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HYPERTENSION
metabolic hormonal
sodium
cardiovascular retention
autonomic
RAA system nervous system
endothelial dysfunction
Arterial Hypertension, Rosenthal, 1982)
Definition of Hypertension (JNC VII)
Systolic Diastolic
Category (mm Hg) (mm Hg)
30
21
20
4 11
10
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+
0
8x
8
7
6
5
4x
Cardiovascular
4
Mortality Risk
3
2x
2
1
0
115/75 135/85 155/95 175/105
Systolic/Diastolic Blood Pressure (mm Hg)
*Measurements taken in individuals aged 40–69 years, beginning with a blood
pressure of 115/75 mm Hg.
Lewington S, et al. Lancet. 2002;360:1903-1913; Chobanian AV, et al. JAMA. 2003;289:2560-2572.
RULE OF HALF
Hypertensive patients
Patients who are aware who are treated
but remain untreated but uncontrolled
and uncontrolled
25% 12.5%
12.5%
50%
Patients on Therapy
US
55 Canada
100 Italy
50
90 Sweden
45 England
80 Spain
40
70 Finland
% 35 % Germany
60
30
50
25
40
20
30
15
20
10
10
5
0
0
Country Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
The percentages of well controlled
hypertension patients
< 140/90 mmHg < 160/95 mmHg
USA Canada Finland Spain Australia
16 20.5 20 19
27
> 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
Hypertension-We try hard but
it does not get much better
About 50% of hypertensive patients remain uncontrolled
100 (NHANES ≈ EUROSPIRE)
75
**
50
**
25
0
1976– 1988– 1991– 1999– 2001– 2003– 2005– 2007–
1980 1991 1994 2000 2002 2004 2006 2008
Year
* BP control defined as BP < 140/90 mmHg; BP < 130/80 mmHg for patients with diabetes or CKD; includes
treated and untreated patients, except ** (only treated patients)
Classification of European Society of
JNC VII -2003 Hypertension / ESH
Blood pressure classification on people
Classification 2003
age > 18 y.o
Adults on no antihypertensive Category Systolic Diastolic
medications and who are not acutely ill.
Hypertension
Grade 2 Hypertension 160-179 and/or 100-109
Stage 1 140-159 And/or 90-99
Grade 3 Hypertension ≥ 180 and/or ≥110
Stage 2 > 160 or ≥100
Isolated Systolic
≥ 140 and 90
Hypertension
Classification of JNC
Des
2013
JNC
JNC 88
Lifestyle modification
JNC 7 Continue throughout management
nonblack black
Hypertension
Peripheral
Vascular
Disease Renal Failure,
Retinopathy
Proteinuria
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy Slide Source
Hypertension Online
Chobanian AV, et al. JAMA. 2003;289:2560-2572. www.hypertensiononline.org
Hypertension complication
Heart
ischaemic heart disease
Kidneys left ventricular hypertrophy
renal failure heart failure Damages depend on:
• How high of the blood
pressures
1. BLOOD PRESSURE
LOWERING
Myocardial Infarction
(20-25%)
Stroke
(35-40%)
2. TARGET ORGAN
Heart Failure
PROTECTION & (>50%)
IMPROVEMENT
Treatment Goals
20
2014 Hypertension Guideline
Management Algorithm (JNC 8)
PATIENTS PHYSICIANS
• Knowledge deficit •Poor physician-patients
• Medication not taken by communication
patient
MEDICATIONS
•Medication cost
•Side effects
•Complicated regimens
Lifestyle Modifications
Approximate Systolic
Modification Recommendation
BP Reduction (mm Hg)
Maintain normal body weight 5–20 per 10-kg
2
Weight loss (BMI 18.5–24.9 kg/m ) weight loss
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
Ideal Antihypertensive Agent
Efek Samping :
1.Batuk & Spasme pada Bronkus
2.Hiperkalemia
3.Hipoglikemi
4.Gangguan pada Eritropoietin
5.Angioedema
ACE Inhibitors
Veins
Arteries
•Contoh:
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: Creatinin dan Kalium
Angiotensin II Receptor Bloacker (ARB)
• Cara Kerja :
ARB menghambat
