HIPERTENSI

Dr. Hascaryo
Nugroho, SpPD
Finasim
Bagian Penyakit
Dalam
RSUD Ambarawa
pendahuluan
Prevalensi
Pengendalian sulit
Penyakit penyerta
Morbiditas & mortalitas
Usia lanjut jumlah HT
HT essensial 95%
Prevalence of Hypertension
by Age and Gender
Prevalence of HTN (%)

2029 3039 4049 5059 6069 70

Data for established market economies (US, Canada, Spain,

England, Germany, Greece, Italy, Sweden, Australia, Japan) Kearney et al. Lancet 2005;365:21723
 Prevalensi dari Hipertensi
Hipertensi salah satu dari penyakit yang sering dijumpai di klinik

70
SBP < 140 mm Hg 65
64
prevalensi dari hipertensi (%)

60 DBP < 90 mm Hg
50 54
44
40

30
21
20
4 11
10

0
Umur (th) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Prevalensi dan Terapi
Hipertensi di Amerika Utara dan
Eropa
Prevalensi Hipertensi Pasien yang diterapi
US
55 Canada
100 Italy
50
90 Sweden
45 England
80 Spain
40
70 Finland
% 35 % 60 Germany
30
50
25
40
20
30
15
20
10
10
5
0
0
Negara Negara
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
 Kriteria baru (WHO-ISH 1999) 140 / 90 mmHg

22% orang Amerika dewasa usia 18-70 tahun menderita hipertensi

20% orang Indonesia dewasa menderita hipertensi

Pasien hipertensi yang diobati

Pasien hipertensi yang diobati dan terkontrol dg baik
tetapi tidak terkontrol

16%
23%

19% 42%

Pasien yg sadar
bhw dia mengidap hipertensi Pasien hipertensi yg tdk menyadari
Tetapi tidak terobati bhw dia mengidap hipertensi
dan tidak terkontrol
Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102
 Presentasi pasien hipertensi yang
terkontrol
< 140/90 mmHg < 160/95 mmHg
USA Kanada Finlandia Spanyol Australia
16 20.5 20 19
27

England France Jerman Scotlandia India

6 9
24 22.5 17.5

< 65 years

USA: JNC VI. Arch Intern Med 1997 Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens
1998
Adapted from G. Mancia / L. Ruilope
Risiko Infark Miokard dan Stroke
15

10
Risiko dlam 5
tahun (%)

MI
MI Stroke
Stroke

0 100 200 300

Tekanan darah sistolik (mm Hg)

Brown, M.J., Lancet 2000;355:653-4

 Hipertensi merupakan faktor risiko utama
penyakit vaskuler
Penyakit Penyakit arteri Gagal
coroner Stroke perifer jantung
Biennial 50
age-
adjusted
rate 40
Normotensive
per 1000
Hypertensive
patients 30

20

10

0
Men Women Men Women Men Women Men Women
Risk ratio: 2.0 2.2 3.8 2.6 2.0 3.7 4.0 3.0
Kannel WB. JAMA. 1996;275:1571-1576.
Garry P. Reams & John H. Bauer
Progression from hypertension to heart
failure

Obesity LVH Diastolic

Diabetes dysfunction

Hypertension
HF Death

Smoking Systolic
Dyslipidaemia MI dysfunction
Diabetes

Normal Subclinical
LV structure LV LV Overt heart
and function remodelling dysfunction failure

Time: decades Time: months

Etiologi Hipertensi
Berdasarkan penyebabnya dapat dibedakan :
Primer (esensial)
tidak ada penyebab yang spesifik yang dapat
diidentifikasi
95% dari kasus hipertensi
Sekunder
diketahui penyebabnya
5% dari kasus hipertensi
penyakit ginjal merupakan penyebab dari
90% kasus hipertensi sekunder
 Hipertensi :
Continuum Penyakit
Paradigma awal

Natural History of CVD Progression

peningkatan BP Kerusakan Target Organ

Paradigma terkini

Disfungsi vaskular Peningkatan BP Kerusakan Target Organ

Paradigm yg diusulkan

Disfungsi Disfungsi Peningkatan Kerusakan

Endothel vaskular BP Target Organ Angina
? LVH Pectoris
Keruskan MI Stroke
ginjal
 Penyebab Hipertensi
(Hipertensi Sekunder )

