Dr.

Irma Wesprimawati,SpPD
.
 Pendahuluan:
Hipertensi adalah keadaan
tekanan darah yang sama atau melebihi
140mmHg sistolik dan /atau sama atau
melebihi 90mmHg diastolik pada
seseorang yang tidak sedang minum
obat antihipertensi

2
Management of Hypertension in Diabetics

JNC-7 KLASIFIKASI
 Cause of Hypertension:

4
Risk Factors of Hypertension:
1. Hyperlipidemia ( Deposition of fat in arteries & kidney )
2. Smoking
3. Diabetes mellitus
4. Stress ( Continuous production of O2- )

5
1- Measure BP Properly
The measurement of BP is likely the clinical
procedure of greatest importance that is
performed in the sloppiest manner.”
(Norman Kaplan, M.D.)
Lancet 2007; 370:591
Health care professionals should take particular
care to ensure that they are using accurate
techniques to measure BP in all their patients.”
(International Working Group, 2008)
J Hum Hypertens 2008; 22:63

∆ BP (mm Hg)
if not done
Rest ≥ 5min, quite ↑ 12/6
Seated, back supported ↑ 6/8
Cuff medsternal level ↑ ↓ 2/inch
Correct cuff size ↑ 6-18/3-14
Bladder center over artery ↑ 3-5/2-3
Deflate 2 mm Hg/ sec ↑ SBP/↓ DBP

Can J Card 2007; 23:529

Measure BP Properly
1- Measure
Joint BP Properly
National Commitee
The patient should be seated for at least 5 minutes, relaxed and not
moving or speaking.
The arm must be supported at the level of the heart. Ensure no tight
clothing constricts the arm.
Place the cuff on neatly with the centre of the bladder over the
brachial artery. The bladder should encircle at least 80% of the arm
(but not more than 100%).
The column of mercury must be vertical, and at the observers eye
level.
Caffeine, exercise, and smoking should be avoided for at least 30 minutes
Estimate the systolic beforehand:
prior to measurement.
a) Palpate JNC-7
the brachial artery
b) b) Inflate cuff until pulsation disappears
c) Deflate cuff
d) Estimate systolic pressure
Then inflate to 30 mmHg above the estimated systolic level needed to
occlude the pulse.
Place the stethoscope diaphragm over the brachial artery and deflate
at a rate of 2-3mm/sec until you hear regular tapping sounds.
Measure systolic (first sound) and diastolic (disappearance) to nearest
2mmHg.
Management of Hypertension in Diabetics

2- Define Hypertensive Patients

Joint National Committee 7 (JNC-7)
 Management of Hypertension in Diabetics

2- Define Hypertensive Patients

Systolic or Diastolic Hypertension???????

 Stronger
250
predictor of risk than diastolic BP:
Nondiabetic
 Cardiovascular
disease
Diabetic
200
CV Diabetic Nephropathy
mortality
65% of 150
rate/ DM hypertensives have isolated systolic hypertension.
Systolic100hypertension more difficult to
10,000

person-yr
control
Lancet 2002; 360:1903 Hypertension 2003; 42:1206
50 National Kidney Foundation: Guideline 8. Am J Kidney Dis 43 (Suppl. 1):S142 –S159, 2004.

Sowers JR et al. Hypertension 37:1053 –1059, 2001.

0
<120 120-139 140-159 160-179 180-199 ≥200
Systolic BP (mm Hg)
CV, cardiovascular; SBP, systolic blood pressure.
Stamler J et al. Diabetes Care. 1993;16:434-444. CV Mortality Risk Doubles With
Each 20/10 mm Hg BP Increment*
Management of Hypertension in Diabetics

2- Define Hypertensive Patients

Systolic or Diastolic Hypertension???????
 Diastolic hypertension predominates before age
50, either alone or in combination with SBP
elevation.

 Systolic hypertension increases with age, and

above 50 years of age, systolic hypertension
represents the most common form of
hypertension.

 DBP is a more potent cardiovascular risk factor

than SBP until age 50; thereafter, SBP is more
important.

