You are on page 1of 111

Hipertensi

HAERANI RASYID
FK UNIVERSITASHASANUDDIN
2015

Epidemiologi,
Klasifikasi dan
Diagnosis

Development of hypertension (%) in people with


high normal blood pressure
45
40
35

Age 35-64
Age 65-94

30
25
20
15
10
5
0
Year 1

Year 3

772 subjects, overweight, mean age 48.5


Not receiving treatment for hypertension
Average of 3 blood pressures at baseline:
SBP 130-139 and DBP < 89 OR

Year 2

SBP < 139 and DBP 85-89

Primary endpoint new onset hypertension

Framingham cohort Vasan. Lancet 2001;358:1682-86

New onset hypertension in people with high


normal blood pressure

80

New hypertension (%)


60

40

20

0
YEAR 1

YEAR 2

40% of overweight patients with systolic


130-139 or diastolic 85-89 mmHg
developed hypertension in 2 years and
63% in 4 years

YEAR 3

YEAR 4

NEJM 2006;354:1685-97

PREVALENSI HIPERTENSI
DI INDONESIA
P
E
R
S
E
N

Usia 18 tahun, berdasarkan JNC 7


RISKESDAS 2007

PROPORSI ANGKA KEMATIAN DI INDONESIA


BERDASARKAN PENYEBABNYA
(PENYAKIT TIDAK MENULAR)

RISKESDAS 2007

RISIKO KEMATIAN KARDIOVASKULER MENJADI DUA


KALI LIPAT UNTUK SETIAP PENINGKATAN TEKANAN
DARAH 20/10 mmHg

Usia 40-69 tahun


Lewington S et al. Lancet. 2002;360:19031913.

Mengapa kontrol tekanan


darah itu penting?

Metaanalisis, 61 penelitian prospektif


observasional, 1 juta subyek dewasa
Lewington S et al. Lancet. 2002;360:19031913

KLASIFIKASI HIPERTENSI
(JNC 7)

The classification of blood pressure and hypertension

Shin et al. Clinical Hypertension

European Society of Hypertension Classification of


Blood Pressure
Category

Systolic

Diastolic

Optimal

<120

and / or

<80

Normal

<130

and / or

<85

High-Normal

130-139

and / or

85-89

Grade 1 (mild hypertension )

140-159

and / or

90-99

Grade 2 (moderate hypertension)

160-179

and / or

100-109

Grade 3 (severe hypertension)

180

and / or

110

Isolated Systolic Hypertension


(ISH)

140

and

<90

The category pertains to the highest risk blood pressure


*ISH=Isolated Systolic Hypertension.
J Hypertens 2007;25:1105-87

Penting diperhatikan saat


evaluasi awal
Konfirmasi diagnostik hipertensi
Analisis risiko KV, kerusakan OT dan
penyakit penyerta lainnya
Deteksi ada tidaknya Ht sekunder

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

PENYEBAB HIPERTENSI YANG


DIKETAHUI

PATOGENESIS
HIPERTENSI

Oparil et al. Ann Inn Med

TANDA DAN GEJALA

Sakit kepala dan pusing


Nyeri kepala berputar
Rasa berat di tengkuk
Marah/emosi tidak stabil
Mata berkunang kunang
Telinga berdengung
Sukar tidur
Kesemutan
Kesulitan bicara
Rasa mual / muntah

SILENT
KILLER
!!!

Pengukuran tekanan darah dan


penatalaksanaan hipertensi

17

Ketidakakuratan pengukuran tekanan darah


overestimasi / underestimasi !!!
Hal-hal yang harus diperhatikan :
Pemilihan alat : aneroid, merkuri, elektronik
Persiapan pasien
Posisi pasien dan lengan
Pemilihan manset
Teknik pengukuran
yang standar

18

PENGUKURAN TEKANAN DARAH


PROSEDUR
-Hindari : kafein, latihan fisik dan merokok
-Stres, cemas atau nyeri : -Menahan kencing : -Ruang pemeriksaan
-Pakaian
-Duduk bersandar min 5 menit, kaki pada lantai,
lengan disanggah setinggi jantung
dan tidak berbicara

19

- Manset yang sesuai : melingkari lengan min 80%


-Posisi manset : batas bawah 2-3 cm dari lipat siku, lebar
manset menutupi 2/3 panjang lengan atas
-Stetoskop di atas a. brakialis
-Raba pulsasi a. radialis