Angiotensin II dari semua
reseptor AT1 yang mana
menghasilkan efek yang
berlawanan dari simulasi
Angiotenin II terhadap
reseptor AT 1 sehingga
mengkibatkan ↓ TD
ARB
Veins
Arteries
ARB •Contoh:
•ARB: Irbesartan 150-300 mg QD,
Losartan 25-100 mg BID,
Olmesartan 20-40 mg, Telmisartan
20-80 mg, Valsartan 90-160 mgQD
•Monitor: Creatinin & Kalium
Calcium Channel Blocker
• Cara Kerja : Efek Samping :
Menghambat pengambilan ion Postural Hipotensi
calcium++ pada otot polos dan Palpitasi
otot jantung Takikardi
↓ Edema
Dilatasi pada arterior Perifer Dizziness
↓ Konstipasi
↓ resistensi pembuluh darah Sedasi
perifer
A-V Block
↓
Pusing
↓ Afterload
Rasa Cepat Lelah
↓
↓ Tekanan Darah
CCB Non-Dihydropyridine:
Diltiazem and Verapamil
Heart
Arteries
Diltiazem •Contoh:
Verapamil •Diltiazem Long acting; CD 100 -400 mg
•Verapamil 60-480 mg, long acting SR
•Monitor: HR
•Verapamil konstipasi
•Kontraindikasi relatif pada gagal jantung
CCB: Dihydropyridine
Arteries
Dihydropyridine •Contoh:
CCBs •Amlodipine 2.5-10 mg PO daily
•Felodipine 2.5-10 mg PO daily
• OROS/GITS. Jangan gunakan nifedipine
kerja cepat
•Monitor: edema perifer, HR ( takikardi)
β-Blocker
Cara Kerja : • Efek Samping :
Kompetitif menghambat 1. Kelelahan
ikatan katekolamin terhadap 2.↑ berat badan
reseptor β– adrenergic
3. ↓ sensitivitas insulin
1. ↓ Cardiac output
4. ↑ serum trigliserida
2. ↓ Jumlah renin yang
5. ↑ malformasi janin
dilepaskan
3. ↓ Jumlah blokade
presinaps yang
menghambat pelepasan
katekolamin
β-Blocker
Heart
Cara Kerja :
Penghambatan aktivitas
saraf simpatis
↓
Menghambat pelepasan
noradernalin
↓
↓ Vasokonstriksi
↓
↓ Tekanan Darah
α-Blocker
Arteries
•Contoh:
•Terazosin 1 – 20 mg daily
Alpha1 Blockers •Doxazosin 1 – 16 mg daily
•Dapat menyebabkan hipotensi
ortostatik dosis diberikan
malam hari
•Dipertimbangkan hanya sebagai
terapi tambahan
•Dapat menguntungkan bagi
pasien dengan BPH
Central Acting Agents
Heart
•Mekanisme : false neurotransmitters
↓ sympathetic outflow ↓ sympathetic
tone
•Contoh:
•Clonidine 0.75-0.6 mg bid,
Central Acting
Methyldopa 250 mg-1000 mg BID
Mechanism:
(Pregnancy), Reserpin 0,1 -0,25 mg QD
Clonidine •Monitor: HR (bradycardia)
•Efek samping: Mulut kering, ortostatik,
sedasi
• Penghentian Rebound effect
Vasodilators
Arteries •Mekanisme: Vasodilatasi langsung terhadap
arteriol melalui ↑ intracellular cAMP
•Contoh:
•Hydralazine 20-400 mg BID-QID
Dihydropyridine •Minoxidil 2.5-40 mg PO daily-BID
CCBs •Monitor: HR ( reflex tachycardia), Retensi
Na & air
Hydralazine
•Hydralazine alternatif pada gagal jantung
Minoxidil jika ACEI kontraindikasi
•Pertimbangkan penggunaan minoxidil pada
pasien refrakter dengan multi-drug
regimens
Hypertension treatment strategy: JNC VII
Lifestyle modifications
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II JNC VII. JAMA 2003;289:2560-2572
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC 7
48
JNC 7
49
50
50
JNC 7 Compelling Indications
Diuretic βB ACEI ARB CCB AA
Heart failure
Post-MI
High CHD risk
Diabetes
Chronic kidney
disease
Recurrent stroke
prevention
AA = aldosterone antagonist
Step 1 A C or D
Step 2 A + C or A + D
Step 3 A + C + D
Pharmacological management
HYPERTENSION STAGE 2
BP ≥ 166/100 mmHg
Pharmacological management
64
THERE ARE MANY GOOD DRUGS
A GOOD DOCTOR
The choice of initial drug is the most important
decision to be made in the treatment of
hypertension.
If the wrong initial choice is made, the blood
pressure may not respond, bothersome side-
effects may appear or other conditions worsen,
discouraging the patient from the overriding
necessity of persistence in achieving the goal of
therapy