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HAERANI RASYID
FK UNIVERSITASHASANUDDIN
2015
Epidemiologi,
Klasifikasi dan
Diagnosis
Age 35-64
Age 65-94
30
25
20
15
10
5
0
Year 1
Year 3
Year 2
80
40
20
0
YEAR 1
YEAR 2
YEAR 3
YEAR 4
NEJM 2006;354:1685-97
PREVALENSI HIPERTENSI
DI INDONESIA
P
E
R
S
E
N
RISKESDAS 2007
KLASIFIKASI HIPERTENSI
(JNC 7)
Systolic
Diastolic
Optimal
<120
and / or
<80
Normal
<130
and / or
<85
High-Normal
130-139
and / or
85-89
140-159
and / or
90-99
160-179
and / or
100-109
180
and / or
110
140
and
<90
DIAGNOSIS HIPERTENSI
Berdasarkan penyebabnya hipertensi dibagi menjadi
2 golongan yaitu :
1. Hipertensi primer / esensial (90-95%)
Hipertensi yang tidak diketahui penyebabnya
2. Hipertensi sekunder (5-10%)
Hipertensi yang diketahui sebabnya
PATOGENESIS
HIPERTENSI
SILENT
KILLER
!!!
17
18
19
20
21
PENATALAKSANAAN HIPERTENSI
TUJUAN
Tujuan jangka pendek : menurunkan tekanan darah
Tujuan jangka panjang : menurunkan morbiditas/mortalitas
akibat kerusakan organ target
PENGKAJIAN
-Faktor risiko dan komorbiditas
-Penyebab hipertensi
-Adanya kerusakan organ target
-Anamnesis dan pemeriksaan fisis
-Laboratorium
-EKG
22
23
Keterangan :
TDS : Tekanan Darah Sistolik;
TDD : Tekanan Darah Diastolik;
PGK : Penyakit Ginjal Kronik;
DM : Diabetes Mellitus;
PKV : Penyakit Kardiovaskuler
2.
3.
4.
Keterangan: BSA = Body Surface Area; CABG = Coronary Artery bypass Graft; eGFR = Estimated Glomerular Filtration Rate;
HbAic = glycated Haemoglobin; PCI = Percutaneous Coronary Intervention; PWV = Pulse Wave Velocity;
Sumber : European Society of Hypertension-European Society of Cardiology (ESH-ESC) 2013
Dementia
Penyakit
cerebrovask
uler
Disfungsi
sistolik
LVH
Gagal jantung
HIPER
TENSI
Proteinuria
Gangguan ginjal
ESRD
Retinopati
Perdarahan
Papiloedema
26
History
+
Examination
Clues to 2o HT
Symptoms
Drugs
Signs
Kecurigaan HT sekunder
1.
2.
3.
4.
5.
LABORATORIUM
Tujuan Evaluasi Laboratorium
Mendeteksi komplikasi yang terjadi (ada
tidaknya kerusakan organ target)
Mengetahui apakah ada faktor resiko
penyakit kardiovaskuler
Mencari penyebab hipertensi
GUIDELINES
JNC VII 2004: berjenjang dan compelling indications
BHS-NICE 2006 : terapi sekuensial
Pengobatan awal dan kombinasi :
ESH-ESC 2009, CHEP 2009, JHS 2009
Diagnostic algorithm for high Blood Pressure including Office, ABPM and HBPM
Penatalaksanaan hipertensi????
Non-farmakologis
Farmakologis :
Guideline :
JNC VII 2004: berjenjang dan compelling
indications
BHS-NICE 2006 : terapi sekuensial
Pengobatan awal dan kombinasi :
ESH-ESC 2009, CHEP 2009, JHS 2009
JNC VIII 2013
Initiation of Tr eatment
SBP 140-1 80 m mHg or DBP 90 -110 mmHg
on seve ral occ asions (Grades 1 & 2 hypertension)
Assess other risk fac tors, TOD1 and ACC2
Initate Lifes tyle Measures
Stratify Absolute Risk
Very High
Begin
drug
treatme nt
High
Medium
Begin
drug
treatme nt
Monitor BP and
othe r risk factors
for 3 - 6 months
Low
Monitor BP and
othe r risk factors
for 6 - 1 2 m onths
High in:
Fresh fruits
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre
Plant protein
Low in:
Saturated fat and cholesterol
Sodium
Dietary Potassium
Daily dietary intake >80 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
Health care cost savings of $430 to 540 million per year related
to fewer office visits, drugs and laboratory costs for