Penyakit Ginjal : Coarctation dari aorta

Penyakit arteri ginjal
Gangguan Neurologic
Penyakit parenkim ginjal
Peningkatan intra kranial
Tumor ginjal
(tumor)
Arteritis (polyarteritis
nodosa, neurofibromatosis)
Hipertensi akibat obat
Kortikosteroids
Gangguan Endokrin Amphetamines
Cushings sindrom Kontrasepsi oral
Akromegali
Primer aldosteronism Gangguan Psychogenic
Pheochromocytoma
 Target Pengontrolan Tekanan
Darah Minimal
Rekomendasi (SBP/DBP mmHg)
Patient Type JNC VII
Hipertensi tanpa komplikasi < 140/90
Hipertensi dg diabetes < 130/85
melitus < 130/80*
Gagal jantung < 130/85
Hipertensi dg < 125/75
gangguan ginjal

*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
Proteinuria < 1 g/24h.
(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive
Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)
 Komplikasi Hipertensi
Mata Otak Kerusakan Target Organ!!
retinopathy stroke

Kerusakan yang disebabkan

Jantung oleh hipertensi tergantung:
ischaemic heart disease
Ginjal left ventricular hypertrophy Besarnya peningkatan
renal failure heart failure tekanan darah
Lamanya kondisi
tekanan darah yang
tidak terdiagnosis dan
Penyakit arteri perifer tidak diobati
Terapi
TERAPI NON
FARMAKOLOGIS
Perubahan gaya hidup
Pola makan seimbang
Hindari Alkohol
Hindari rokok
OR
Turunkan BB
Diet rendah garam
~10% Weight loss = ~30%
Visceral
adipose tissue loss
 Pengobatan Hypertension
( Farmakologik )

Tujuan pengobatan
Memperbaiki fungsi endothel
Menurunkan resistensi pembuluh darah sistemik
Menjaga output jantung & suplai darah ke organ

Terapi seumur hidup

Farmakologi
Diuretik
ACEI
BB
ARB
CCB
Vasodilator
Agonis beta
Bipiridin
TARGET PENGOBATAN HIPERTENSI

1PENURUNAN TEKANAN DARAH

2. PERLINDUNGAN DAN PERBAIKAN

PEMBULUH DARAH
 Hypertension Treatments
Hypertension
Hypertension
Rules
Rulesof
ofHalves
Halves

50
50%
% not
notdiagnosed
diagnosed 50
50%
%Diagnosis
Diagnosis

50 % not treated 50 % Treated

50
50%
%
7 million pts poorly controlled
poorly controlled 50
50%%well
welltreated
treated
(12.5
(12.5 % ofall
% of all
hypertensives)
hypertensives)
Hypertension in practice 2nd, Beevers & MacGregor
BP Differences of 10 mmHg Are Associated
With Up to a 40% Effect on
CV Risk
Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years

30% reduction in
risk of IHD
mortality
10 mmHg decrease
in mean SBP

40% reduction in risk

of stroke mortality

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

 Initiation of Antihypertensive Treatment
Other risk
factor, OD, Normal High normal Grade I HT Grade II HT Grade III HT
or disease
Lifestyle changes Lifestyle changes
Lifestyle changes
for several months for several weeks
No other No BP No BP and immediate
than drug than drug
risk factors intervention intervention drug
treatment if BP treatment if BP
treatment
uncontrolled uncontrolled

Lifestyle changes Lifestyle changes

Lifestyle changes
for several weeks for several weeks
1-2 risk Lifestyle Lifestyle and immediate
than drug than drug
factors changes changes
treatment if BP treatment if BP
drug
treatment
uncontrolled uncontrolled

Lifestyle
3 risk
Lifestyle changes and
factors, MS, Lifestyle changes
changes consider drug
or OD Lifestyle changes Lifestyle changes
treatment and immediate
and and
drug
drug treatment drug treatment
Lifestyle treatment
Lifestyle
Diabetes changes and
changes
drug treatment

Lifestyle Lifestyle
Lifestyle changes Lifestyle changes Lifestyle changes
Established changes and changes and
and immediate and immediate and immediate
CV or renal immediate immediate
drug drug drug
disease drug drug
treatment treatment treatment
treatment treatment