20

Pompa manset : sampai 30 mmHg setelah pulsasi a.


radialis menghilang
Buka katup manset, tekanan manset turun perlahan
(2-3 mmHg/detik)
Bunyi pertama : tekanan sistolik
Bunyi terakhir : tekanan diastolik
Turunkan tekanan sampai 0 mmHg, lepaskan manset
Pengukuran dilakukan dua kali untuk mendapatkan
tekanan rerata

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

FAKTOR RISIKO KARDIOVASKULER


-Obesitas
-Dislipidemia
-DM
-Merokok
-Inaktivitas fisik
-Mikroalbuminuria
-Usia lanjut
-Riwayat keluarga penyakit kardiovaskuler

23

Tabel Model Stratifikasi Faktor


Risiko Global Kardiovaskuler

Keterangan :
TDS : Tekanan Darah Sistolik;
TDD : Tekanan Darah Diastolik;
PGK : Penyakit Ginjal Kronik;
DM : Diabetes Mellitus;
PKV : Penyakit Kardiovaskuler

Sumber : European Society of Hypertension-European Society of Cardiology


(ESH-ESC) 2013

Tabel Faktor Selain TD yang memengaruhi Prognosis


yang
digunakan pada Stratifikasi Faktor Risisko Global Kardiovaskuler (
1.

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

KERUSAKAN ORGAN TARGET


PJK

Dementia
Penyakit
cerebrovask
uler

Disfungsi
sistolik
LVH
Gagal jantung

HIPER
TENSI
Proteinuria
Gangguan ginjal
ESRD
Retinopati
Perdarahan
Papiloedema

26

Hypertension risk factors


Weight
Family history
Salt, Alcohol,Stress
Concurrent conditions
Asthma
Gout
Pregnancy

Other CV risk factors


Lipids
Smoking
Diabetes
Exercise

History
+
Examination

Clues to 2o HT
Symptoms
Drugs
Signs

Target organ damage


Heart
Brain
Eyes
Kidneys
27

Kecurigaan HT sekunder
1.
2.
3.
4.
5.

Hipertensi berat atau hipertensi resisten


Peningkatan TD akut, dengan TD sebelumya stabil
Usia 30 tahun tanpa obes dan tanpa riwayat HT
HT terakselarasi
Awitan HT sebelum pubertas

LABORATORIUM
Tujuan Evaluasi Laboratorium
Mendeteksi komplikasi yang terjadi (ada
tidaknya kerusakan organ target)
Mengetahui apakah ada faktor resiko
penyakit kardiovaskuler
Mencari penyebab hipertensi

Tabel Pemeriksaan Laboratorium

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

Paradigm Shift in HT Therapy


It is not just B.P
TODAY
.
we must
striverisk
to factors
1. Alter the modifiable
2. Keep the SBP < 140 and DBP < 90
3. Prevent or halt or reduce TOD
LVH, CHD, CHF, CVA, CRF, PVD &
Retino.
4. Prevent or control DM (as HT + DM is
hazardous)
5. Prevent or control Dyslipidemia
6. Prevent or control Endothelial
Dysf.unction
7. Reduce morbidity and mortality
34

8. Improve QUALY Quality Adjusted Life

TERAPI NON FARMAKOLOGIS (GIZI)


& TERAPI FARMAKOLOGIS PASIEN
HIPERTENSI

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

SBP > 140 or


DBP > 90
Begin drug
treatme nt
1. TOD
2. ACC

Low

SBP < 140 or


DBP < 90
Continue to
monitor

Monitor BP and
othe r risk factors
for 6 - 1 2 m onths

SBP > 140


or DBP > 90
Begin drug
treatme nt

- Taeget Organ Damage (precious WHO Stage 2 hypertension) [6]


- Associated Clinical Condition including clinical cardiovascular disease and renal disease
(previous WHO St age 3 hypertension) [6]

SBP < 140


or DBP < 90
Continue to
monitor

LIFESTYLE MODIFICATION IN HYPERTENSION


Lifestyle measures should be instituted, whenever
appropriate in all hypertensive patients, including those
who require drugs
Lifestyle measures are also advisable in subjects with
high normal BP and additional risk factors to reduce the
risk of developing hypertension
Lifestyle recommendations should not be given as lip
service and reinforced periodically

Lifestyle Recommendations for Hypertension:


Dietary
Dietary Sodium

High in:
Fresh fruits
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre
Plant protein

Low in:
Saturated fat and cholesterol
Sodium

Less than 2300mg / day


(Most of the salt in food is hidden and comes
from processed food)

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.

