Hipertensi

Andria Priyana

Fakultas Kedokteran
Universitas Tarumanegara
2011

Peningkatan tekanan arterial

Diukur berdasarkan tekanan darah arteri
perifer
Dibagi atas
Hipertensi esensial/primer (>90%)
penyebab kompleks dari berbagai faktor
Hipertensi sekunder penyebab organ
tertentu

Kenapa penting ?

??

Kidney
Renal Insufficiency

Heart
Left Ventricular
Hypertrophy

Hypertension

Brain

Chronic Heart Failure

Myocardial Infarction
Congestive Heart
Disease
Arrhythmia

Vessel
Arteriosclerosis
Peripheral Vascular Disease
Coronary Heart Disease

Stroke

Pathogenesis of
Hypertension

Kaplan. Clinical Hypertension. 2006

Hipertensi esensial
Tidak ada sebab spesifik
Berbagai faktor berperan:
Genetik
Lingkungan dan perilaku
Adrenergik
Renal
Hormonal
Vaskular

Genetik
Dominiczac: faktor keturunan 20-40%
Masih berlangsung penelitian ttg gen
terlalu kompleks
Berbagai polimorfisme gen berhubungan
dengan hipertensi
Mutasi gen juga berperan (polycystic
kidney, neoplasia endokrin, dll)

Blood pressure =
Cardiac Output X Peripheral Resistance

Cardiac output
Preload
Contractility
Heart rate

Autoregulation
CO blood flow ke jaringan konstriksi
vaskular PR
CO normal & PR menetap

Altered responsiveness
Respon reseptor di jantung
Respons reseptor di vaskular

Intake natrium
preload
intracellular Calcium
oxidative stress
Angiotensin type I receptors
Pengaruh langsung ke
Jantung: left ventricular hypertrophy (LVH)
Ginjal: hiperfiltrasi merusak glomerulus

Retensi / ekskresi Na+ oleh ginjal

Gangguan pressure natriuresis
Arterisklerosis aktivasi renin
Penurunan jumlah nefron

Renin Angiotensin System

Nitric oxide (NO)

Angiotensinogen
Renin

Bradykinin

AI

ACE

A II

Degradation
products

CAGE
Cathepsin G
Chymase

t-PA
Cathepsin G
Tonin

ACEI site of action

ARB site of
action

AT1 receptor

Hypertrophy/proliferation
Vasoconstriction
Aldosterone release
Antidiuretic hormone release
Symphatetic discharge

AT2 receptor

Antiproliferation
NO Release
Differentiation
Vasodilation

de Gasparo M, et al. Hypertension. Pathophysiology, Diagnosis, and Management. 2nd ed. Dzau VJ. J
Hypertens. 1989;7:933-936.

Sistem simpatis
Aktivasi simpatis (norepinefrin )
Malfungsi baroreseptor

Resistensi perifer
Mekanik: Remodeling hipertrofi &
konstriksi lumen
Fungsional: hormonal & neural
Hormonal: AT II, endotelin, vasopresin
Neural: simpatis

Pengukuran tekanan darah

Klinik
Ambulatory (24 jam)
Home

Pasien duduk tenang dahulu selama 5 menit

Lengan disandarkan di meja setinggi jantung
Lakukan min 2x pemeriksaan (interval 1-2 mnt)
Palpasi a. radialis sd hilang 20 mmHg di
atasnya
Turunkan tekanan 2-3 mmHg/detik
Tentukan nilai korotkoff I & V

JNC VII: Klasifikasi tekanan darah

Klasifikasi
tekanan darah
Normal

Sistolik
(mm Hg)

Diastolik
(mm Hg)

<120

<80

Prehipertensi

120-139

80-89

Hipertensi
tingkat 1

140-159

90-99

Hipertensi
Tingkat 2

160

100

The JNC VII. JAMA 2003;289:2560-72

Organ damage
Jantung
Otak
Ginjal
Pembuluh darah perifer
Mata (retinopati)

Laboratory Tests
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR
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

Tatalaksana
Lifestyle management
Terapi medikamentosa

Target TD:
<140/90
<130/80 bila terdapat DM atau CKD (chronic
kidney disease)