HT: hypertension; MS: metabolic syndrome; CV: cardiovascular; OD: organ damage
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
Possible combinations of antihypertensive
agents
Diuretic
s

- ARBs
blockers

- CCBs
blockers

ACE
inhibitors
2007 ESH/ESC guidelines for the management of arterial hypertension
 Reappraisal of ESH/ESC Guidelines suggests
4 Preferred Antihypertensive Drug Classes
2007 2009
Diuretics Diuretics

-blockers
ARB ONTARGET ARB
ACCOMPLISH
HYVET

CCB CCB
-blockers

ACE-I ACE-I

Most rational combinations

Combinations used as necessary
Mancia et al. Eur Heart J. 2007;28:14621536;
Mancia et al. J Hypertens. 2009;27:21212158.
 CV Mortality Risk Doubles With
Each 20/10 mm Hg BP Increment*
8
7
6

CV 5
mortality 4
risk
3
2
1
0
115/75 135/85 155/95 175/105
SBP/DBP (mm Hg)

*Individuals aged 40-69 years, starting at BP 115/75 mm Hg.

CV, cardiovascular; DBP, diastolic blood pressure; SBP, systolic blood pressure.
Lewington S et al. Lancet. 2002;360:1903-1913.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
Importance of Lowering BP
(Data from Multiple Clinical Trials
Measuring the Impact of Hypertensive Therapy on Cardiovascular
Mortality)
Cardiovascular Mortality

1.50 MIDAS/NICS/VHAS actively controlled trials.

UKPDS C vs A P=0.002 placebo-controlled studies
or trials with an untreated
1.25
(experimental/reference)

NORDIL control group.

INSIGHT
HOT L vs H
STOP2/ACEIs
Negative values indicate
HOT M vs H MRC1 tighter BP control on
1.00
Odds Ratio

MRC2
STOP2/CCBs reference treatment.
SHEP HEP
0.75 CAPPP STONE Syst-Eur EWPHE
HOPE
UKPDS L vs H
Syst-China RCT70-80
0.50
PART2/SCAT STOP1
ATMH
0.25

5 0 5 10 15 20 25
Difference (reference treatment minus experimental treatment) in Systolic BP (mmHg)
Greater differences in BP reduction mean greater reductions in the risk of
cardiovascular mortality.
BP, blood pressure
Staessen JA et al. Hypertension Research. 2005;28:385-407.
Current Antihypertensive Therapy
Reduces CV Events
Major CV
Stroke Events CV Death
0

20
Average Reduction in

20%30%
40
Events, %

30%40% 30%40%

60
Can we do better?
80

100

CV=cardiovascular.
Neal B et al. Lancet. 2000;356:19551964.
 JNC VII & ESH/ESC 2003:
Treatment Considerations

Most patients with hypertension will require 2 or

more antihypertensive drugs to achieve BP goals
According to baseline BP and presence or absence
of complications, therapy can be initiated either with
a low dose of a single agent or with a low-dose
combination of 2 agents
When BP is <20/10 mm Hg above goal, consideration
should be given to initiating 2 drugs, either as
separate prescriptions or in fixed-dose combinations,
one of which should be a thiazide-type diuretic

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

Guidelines Committee. J Hypertens. 2003;21:1011-1053.
 CCB + ARB:
The Synergies of Counter-Regulation (2)

CCB
Arteriodilation ARB
Peripheral oedema RAS blockade
Effective in low-renin patients CHF and renal
Reduces cardiac ischaemia benefits
BP

ARB CCB
Venodilation Synergistic RAS activation
Attenuates peripheral oedema BP reduction No renal or CHF
Effective in high-renin benefits
No effect on cardiac ischaemia Complementary
clinical benefits

Mistry et al. Expert Opin Pharmacother. 2006;7:575581; Sica. Drugs 2002;62:443462;

Quan et al. Am J Cardiovasc Drugs. 2006;6:103113.
Interaction of CCBs and ARBs on Vascular and Renal
Function,
SNS and RAS Activity

Natriuresis

Vasodilation
Arterial Arterial +
Venous

CCB ARB

RAS RAS
SNS SNS
Renal Hyperfiltration Induced by Amlodipine is
Reduced by Telmisartan

Amlodipine Amlodipine + Telmisartan

L-type Ca
L-type Ca channels
channels

Increased Decreased
Glomerular pressure Glomerular pressure
and filtration and filtration