Potential Benefits of a Wide Spread Reduction in


Dietary Sodium
Reduction in average dietary sodium from about
3500 mg to 1700 mg1,2

1 million fewer hypertensives

5 million fewer physicians visits a year for hypertension

Health care cost savings of $430 to 540 million per year related
to fewer office visits, drugs and laboratory costs for
hypertension

Improvement of the hypertension treatment and control rate

13% reduction in CVD

Total health care cost savings of over $1.3 billion/year


1. Penz ED. Cdn J Cardiol 2008
2. Joffres MR. Cdn J Cardiol 2007:23(6)

Recommendations for adequate daily sodium intake

Age

Adequate
Intake
(mg)

Upper
Limit
(mg)

19-50

1500

2300

51-70

1300

2300

71 and
over

1200

2300

2,300 mg sodium (Na)


= 100 mmol sodium (Na)
= 5.8 g of salt (NaCl)
= 1 level teaspoon of
table salt

80% of average sodium intake is in processed foods


Only 10% is added at the table or in cooking
Institute of Medicine, 2003

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

Average Reduction of sodium


in mg/day
1700 mg/day
2300 mg/day

Normotensives
Reduction of BP
2.0 / 1.0 mmHg
3.6/1.7 mmHg

The Cochrane Library 2006;3:1-41

Salt mechanisms leading to hypertension:


By expanding the extracellular volume
High salt intake increases the action of aldosterone
High salt intake is a permissive factor for the hypertensinogenic
effect of aldosterone
Increase in the sodium concentration progressively increases
endothelial cell stiffness, causes inhibition of endothelial NO
synthase and decreases release of nitric oxide
Changes in plasma sodium concentration are transmitted into the
cerebrospinal fluid triggering the release of cardiotonic steroids,
namely, analogues of digitalis such as ouabain and
marinobufagenin which cause vasoconstriction

NON-BLOOD PRESSURE-RELATED EFFECTS OF


DIETARY SALT

Atherosclerosis
Stroke
Left ventricle hypertrophy
Proteinuric kidney disease
Heart failure

Putative mechanisms of the deleterious cardiovascular


effects of excessive dietary sodium through blood pressure
increase independent of blood pressure

All cases of hypertension should restrict sodium


intake to approximately 6 g sodium chloride salt or
2.4 g sodium per day by adopted the following
measures:
Reduce salt for cooking by 50%
Substitute natural foods for processed foods.
No sprinkling of salt on dining table
Avoid salty snacks such as pickles, chutneys, papad,
salted nuts
Use salt substitutes containing potassium
Avoid medications such as antacids as these are rich in
salt

Lifestyle Recommendations for Hypertension:


Physical Activity
Should be prescribed to reduce blood pressure

Frequency

Intensity

Time

Type

- Four to seven days per week


- Moderate
- 30-60 minutes

Cardiorespiratory Activity
- Walking, jogging
- Cycling
- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension:


Weight Loss
Height, weight, and waist circumference (WC) should be measured
and body mass index (BMI) calculated for all adults.

Hypertensive and all patients


BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference
Men <102 cm

Women <88 cm

For patients prescribed pharmacological therapy: weight loss has


additional antihypertensive effects. Weight loss strategies should employ a
multidisciplinary approach and include dietary education, increased physical
activity and behaviour modification
CMAJ 2007;176:1103-6

Waist Circumference Measurement

Measure here
Iliac crest

Courtesy J.P. Desprs 2006

Lifestyle Recommendations for Hypertension:


Alcohol
Low risk alcohol consumption
0-2 standard drinks/day
Men: maximum of 14 standard drinks/week
Women: maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or
12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

Lifestyle Recommendations for Hypertension:


Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behaviour Modification
Individualized cognitive behavioural interventions are
more likely to be effective when relaxation techniques
are employed.