hypertension
Age
Adequate
Intake
(mg)
Upper
Limit
(mg)
19-50
1500
2300
51-70
1300
2300
71 and
over
1200
2300
Sodium: Meta-analyses
Average Reduction of sodium
in mg/day
1800 mg/day
2300 mg/day
Hypertensives
Reduction of BP
5.1 / 2.7 mmHg
7.2/3.8 mmHg
Normotensives
Reduction of BP
2.0 / 1.0 mmHg
3.6/1.7 mmHg
Atherosclerosis
Stroke
Left ventricle hypertrophy
Proteinuric kidney disease
Heart failure
Frequency
Intensity
Time
Type
Cardiorespiratory Activity
- Walking, jogging
- Cycling
- Non-competitive swimming
Waist Circumference
Men <102 cm
Women <88 cm
Measure here
Iliac crest
Non-pharmacological Treatment
Objective of lifestyle changes in
hypertension
Lower blood pressure
Minimize drug use
Reduce overall cardiovascular risk
Improve outcome
Maintain or improve quality of life
Non-pharmacological Treatment
Intervention
Weight Reduction
Recommendation
20 to 55 mmHg
Dietary sodium
restriction
Physical Activity
Alcohol
moderation
2-8 mmHg
4-9 mmHg
2-4 mmHg
Intervention
Target
Weight loss
Alcohol restriction
< 2 drinks/day
Physical activity
Dietary patterns
DASH diet
Smoking cessation
Waist circumference
Men <102 cm
Women <88 cm
PHARMACOLOGIC TREATMENT
OF HYPERTENSION
58
GOALS OF TREATMENT
As low as possible
without
complication
Tabel 2.6 Faktor Risiko dan Pemberian Obat Berdasarkan derajat Hipetensi
Main Classes of
Antihypertensive Drugs
Diuretics
Calcium-channel antagonists
Beta-blockers
Vasodilators
Direct renin inhibitors
Sympathetic
Stimulation
Cardiac
output
Vasomotor
Sympathetic
tone
Stimulation
Plasma
volume
1 3
Heart
12
Sympathetic
Stimulation
Precapillary Arteriole
(Resistance Vessels)
1
4
12
Renin
Activates
3
Kidney
Postcapillary Venules
(Capacitance Vessels)
Angiotensin
Activates
Aldosterone
Sympathetic
Stimulation
Thiazide Diuretics
Veins
Thiazides
Loop Diuretics
Veins
Thiazides
Loops
Furosemide 20 mg BID
Aldosterone Receptor
Antagonists
Veins
Thiazides
Loops
Aldosterone Ant.
Spironolactone 25 mg daily
Beta Blockers
Heart
Beta Blockers
Heart
Diltiazem
Verapamil
Dihydropyridine
CCBs
Renin-Angiotensin Cascade
Angiotensinogen
Non-renin
(eg tPA)
Renin
Bradykinin
Angiotensin I
Non-ACE
(eg chymase)
ACE
Angiotensin II
AT1
AT2
ATn
Inactive
peptides
Slide Source
Hypertension Online
www.hypertensiononline.org
ARBs
Arteries
Veins
ARB
ARB: Irbesartan 150-300 mg QD, Losartan 25100 mg BID, Olmesartan 20-40 mg, Telmisartan
20-80 mg, Valsartan 90-160 mgQD
Monitor: S Cr, K
Compelling indications: HF, post-MI, High
CAD risk, Diabetes, CKD, Stroke
ACEI
Arteries
Veins
ACEI
Monitor: S Cr, K
Compelling indications: HF, post-MI, High
CAD risk, Diabetes, CKD, Stroke
Alpha1 Blockers
Arteries
Alpha1 Blockers
Terazosin 1 20 mg daily
Doxazosin 1 16 mg daily
Central Acting
Mechanism:
Clonidine
Monitor: HR (bradicardia)
Side effects often limiting: Dry mouth,
orthostasis, sedation
Withdrawal/Rebound effect
Vasodilators
Arteries
Dihydropyridine
CCBs
Hydralazine
Minoxidil
NEW ANTIHYPERTENSIVE
AGENTS
Direct Renin Inhibitor; ALISKIREN
Monotherapy effective in lowering SBP and DBP
in hypertensive patients
Effective also in combination with a thiazide
diuretic, a CCB and an ACE inhibitor or an ARB
Protect against subclinical organ damage when
combined with an ARB
= the available evidence justifies its use in hypertension, in
combination with other agents.