Peti-Peterdi; Abstract ESC 2010 (submitted)

Complementary Effects of a CCB/RAS Inhibitor:
Reduction of CCB-associated Edema

I.
Arterial hypertension
Constricted blood vessels, high
resistance

II.
Edema CCBs
BP reduction due to arterial vasodilation
Tendency towards edema due to absent
venodilation
Edema
BP reduction stimulates RAS and
increases angiotensin II level
III. CCBs + RAS inhibitors*
Blockade of RAS inhibits effects of
angiotensin II, giving rise to additional
BP reduction
Additional venodilation by RAS
*Angiotensin receptor blockers or angiotensin-converting enzyme inhibitors inhibitors reduces edema Messerli. Am J Hypertens 2001;14:9789
 ARBs and DHP-CCBs are Recommended for Complementary
Indications (ESC/ESH Guidelines)

ARBs DHP-CCBs

Essential hypertension Isolated systolic hypertension

Heart failure Coronary artery disease
Post-MI Angina pectoris
Diabetic nephropathy Hypertension in Blacks
Proteinuria/microalbuminuria (Pregnancy)
Atrial fibrillation Left ventricular hypertrophy
Metabolic syndrome
ACE-I-induced cough
Left ventricular hypertrophy

Mancia et al. Eur Heart J. 2007;28:14621536.

 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

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(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) indications
2-drug combination for most (usually
thiazide-type diuretic and Other antihypertensive drugs
ACEI, or ARB, or BB, or CCB) (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.
2006 NICE Clinical Guidelines

www.nice.org.uk
Updated UK NICE Guidelines for the Treatment of
Newly Diagnosed Hypertension
55 years or
<55 years black patients at
any age
CCB or thiazide-
Step 1 ACEI (or ARB*)
type diuretic

ACEI (or ARB*) + CCB or

Step 2
ACEI (or ARB*) + thiazide diuretic

Step 3 ACEI (or ARB*) + CCB + diuretic

Add further diuretic therapy, -blocker, or -blocker.

Step 4
Consider seeking specialist advice

National Institute for Health and Clinical Excellence (NICE) (2006)

Hypertension: management of hypertension in adults in primary care (Quick Reference Guide).
*If ACE inhibitor (ACEI) not tolerated London: NICE. Available from www.nice.org.uk/034. Reproduced with permission
Treatment of Adults with Systolic/Diastolic Hypertension
without Other Compelling Indications

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Long- Beta-
Thiazid
ACE-I acting blocker
e CCB *

* BBs are not indicated as first line therapy for age 60 and above

ACEI and ARB are contraindicated in

pregnancy and caution is required in
prescribing to women of child bearing
potential
2007 Canadian Hypertension Education Program Recommendations
Total risk management

Lifestyle and risk factor goals

Healthy food choices
Be physically active
Achieve ideal weight
Reduce blood pressure to < 140/90 mmHg
Reduce total cholesterol to < 5.0 mmol/l (190 mg/dl)
Reduce LDL cholesterol to <3.0 mmol/l (115 mg/dl)
Achieve optimal glycaemic and blood pressure
control in patients with diabetes mellitus (HbA level
between 6.2 and 7.5%) and a blood pressure
<130/85 mmHg
Keadaan klinik khusus atau faktor-faktor yg
mempengaruhi prognosis pada hipertensi (JNC-7)
1. Hipertensi dengan diabetes :
a. Hipertensi dengan diabetes, metabolic syndrome?
b. Hipertensi, diabetes pada nephropathy diabetic

2. Hipertensi dengan target organ damage :

a. Hipertropi ventrikel kiri
b. Atherosclerotic plaque
c. Serum kreatinin meningkat ringan (1,2 1,5 mg/dl)
d. Mikroalbuminuria

3. Hipertensi dengan Associated clinical condition

a. Cerebrovascular disease (TIA, ischemic stroke, CVA
b. Penyakit jantung (AMI, angina, CHF)
c. CKD (Chronic kidney diseases) :
Diabetic nephropathy
Non diabetic kidney diseases
KESIMPULAN
Insiden dan prevalensi
makin tahun makin
meningkat.

Penanganan HT banyak
kendala.

Penanganan dini
menurunkan mortalitas &
morbiditas serta komplikasi.