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

Expected systolic blood


Pressure reduction (range)

Maintain ideal body mass index


(20-23 kg/m2)

5-10 mmHg per 10 kg


weight loss

All put together reduce SBP 8-14


by mmHg

DASH eating plan Consume diet rich in fruit, vegetables,


low-fat dairy products with reduced
content of saturated and total fat

20 to 55 mmHg

Dietary sodium
restriction

Physical Activity

Alcohol
moderation

Reduce dietary sodium intake to


<100 mmol/day (<2.4 g sodium or
<6 g sodium chloride)

2-8 mmHg

Engage in regular aerobic


physical activity, for example,
brisk walking for at least 30 min
most days
Men < 21 units per week
Women < 14 units per week

4-9 mmHg

2-4 mmHg

Lifestyle Therapies in Adults with Hypertension:


Summary

Intervention

Target

Reduce foods with


added sodium

< 2300 mg /day

Weight loss

BMI <25 kg/m2

Alcohol restriction

< 2 drinks/day

Physical activity

30-60 minutes 4-7 days/week

Dietary patterns

DASH diet

Smoking cessation

Smoke free environment

Waist circumference

Men <102 cm

Women <88 cm

PHARMACOLOGIC TREATMENT
OF HYPERTENSION

Obat Antihipertensi yang


ideal
Tidak ada kontraindikasi
Dapat dikombinasi dengan obat lain
Tidak ada efek samping atau efek metabolik lain
Memperbaiki morbiditas dan mortalitas
Mencegah kerusakan organ target
Dosis sekali sehari
Efektif sebagai monoterapi
Harga terjangkau

58

GOALS OF TREATMENT

Is to achieve the maximum reduction


in the total risk of Cardiovascular
morbidity and mortality

As low as possible
without
complication

Tabel 2.6 Faktor Risiko dan Pemberian Obat Berdasarkan derajat Hipetensi

Main Classes of
Antihypertensive Drugs
Diuretics

Inhibit the reabsorption of salts and water from


kidney tubules into the bloodstream

Calcium-channel antagonists

Inhibit influx of calcium into cardiac and smooth


muscle

Beta-blockers

Inhibit stimulation of beta-adrenergic receptors

Angiotensin-converting enzyme (ACE) inhibitors


Inhibit formation of angiotensin II

Angiotensin II receptor blockers (ARBs)

Inhibit binding of angiotensin II to type 1 angiotensin


II
Receptors

Vasodilators
Direct renin inhibitors

Control of Blood Pressure and


Antihypertensive Sites of Action
BP is controlled
via changes in

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

Mechanism: inhibit Na/K pumps in the


distal tubule
Examples:

Thiazides

Hydrocholorthiazide 12.5-25 mg daily


Chlorthalidone 12.5-50 mg daily

Effective first line agent and provides


synergistic benefit
As single agent more effective if CrCl
>30 ml/min
Compelling indications: HF, High CAD
risk, Diabetes, Stroke, ISH

Loop Diuretics
Veins

Mechanism: Inhibit Na/K/Cl ATPase in


ascending loop of henle
Examples:

Thiazides
Loops

Furosemide 20 mg BID

Typically only beneficial in patients


with resistant HTN and evidence of
fluid; effective if CrCl <30 ml/min
MUST be dosed at least twice daily
(Lasix = Lasts six hours)
Administer AM and lunch time to avoid
nocturia

Aldosterone Receptor
Antagonists
Veins

Mechanism: inhibit aldosterones effect


at the receptor, reducing Na and water
retention
Examples:

Thiazides
Loops
Aldosterone Ant.

Spironolactone 25 mg daily

Can provide as much as 25 mmHg BP


reduction on top of 4 drug regimen in
resistant hypertension
Monitor SCr and K
Compelling indications: HF
Am J Hypertension. 2003; 16:925-930.