Mancia et al.Reappraisal of ESC Hypertension Guidelines 2007
FARMAKOLOGIK :
Tabel 1. Obat antihipertensi oral
DOSIS
(mg/hr)
FREKUEN
SI
12,5-50
Indapamide
1,25-2,5
12,5-25
Diuretik loop
Chlorthalido
ne
Furosemide
20-80
Potassium-sparing
diuretics
Amiloride
Triamterene
510
50100
12
12
Aldosterone receptor
blockers
Spironolact
one
2550
KELAS
Diuretik thiazide
NAMA
HCT
77
KELAS
Beta blockers
NAMA
Atenolol
Bisoprolo
l
Propranol
ol
Acebutol
ol
DOSIS
(mg/hr)
FREKUENS
I
25100
2.510
40160
200800
Carvedilo
l
Labetalol
12.550
200800
Captopril
25100
Lisinopril
1040
Ramipril
2.520
78
KELAS
Angiotensin II
antagonists
DOSIS
(mg/hr)
FREKUENSI
832
150300
Losartan
25100
12
Olmesartan
2040
Telmisartan
2080
80320
12
180420
120480
12
2.510
3060
NAMA
Candesartan
Irbesartan
Valsartan
CCBs
nondihydropyri
dines
Diltiazem extended
release
Verapamil long
acting
Amlodipine
CCBs
dihydropyridine Nifedipine longs
acting
79
KELAS
Alpha-1 blockers
Central alpha-2
agonists
and other
Direct
vasodilators
DOSIS
(mg/hr)
FREKUENS
I
116
Prazosin
220
23
Terazosin
120
12
Clonidine
0.10.8
2501,000
25100
2.580
12
NAMA
Doxazosin
Methyldop
a
Hydralazin
e
Minoxidil
80
Aged under
55 years
C2
A
A + C2
A+C+D
Resistant hypertension
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Summary of
antihypertensive
drug treatment
Step
1
Step
2
Step
3
Step
4
Key
A ACE inhibitor or lowcost angiotensin II
receptor blocker (ARB)1
C Calcium-channel
blocker (CCB)
D Thiazide-like diuretic
82
Stage 1 Hypertension
(SBP 140-159 or DBP 90-99 mm Hg)
Thiazide-type diuretics for most
May consider ACEI, ARB, BB, CCB,
or combination
With Compelling
Indications
Stage 2 Hypertension
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved
Consider consultation with hypertension specialist
84
Normal
High normal
Grade 1 HT
Grade 2 HT
Grade 3 HT
SBP 120-129 or
DBP 80-84
SBP 130-139 or
DBP 85-89
SBP 140-159 or
DBP 90-99
SBP 160-179 or
DBP 100-109
SBP 180 or
DBP 110
No BP intervention
Lifestyle changes
for several months
then drug treatment
if BP uncontrolled
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes
Lifestyle changes
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes
Lifestyle changes
and consider drug
treatment
Lifestyle changes +
drug treatment
Lifestyle changes +
drug treatment
Diabetes
Lifestyle changes
Lifestyle changes +
drug treatment
Lifestyle
changes +
immediate drug
treatment
Established
CV or renal
disease
Lifestyle changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
No other risk
factors
1-2 risk
factors
>3 risk
factors, MS
or TOD
No BP intervention
Terapi kombinasi
KAPAN ?
JNC 7 DAN ESH-ESC 2007 :
Tekanan darah 20/10 mmHg di atas target
Individual
MENGAPA ?
Patogenesis hipertensi : multifaktorial kombinasi 2
obat atau lebih = efek sinergis dan pengendalian
tekanan darah yang lebih baik
86
SYARAT
1.Mekanisme kerja obat saling mendukung
2.Ada bukti bahwa kombinasi lebih baik
3.Profil keamanan yang lebih baik
MANFAAT
1.Kontrol tekanan darah yang lebih baik, terutama
pada hipertensi berat, resisten, sekunder, mildmoderate hypertension, dan hipertensi dengan
komorbid
2.Memaksimalkan efikasi
3.Meminimalkan efek samping
87
Choose between:
Marked BP elevation
High/very high CV risk
Lower BP target
Two-drug combination
at low dose
Single agent
at low dose
If goal BP not achieved
Previous agent
at full dose
Switch to different
agent at low dose
Previous combination
at full dose
Full-dose
monotherapy
Two-three-drug combination
at effective doses
ESH/ESC Guidelines 2007
European Heart Journal. 2007;28:1462-1536
JNC
8 Algorithm
for Treatment ofGuideline
Hypertension
2014
Hypertension
PROBLEM
Difficult-to-Control
Hypertension
Difficult-to-Control
Hypertension
Difficult-to-Control
Hypertension
Associated factors:
Medications (NSAID, oral contraceptive,
sympathomimetic, corticosteroid,
erythropoetin, cyclophospamid.
Excessive alcohol consumption
Chronic kidney disease
Obesity
Obstructive sleep apnea
Difficult-to-Control
Hypertension
Suboptimal Medical
Treatment
Clinical inertia : the providers failure to
increse therapy when the treatment
goal is not reached.
Lack of knowledge of treatment
guidelines
Underestimation of cardiovascular risk
The use of spurious reason to avoid
intensification of therapy.
99
100
101
102
Thiazide-type
diuretic present?
NO
YES
* if not already part of
regimen, consider B for
addition if pulse >84
A= ACEI or ARB
B = Beta Blocker
C= CCB (long-acting)
D= Diuretic
Re-evaluate
If blood pressure
remains uncontrolled
ACEI
+ ARB
or
2 CCBs
(different types)
or
alpha-blocker or
combined
alpha/beta blocker
or
Centrally-acting
(e.g. Clonidine)
+ vasodilator (e.g.
hydralazine)
specialist referral ?
Indication :