 DBP control rates exceeded 90 percent, but SBP

 Three-fourths
control rates wereof 1ry care physicians
considerably failed to initiate therapy if SBP 140-159.
less (60–70
 Most physicians have been taught that the diastolic pressure is more important
percent)
than SBP and thus treat accordingly.
J Clin Hypertens 2002;4:393-404.
 Most primary care physicians did not pursue control to <140 mmHg.
Hypertension 2001;37:12-8.
J Clin Hypertens. 2000;2:324-30.
Management of Hypertension in Diabetics

2- Define Hypertensive Patients

Follow up BP Measurements
Management of Hypertension in Diabetics

3- Evaluate Hypertensive Pts.

 Estimate CV Risk Factors.

 Diagnose Target Organ Damage.
 Exclude Identifiable Causes of HTN.
 Routine Laboratory work up with ECG, lipid profile and urinary albumin.
Management of Hypertension in Diabetics

3- Evaluate Hypertensive Pts.

Cardiovascular Risk Factors
 HTN*
(
 Age:
 Older than 55 years for men (140-age) x Weight (Kg) x (0.85 if female)
 Older than 65 years for women 72 x S Creatinine (mg/dl)
 DM*
 Abnormal Lipid Profile*:
 Elevated LDL (or total) cholesterol
 Low HDL cholesterol* Normoalbuminuria < 30 mg/day
 Estimated GFR <60 mL/min Microalbuminuria 30 - 300 mg /d
 Family history of premature CVD: Macroalbuminuria > 300 mg / day
 men <55 years of age
 women <65 years of age BMI= Weight (Kg) / (Height in meter)2
 Microalbuminuria
 Obesity* (BMI >30 kg/m2)
 Physical inactivity

 Tobacco usage, particularly cigarettes

Management of Hypertension in Diabetics

3- Evaluate Hypertensive Pts.

Target Organ Damage
 Heart
 LVH
 Angina/prior MI
 Prior coronary
revascularization
 Heart failure
 Brain
 Stroke or transient
ischemic attack
 Dementia
 CKD
 Peripheral arterial
disease
 Retinopathy
Management of Hypertension in Diabetics

3- Evaluate Hypertensive Pts.

Identifiable Causes of HTN
 ABCD diagnosis of 2ry HTN

A: Accuracy, Apnea,
Aldosteronism
B: Bruit, Bad Kidney
C: Catecholamines,
Coarctation, Cushing's S.
D: Drugs, Diet
Investigations of Hypertension
 Basic test for initial evaluation
a) Always included:
1. Urine for: Protein, blood, glucose
2. Haematocrit
3. Serum electrolytes- specially POTASSIUM
4. Blood urea & serum creatinine
5. ECG
6. Plasma cholesterol
 Investigations of Hypertension
 Basic test for initial evaluation
b) Usually included depending on cost & other factors:
1. Microscopic analysis
2. WBC
3. Blood / plasma glucose
- Fasting Blood glucose level
- 2 HPP blood glucose level
4. Serum – Total cholesterol, HDL, LDL, Triglycerides
5. Serum – calcium, phosphate, uric acid
6. X-ray chest P/A view
7. ECG
Management of Hypertension in Diabetics

4- Therapy
1. Blood Pressure Goal
2. Life Style Modification
3. Phamacological Therapy
4- Therapy
Life Style Modifications
Management of Hypertension in Diabetics

4- Therapy
Resistant Hypertension
Marketed antihypertensive drugs:

24
Anti Hypertensive Drugs
Class Drug (Trade Name) Usual Dose Range in MG/ DAY

Thiazide diuretics Chlorothiazed (Diuril) 125-500

Chlorthalidone (generic) 12.5-25
Hydroclorothiazide (Microzide, Hydro DIURIL) 12.5-50
Polythiazide (Renese)
Indapamide (Lozol) 2-4
Metalozol (Mykrox) 1.25-2.5
Metalazone (zaroxolyn) 0.5-1.0
2.5-5
Loop diuretics Bumetanide (bumex) 0.5-2
Furosemide (Lasix) 20-80
Torsemide (Demadex) 2.5-10
Potassium-sparing diuretics Amiloride (Midamor) 5-10
Triamtrene (Dyrenium) 50-100

