syndrome

Clinical assesment of hypertension

Sign and symptoms

Pointers to secondary hypertension
Features of malignant hypertension
End organ damage
Hypertensive nephropathy
Left ventricular hypertrophy
Hypertensive retinopathy

Grades of hypertension retinopathy

Grade
I

II

III
IV

Features
Mild narrowing or sclerosis of the retinal
arteriole, no symptoms,
Good general health
Venous compression at artriovenous
crossing (A-V nipping) no symptoms,
good general health
Retinal oedema, cotton wool spots,
hemmorhages, often symptoms
All above
Papiloedema,Symptomatic
Cardiac and renal function often
impaired, reduced survival

Treatment

Non Pharmacotherapy
(lifestyle modification)
Pharmacotherapy

WHO-ISH Guidelines for Management

of Hypertension: Stratification of
Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1

Grade 2

Grade 3

Mild
hypertension

Moderate
hypertension

Severe
hypertension

Other risk factors and

disease history

SBP 140159
or DBP 9099

SBP 160179
or DBP 100109

SBP 180
or DBP 110

I No other risk factors

Low risk

Med risk

High risk

II 12 risk factors

Med risk

Med risk

Very high risk

III 3 or more risk factors

or TOD or diabetes

High risk

High risk

Very high risk

Very high risk

Very high risk

Very high risk

IV ACC

TOD = Target-organ damage

ACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH

Guidelines. J Hypertens 1999;17:151-183.

BP TARGETS:
WITHOUT COMPLICATION : <140/80 mmHg
DIABETES

: < 130/80 mmHg

CKD

: < 130/80 mmHg

PROTEINURIA > 1 g/d

: <125/75 mmHg

Lifestyle Modification
Modification

Weight reduction
Adopt DASH
eating plan
Dietary sodium
reduction
Physical activity
Moderation of
alcoholconsumption

Approximate SBP
reduction
(range)
520 mmHg/10 kg weight
loss
814 mmHg
28 mmHg
49 mmHg
24 mmHg

Lifestyle Recommendations for

Hypertension: Physical Activity
Should be prescribed to reduce blood pressure

Frequency

- Four or five times per week

Intensity

- Moderate

Time

- 45-60 minutes

Type

Dynamic exercise
- Walking
- Cycling
- Non-competitive swimming

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Treatment of Hypertension

Diuretic
ACE
ARB
Beta blocker
Alpha blocker

Treatment Algorithm for Adults with SystolicDiastolic Hypertension without another

compelling indication
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Thiazide

ACE-I

ARB

Long-acting
DHP-CCB

Betablocker

Alpha-blocker
as initial
monotherapy

Indications for
Pharmacotherapy

Strongly consider prescription if:

Average DBP equal or over 90 mmHg and:

Hypertensive Target-organ damage (or CVD) or
Independant cardiovascular risk factors

Elevated systolic BP
Cigarette smoking
Abnormal lipid profile
Strong family history of premature CV disease
Truncal obesity
Sedentary Lifestyle

Average DBP equal or over 80 mmHg and

diabetes

Diuretics

-blockers

AT1 receptor
blockers

-blockers

Ca Antagonist

ACE Inhibitors
2003 Guidelines for Management of Hypertension, J of Hypertension 2003
C.I. : Verapamil + Blocker

ESH-ESC 2003

JNC 7: Management of Hypertension by

Blood Pressure Classification
Initial Drug Therapy
BP Classification
Normal
<120/80 mm Hg

Lifestyle
Modification

Without Compelling
Indication

With Compelling
Indication

Encourage

Prehypertension
120-139/80-89 mm Hg

Yes

Stage 1 hypertension
140-159/90-99 mm Hg

Yes

Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination

Drug(s) for the compelling

indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed

Stage 2 hypertension
160/100 mm Hg

Yes

2-drug combination for most

(usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)

Drug(s) for the compelling

indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed

No drug indicated

Drug(s) for the

compelling indications

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta

blocker; CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.

Compelling Indications for

Individual Drug Classes
Compelling
Indication

Initial Therapy
Options

Clinical Trial
Basis

Diabetes

THIAZ, BB, ACE,

ARB, CCB

NKF-ADA
Guideline, UKPDS,
ALLHAT

Chronic kidney
disease

ACEI, ARB

Recurrent stroke THIAZ, ACEI

prevention

NKF Guideline,
Captopril Trial,
RENAAL, IDNT,
REIN, AASK

PROGRESS

JNC 7 2003