Rekomendasi JNC VII pola hidup untuk

kontrol TD*
Modifikasi

Rekomendasi

Efek penurunan
tekanan darah

Penurunan berat
badan (BB)

Jaga berat badan normal

(BMI=18.5-24.9)

5-20 mmHg/10 kg
penurunan BB

Diet kaya buah & sayur, rendah lemak

(termasuk produk susu rendah lemak)

8-14 mmHg

Batasi asupan
garam

<2.4 gram natrium/hari

(1/4 sendok teh= 600 g Na)
(1,2 gr anak 4-8 tahun;
1,5 gr >8 tahun) **

2-8 mmHg

Aktifitas fisik

Latihan aerobik rutin minimal 30

menit, 3x/minggu

4-9 mmHg

Batasi alkohol

<2 drinks/day (Laki) and <1 drink/day

(perempuan)
1 drink= 150 ml wine, 45 ml wiski

2-4 mmHg

Diet DASH

DASH= Dietary Approaches to Stop Hypertension Study

+

Krebs. Pediatrics. 2003;112:424430

* Chobanian AV et al. JAMA. 2003;289:2560-2572

** Panel of Dietary Intakes for Electrolytes and Water 2004

Obat
ACE-inhibitor
Angiotensin receptor blocker (ARB)
Calcium antagonist
Diuretik
Beta blocker
-receptor blocker (prazosin, terazosin)
Sentral, 2-agonist (clonidin, metildopa)

2007 Guidelines for the management of arterial hypertension

Algorithm for Treatment of

Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

With Compelling
Indications

Without Compelling
Indications

Stage 1 Hypertension

Stage 2 Hypertension

(SBP 140159 or DBP 9099

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

(SBP >160 or DBP >100 mmHg)

2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.

Drug(s) for the compelling

indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.

Classification and Management

of BP for adults
Lifestyle
BP
SBP* DBP*
modificatio
classification mmHg mmHg
n

Initial drug therapy

Without compelling
indication

With compelling
indications

Normal

<120

and
<80

Encourage

Prehyperten
sion

120
139

or 80
89

Yes

No antihypertensive drug Drug(s) for

indicated.
compelling
indications.

Stage 1 HT

140
159

or 90
99

Yes

Thiazide-type diuretics for

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

Stage 2 HT

>160

or
>100

Yes

Drug(s) for the

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

Compelling Indications for

Individual Drug Classes
Compelling Indication

Initial Therapy Options

Clinical Trial Basis

Heart failure

THIAZ, BB, ACEI, ARB,

ALDO ANT

ACC/AHA Heart Failure

Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES

Postmyocardial
infarction

BB, ACEI, ALDO ANT

ACC/AHA Post-MI
Guideline, BHAT, SAVE,
Capricorn, EPHESUS

High CAD risk

THIAZ, BB, ACE, CCB

ALLHAT, HOPE, ANBP2,

LIFE, CONVINCE

Compelling Indications for

Individual Drug Classes
Compelling Indication

Initial Therapy Options

Diabetes

THIAZ, BB, ACE, ARB, CCB NKF-ADA Guideline,

UKPDS, ALLHAT

Chronic kidney disease

ACEI, ARB

Recurrent stroke prevention THIAZ, ACEI

Clinical Trial Basis

NKF Guideline, Captopril

Trial, RENAAL, IDNT,
REIN, AASK

PROGRESS

Hipertensi sekunder
Disebabkan oleh kelainan spesifik
(penyakit atau obat)
5-10%
Penting: koreksi masalah koreksi
hipertensi

Dicurigai bila
Onset hipertensi usia <30 th (tanpa riw keluarga)
atau >55
Abdominal bruit
Accelerated hypertension (HT stage 3)
Hipertensi yang biasanya mudah terkontrol tapi
sekarang resisten
Edema paru berulang dengan hipertensi
Gagal ginjal tanpa sebab jelas, terutama bila
tanpa proteinuria atau kelainan urinalisis
ARF yang dipicu ACEi/ARB

JNC VII

K, Na,
Mg

JNC VII

Am Fam Physician 2003;67:67-74