Beta Blockers
Heart

Beta Blockers

Mechanism: Competitively inhibit the


binding of catecholamines to betaadrenergic receptors
Examples:
Atenolol 25-100 mg QD, Metoprolol 25
-100 mg BID, Bisoprolol 2.5 10 mg QD
Carvedilol 6.25-50 mg (alfa+Beta)BID

Monitor: HR, Blood Glucose in DM


Not contraindicated in asthma or COPD
but use caution
Compelling indications: HF, post-MI,
High CAD risk, Diabetes

Calcium Channel Blockers Non-Dihydropyridine:


Diltiazem and Verapamil
Arteries

Heart

Mechanism: Decrease calcium influx into cells


of vascular smooth muscle and myocardium
Examples:

Diltiazem
Verapamil

Diltiazem Long acting; CD 100


-400 mg
Verapamil 60-480 mg, long acting
SR
Monitor: HR
Verapamil causes constipation
Relatively contraindicated in heart failure
Compelling indications: Diabetes, High CAD
risk

Calcium Channel Blockers:


Dihydropyridine
Arteries

Mechanism: Decrease calcium influx


into cells of vascular smooth muscle
Examples:
Amlodipine 2.5-10 mg PO daily

Dihydropyridine
CCBs

Felodipine 2.5-10 mg PO daily


OROS/GITS. Do not use immediate release
nifedipine

Monitor: Peripheral edema, HR (can


cause reflex tachycardia)
Good add on agent if cost is not an
issue

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

Mechanism: Inhibit vasoconstriction by


blocking action of angiotensin II; provides
balanced vasodilation
Examples:

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

Mechanism: Inhibit vasoconstriction by


inhibiting synthesis of angiotensin II;
provides balanced vasodilation
Examples:

ACEI

ACEI: Captopril 12.5 -50 BID, Enalapril 2.5-40


mg daily BID, Lisinopril 5 40 mg daily,
Imidapril 5-10 QD, Perindopril 4-8 mg QD,
Ramipril 2.5-20 mg

Monitor: S Cr, K
Compelling indications: HF, post-MI, High
CAD risk, Diabetes, CKD, Stroke

Alpha1 Blockers
Arteries

Mechanism: Inhibit peripheral postsynaptic alpha1 receptors causing


vasodilation
Examples:

Alpha1 Blockers

Terazosin 1 20 mg daily
Doxazosin 1 16 mg daily

Cause marked orthostatic hypotension,


give dose at bedtime
Consider only as add on therapy
Can be beneficial in patients with BPH

Central Acting Agents


Heart

Mechanism: false neurotransmitters


reduce sympathetic outflow reducing
sympathetic tone
Examples:

Central Acting
Mechanism:
Clonidine

Clonidine 0.75-0.6 mg bid, Methyldopa 250


mg-1000 mg BID (Pregnancy), Reserpin 0,1
-0,25 mg QD

Monitor: HR (bradicardia)
Side effects often limiting: Dry mouth,
orthostasis, sedation
Withdrawal/Rebound effect

Vasodilators
Arteries

Mechanism: Direct vasodilation of arterioles


via increased intracellular cAMP
Examples:

Dihydropyridine
CCBs
Hydralazine
Minoxidil

Hydralazine 20-400 mg BID-QID


Minoxidil 2.5-40 mg PO daily-BID
Monitor: HR (can cause reflex tachycardia),
Na/Water retention
Hydralazine is an alternative in HF if ACEI
contraindicated
Consider minoxidil in refractory patients on
multi-drug regimens

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

BBs with intrinsic


sympathomimetic
activity
Combined alphaand BBs
ACEIs

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

Aged over 55 years


or black person of
African or
Caribbean family
origin of any age

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

Consider seeking expert advice


NICE guideline 2011

2009 Reappraisal of 2007 European Guidelines:


recommended combinations

82

JNC 7 Algorithm for Treatment of Hypertension


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

Initial Drug Choices


Without Compelling
Indications

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

(SBP 160 or DBP 100 mm Hg)


2-drug combination for most (usually
thiazide-type diuretic and
ACEI, ARB, 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

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

Drug(s) for the compelling


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

REKOMENDASI TERAPI PADA


KEADAAN KHUSUS (JNC 7)

84

Initiation treatment of hypertension


Other risk
factors, Target
Organ Damage or
disease

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

Hypertension treatment strategy: ESH/ESC


2007
Mild BP elevation
Low/moderate CV risk
Conventional BP
target

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

Add a third drug


at low dose

If goal BP not achieved


Two- to three-drug
combination
BP, blood pressure

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

Management Algorithm (JNC 8)

James P et al. JAMA. 2013;289: E1-E14

James P et al. JAMA. 2013;289: E1-E14

James P et al. JAMA. 2013;289: E1-E14

Tabel Strategi Pengobatan dan pemilihan Obat

PROBLEM

Difficult-to-Control
Hypertension

Percentage of treated hypertensive patients


with controlled blood pressure values (<140/90
mmHg) in different countries

Difficult-to-Control
Hypertension

Inadequately treated hypertension (pseudo-resistance)


True resistant hypertension
Mancia G, Seravalie G, Grassi G. Am J Hypertens 2003;16:1067.