Aldosterone receptor Eplernone ( Inspra) 50-100

blockers Spironolactone (Aldactone) 25-50
Anti Hypertensive Drugs
ACE Inhibitors Benazepril (Lotensin) captopril (capoten) 10-40
Enalapril (vasotec) 25-100
Fosinopril (monopril) 2.5-40
Lisinopril (prinivil, zestril) 10-40
Moexipril (Univasc) 10-40
Perindopril (Accupril) 7.5-30
Quinapril (Accupril) 4-8
Ramipril (Altace) 10-40
Trandolapril(Mavik) 2.5-20
1-4
Angiotensin II Candesartan (Atacand) 8-32
Antagonists Eprosartan (Teveltan) 400-800
Irbesartan (Avapro) 150-300
Losartan (Cozaar) 25-100
Olmesartan (Benicar) 20-40
Telmisartan (Micardis) 20-80
Valsartan (Diovan) 80-320
Anti Hypertensive Drugs
Beta-Blockers Atenolol (Tenormin) 25-100
Betaxolol (Kerlone) 5-20
Bisoprolol (zebeta) 2.5-10
Metoprolol (lopressor) 50-100
Metoprolol extended release (Toprol XL)
Nadolol (Corgard) 50-100
Propranolol (Inderal) 40-120
Propranolol long-acting (Inderal LA) 40-160
Timolol (Blocadren)
60-180
20-40

Beta-Blockers with intrinsic Acebutolol (Sectral) 200-800

sypathomimetic activity Penbutolol (Levatol) 10-40
Pindolol (generic) 10-40

Combined Alpha– and beta-blockers Carvedilol (Coreg) 12.5-50

Labetalol (Normodyne) 200-800
Anti Hypertensive Drugs
Calcium channel blockers- non Diltiazem extended release 180-420
Dihydropyridines (cardizem CD, Dilacor XR, Tiazac) Diltiazem extended release
(Cardizem LA) 120-540
Verapamil immediate release (calan, isoptin) 80-320
Verapamil long acting (calan SR, 120-360
Isoptin SR)
Verapamil – Coer (Covera HS, Verelan PM) 120-360

Calcium Channel Blockers - Amlodipine ( Norvasc ) 2.5-10

Dihydropyridines Felodipine (plendil) 2.5-20
Isradipine (Dynaciric CR) 2.5-10
Nicardipine sustained release (Cardene SR) 60-120
Nifedipine long-acting (Adalat CC, procardia XL)
30-60
Nisoldipine (Sular)
10-40
Anti Hypertensive Drugs

Alpha- Blockers Doxazosin ( Cardura) 1-16

Prazosin (minipress) 2-20
Terazosin (Hytrin) 1-20

Central alpha-agonists and Clonidine (Catapres) 0.1-0.8

other centrally acting drugs Clonidine patch (catapres-TTS)
Methyldopa (Aldomet) 0.1-0.3
Resrpine (generic) 250-1000
Guanfacine (generic) 0.05-0.25
0.5-2
Direct Vasodilators Hydralazine (Apresoline) 25-100
Minoxidil (Loniten) 2.5-80
Management of Hypertension in Diabetics

Deleterious Effects of Angiotensin II

Angiotensin II

CNS
Dypsogenia

 AVP Vaso-
constriction
Efferent
Constriction
+
Mesangial Na
Contraction Retention

Vessel Myocardial
 Aldosterone Hypertrophy Hypertrophy Increased
Norepinephrine
Release
Treatment of Hypertension in Special
Situations
 Complications of Hypertension:

Hypertension is a
risk factor
TIA, stroke LVH,
HF,CHD,

Renal failure
Peripheral vascular disease

TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease;
HF = heart failure.
Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22.
 Prehypertension …
 Is not a disease,

 Is not “hypertension”,

 Is not an indication for drug treatment of HTN,

 Does not have a BP goal,

 Does predict a higher risk for developing CV events,

 Does predict a higher risk for developing HTN,

 Should be an incentive to improve lifestyle practices for

prevention of HTN and CVD.
Treatment of hypertension in special situations

 Life style modification,. if fail pharmacological therapy

should be started
 Dosage of antihypertensive medication should be
smaller and adjusted very carefully for children.
 ACE inhibitor & A-II receptor blocker should not be used
In pregnant mother
 Use of anabolic steroid for body building & smocking
strictly prohibited.
Hypertension in PREGNANCY

 In the 2nd & 3rd trimester, antihypertensive agents often are not
indicated unless the Diastolic BP exceeds 100 mm Hg.

