HIPERTENSI

Sahala Panggabean
BAGIAN
ILMU PENYAKIT DALAM
FK UKI
Jakarta, 22 September 2015

PATOFISIOLOGI HIPERTENSI
Autoregulation
BLOOD PRESSURE
Hypertension

= CARDIAC OUTPUT
= Increased CO

Preload

Fluid
Volume

x
and/or

Contractility

PERIPHERAL RESISTANCE
Increaced PR

Functional

Structural

Constriction

hypertrophy

Volume
Redistribution

Renal
Sodium
Retension

Decreased
filtration
surface

Sympathetic
nervous overactivity

ReninAngiostensin
Excess

Cell
Membran
Alteration

Stress
Excess
Sodium
Intake

Hyper
Insulinemia

Obesity

Genetic
Alteration

Genetic
Alteration
factors

Endothelium
derived

Classification and managemen of

blood pressure for adults (JNC VII)
INITIAL GRUG THERAPY

BP
Classification

SBp*
mmHg

DBp*
mmHg

Lifestyle

Without Compelling
Indication

With Compelling
indication

Normal

<120

And <80

Encourage

No Antihypertension
Drug indicated

Drug(s) for comppelling

indication

Prehypertension

120-139

Or 80-89

Yes

Stage 1
hypertension

140-159

Or 90-99

Yes

Thiazide-type diuretics
for most. May consider
ACEI,ARB,BB, CCB or
combination

Yes

Two drug combination for

most (usually Thiazidetype diuretics an ACEI or
ARB or BB or CCB)

Drug(s) for the

compelling indications
Other antihypertensive
drugs (diuratics, ACEI,
ARB, BB, CCB) as
needed

Stage 2
hypertension

<160

Or <210

MODIFICATION

DBP* diagnostic blood pressure, SBP, systotic blood pressure

Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.
*
.
.

Evaluation Objectives
To identify know causes
To assess presence or absence of target
organ damage and cardiovascular disease
To identify other risk factors or disorders
that might guide treatment

Evaluation Components

Medical history
Physical examination
Routine laboratory tests
Optional tests

MEDICAL HISTORY

Duration and classification of hypertension

Patient history of cardiovascular disease
Family history
Symptoms suggesting causes of
hypertension
Lifestyle factors
Current and previous medications

Physical Examination

Blood pressure readings (two or more)

Verification in contralateral arm.
Height, weight, and waist circumference
Funduscopic examination
Examination of the neck, heart, lungs,
abdomen, and extremities
Neurological assessment

Laboratory Tests Recommended

Before Initiating Therapy
Urinalysis
Complete blood count
Blood chemistry (potassium, sodium,
creatinine, and fasting glucose)
Lipid profile (total cholesterol and HDL
cholesterol)
12-lead electrocardiogram

Optional Tests and Procedures

Creatinine clearance
Microalbuminuria
24-hour urinary protein
Serum calcium
Serum uric acid
Fasting triglycerides
LDL cholesterol
Glycosolated
hemoglobin

Thyroid-Stimulating
hormone
Plasma rennin
activity/urinary sodium
determination
Limited echocardiography
Ultrasonography
Measurement of ankle/arm
index

Examples of Identifiable
Causes of Hypertension
Renovascular disease
Renal parenchymal disease
Polycystic kidneys
Aortic coarction
Pheochromocytoma

Primary aldosteronism
Cushing syndrome
Hyperparathyroidism
Exogenous causes

Components of Cardiovascular
Risk in Patients With Hypertension
Major Risk Factors :
Smoking
Dyslipidemia
Diabetes mellitus
Age older than 60 years
Sex (men or postmenopausal women)
Family history of cardiovascular disease

Clinical Risk Factors for Stratification

Of Patients With Hypertension

Heart diseases
Stroke or transient ischemic attack
Nephropathy
Peripheral arterial disease
Retinopathy

Types of Hypertension

Primary HTN:
also known as essential HTN.
accounts for 95% cases of HTN.
no universally established cause known.

Secondary HTN:
less common cause of HTN ( 5%).
secondary to other potentially rectifiable causes

Causes of Secondary HTN

Common
Intrinsic renal disease
Renovascular disease
Mineralocorticoid excess
Sleep Breathing disorder

Risk Stratification
Risk Group A

No risk factors
No target organ disease/clinical cardiovascular disease

Risk Group B

At least one risk factor, not including diabetes

No target organ disease/clinical cardiovascular disease

Risk Group C

Target organ disease /clinical cardiovascular disease and/or

diabetes.
With or without other risk factors

Treatment Strategies and

Risk Stratification
Blood Pressure
Stages (mmHg) Risk Group A

Risk Group B

High-normal
(130-139/85-89)

Lifestyle modification

Lifestyle modification Drug therapy

Lifestyle modification

Stage 1
(140-159/90-99)

Lifestyle modification
(up to 12 months)

Lifestyle modification Drug therapy

(up to 6 months)**
Lifestyle modification

Stages 2 and 3
(160/ 100)

Drug therapy
Lifestyle modification

Drug therapy
Drug therapy
Lifestyle modification Lifestyle modification

Risk Group C

Or those with heart failure, renal insufficiency, or diabetes

For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification

Goal of Hypertension
Prevention and Management
To reduce morbidity and mortality by the least
intrusive means possible. This may be
accomplished by
- Achieving and maintaining SBP < 140 Hg
and DBP < 90 mm Hg.
- Controlling other cardiovascular risk factors.