Difficult-to-Control
Hypertension

Inadequately treated hypertension (pseudo-resistance)


True resistant hypertension
Identifiable causes
Primary aldosteronism
Renovascular disease
Pheocromocytoma
Coarctation of the aorta
Intracranial tumor

Associated factors:
Medications (NSAID, oral contraceptive,
sympathomimetic, corticosteroid,
erythropoetin, cyclophospamid.
Excessive alcohol consumption
Chronic kidney disease
Obesity
Obstructive sleep apnea

Difficult-to-Control
Hypertension

Inadequately treated hypertension (pseudo-resistance)


Under treatment
Treatment with inappropriate agents
Incorrect blood pressure measurement
White coat effects
Medications nonadherence
Pseudo-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

Medication Poor Adherence

High cost of treatment


Complex medical regimen
Adverse effect of medical
therapy
Poor relation between doctors
and patients

100

Clinical clues suggestive of


pseudohypertension

Marked hypertension in the absence of target


organ damage
Antihypertensive therapy produces symptoms
consistent with hypotension in the absence
of successful reduction of BP
Radiological evidence of pipe stem
calcification in the brachial arteries
Brachial artery pressure higher than lower
extremity pressure
Severe and isolated systolic hypertension

101

Clinical clues suggestive


of white coat effects

Clinic blood pressure measurements


are consistently higher than out-ofoffice measurements.
Patients show signs of overtreatment,
particularly orthostatic symptoms.
Patients with chronically high office

blood pressures values but an


absence of target organ
damage.

102

Characteristics patients associated with


Resistant hypertension
Volume overload
Older age
High baseline blood pressure
Obesity
Excessive dietary salt ingestion
Chronic kidney disease
Diabetes
Black race
Genetic factors

Suggested algorithm for the treatment of resistant hypertension


Insure therapy meets JNC-7 criteria for compelling indications
Uncontrolled blood pressure
on 3 or more antihypertensives
Consider ambulatory blood
pressure monitoring if
available to rule out whitecoat phenomenon

Thiazide-type
diuretic present?

Correct identifiable causes if


present; consider work-up of
secondary conditions

NO

Add low-dose diuretic


(chlorthalidone 12.5 mg
preferred; titrate to 25mg/d)

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

Optimize combination as follows:


A or B* + C + D
If blood pressure
remains uncontrolled

Re-evaluate
If blood pressure
remains uncontrolled

+ spironolactone (12.5 mg/d to 25 mg/d)

If blood pressure remains uncontrolled, adjust regimen to include:


Trewet CLB, et al. South Med. 2008;101(2):166-174

Suggested algorithm for the treatment of resistant hypertension


If blood pressure remains uncontrolled, adjust regimen to include:

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)

Trewet CLB, et al. South Med. 2008;101(2):166-174

specialist referral ?

Indication :

Suggested indications for


specialist referral (1)
Urgent treatment needed
Accelerated hypertension (severe hypertension and
grade III-IV retinopathy)
Particularly severe hypertension (>220/120 mmHg)
Impending complication (for example, transient
ischemic attack, left ventricular failure)

Suggested indications for


specialist referral (2)
Possible underlying cause
Any clue in history or examination of a secondary
cause, such as hypokalemia with increased or high
normal plasma sodium (Conns Syndrome)
Elevated serum creatinine
Proteinuria or haematuria
Sudden onset or worsening of hypertension
Resistant to multi-drug regimen (3 drugs)
Young age (any hypertension <20 years; needing
treatment <30 years)

Suggested indications for


specialist referral (3)
Therapeutic problems
Multiple drug intolerance
Multiple drug contraindications
Persistant non-adherence or non-compliance

Suggested indications for specialist


referral (4)
Special situation
Unusual blood pressure variability
Possible white coat hypertension
Hypertension in pregnancy

You might also like