Lifestyle Modifications
For Prevention and
Management

Lose weight if overweight

Limit alcohol intake
Increase aerobic physical activity
Reduce sodium intake
Maintain adequate intake of
Potassium

For Overall and

Cardiovascular Health

Maintain adequate intake of

calcium and magnesium
Stop Smoking
Reduce dietary saturated fat and
cholesterol

Pharmacologic Treatment
Decreases cardiovascular morbidity and mortality
based on randomised controlled trials
Protects against stroke, coronary events, heart
failure, progression of renal disease, progression
to more severe hypertension, and all-cause
mortality

Special Considerations
In Selecting Drug Therapy
Demographics
Coexisting diseases and Therapies
Quality of life
Physiological and biochemical measurements
Drug interactions
Economic considerations

Drug Therapy
A low dose of initial drug should be used slowly
titrating upward.
Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least 50% of
peak effect remaining at end of 24 hours
Combination therapies may provide additional
efficacy with fewer adverse effects

Classes of
Antihypertensive Drugs

ACE inhibitors
Adrenergic inhibitors
Angiotensin II receptor blockers
Calcium antagonists
Direct vasodilators
Diuretics

Combination Therapies

adrenergic blockers and diuretics

ACE inhibitors and diuretics
Angiotensin II receptor antagonists and diuiretics
Calcium antagonists and ACE inhibitors
Other combinations

Followup
Follow up within 1 to 2 months after initiating therapy
Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
Consider reducing dose and number of agents after 1
year at or below goal.

Causes for inadequate

Response to drug Therapy

Pseudo resistance
Non adherence to therapy
Volume overload
Drug-related causes
Associated conditions
Identifiable cause of hypertension

Hypertensive Emergencies
And Urgencies
Emergencies

require immediate blood

pressure reduction to prevent or limit
target organ damage
Urgencies benefit from reducing blood
pressure within a few hours
Elevated blood pressure alone rarely
requires emergency therapy
Fast-acting drugs are available.

Drugs Avaiblable for

Hypertensive Emergencies
Vasodilators
Nitroprusside
Nicardipine
Fenoldopam
Nitroglycerin
Enalaprilat
Hydralazine

Adrenergic Inhibitors

Labetalol
Esmolol
Phentolamine

Algorithm For Treatment of

Hypertension
( JNC VII)

Lifestyle Modifications
(JNC VII)
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patiens with diabetes or chronic kidney disease
Initial Drug Choices
Without Compelling
Indication

Stage 1
Hypertension
(SBP 140-159 or DBP
90-99 mmHg

Stage 2
Hypertension
(SBP >=160 or DBP
>=100 mmHg

Thiazide -type diuretc

for most. May consider
ACEI, ARB, BB, CCB,
or combination

To-drug combination for

most (usually thiazide type diuretic and ACEI
or ARB or BB or CCB)

With Compelling Indication

Drug(S) for the

compelling indications
(se table *
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
DBP, diastolic blood pressure, SBP, systolic blood pressure
Drug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin
receptor blocker; BB= beta-blocker; CCB= calcium channel blocker.

Algorithm for Treatment of

Hypertension (continued)
Begin or Continue Lifestyle Modifications

Lose weight
Limit alcohol
Increase physical activity
Reduce sodium

Maintain potassium
Maintain calsium and magnesium
Stop Smoking
Reduce saturated fat cholesterol

Not at Goal Blood Pressure

Specific Drug Indications

Some antihypertensive drugs may have
favourable affects on co-morbid conditions :
Heart failure
Angina
- Carvedilol
- -blockers
- Losartan
- Calcium antagonists
Myocardial infarction
Atrial tachycardia and
- Diltiazem
fibrillation
- Verapamil
- -blockers
- Nondihydropyridine Calcium antagonists

Specific Indications (continued)

Some antihypertensive drugs may have favourable affects
on co-morbid conditions :
Cyclorsporine-induced
hypertension
- Calcium antagonists

Diabetes mellitus (1 and 2)

with proteinuria
- ACE Inhibitos (preferred)
- Calcium antagonists

Diabetes mellitus (type 2)

- Low-dose diuretics
Dyslipidemia
- -blockers

Prostatism (benign prostatic

hyperplasia)
- -blockers
Renal insufficiency (caution
in renovascular hypertensio
and creatinine > 3 mg/dl [>
265. mol/L])
- ACE inhibitors

SELAMAT BELAJAR