 If drugs will be methyldopa, Beta-blocker, CCB in order of

preference.

 Hydralazine (Parenteral) & prazosin may be used.

 Should not be used:

ACEi, A-II Receptor blocker, Diuretics, Nitroprusside
3. Hypertension with co-existing cardiovascular diseases

a) Hypertension with CCF

 Diuretics & ACEi are preferable drugs.
 Contraindications: Ca++ channel blockers & β-blockers.
 ACEi used alone or in conjugation with DIGOXIN or DIURETICS.
 When ACEi is contraindicated, the vesodilators combination of HYDRALAZINE and
ISOSORBIDE DINITRATE is also effective in this patient.
 In one trial A-II receptor blocker (LOSARTAN POTASSIUM) was superior to
CAPTROPIL in decrease mortality.
b) Hypertension with coronary artery disease:

 Goal BP < 140/ 90 mm Hg

 β-blocker & Ca++ channel blocker may be specially useful in patient
with HTN & angina pectoris.
 ACEi also useful in MI.
 If β-Blockers are ineffective on contraindicated VERAPAMIL or
DILTIAZEM may be used in following conditions
 (i) Non- myocardial infraction
 (ii) After MI with presented left ventricular function.
c)Hypertension with LVF:
 All antihypertensive drug can be used except direct vasodilatation e.g.
HYDRALAZINE

 In one study treatment with diuretics & an ACEi are better than other drug.

d) Hypertension with BRADYCARDIA:

 Nifidipine & ACEi are preferable drugs.

 Better to avoid β-BLOKERS, VERAPAMIL, DILTIAGEM

4. Hypertension in Diabetes:

 Goal BP <140 / 80 mm Hg [ref: Davidson’s 20th ]

 Goal BP <130 / 80 mm Hg [ref: JNC 7 ]
 Life style modification

 No antihypertensive are contraindicated in DM

 ACEi, A-II receptor, Alpha blocker, CCB, low dose diuretics are preferred choice.
 Better avoid β-blocker and high dose diuretics unless special situation.

 *ACEi →↓69% protein urea in type-I DM

[ref: Davidson’s 20th ]
Management of Hypertension in Diabetics

HTN in DM: 4- Therapy

Goal Blood Pressure

Less Than 130/80

 HOT (Hypertension Optimal Treatment).
 ABCD-NT (Appropriate Blood Pressure Control in Diabetes)
 UKPDS (UK Prospective Diabetes Study)
 IDNT (Irbesartan in Diabetic Nephropathy Trial)
 INVEST (International Verapamil-Trandolapril)
 ADA (American Diabetic association)
 ISHIB (International Society of Hypertension in Blacks)
 CHEP (Canadian Hypertension Education Program)
 BHS (British Hypertension Society)
 JNC 7 (Joint National Committee 7)
Management of Hypertension in Diabetics

HTN in DM: 4- Therapy

Goal Blood Pressure Less Than 130/80

Can We Go to More Lower Target ?

 National Kidney Foundation Hypertension and Diabetes Executive Committees
Working Group. Am J Kidney Dis. 2000;36(3):646-661.
 American Association of Clinical Endocrinologist, 2006
 Target BP 125/75 If Proteinuria > 1gm

IDNT
JASN 2005;16(7):2170–2179
Management of Hypertension in Diabetics

HTN in DM: 4- Therapy

Compelling Indications
Management of Hypertension in Diabetics

HTN in DM: 4- Therapy

ACE-I or ARBs and Hyperkalemia
 ACE-I or ARBs may cause Hyperkalemia:
1. Avoid other medications that cause hyperkalemia (K suppl, NSAIDs,
Cox2 inhibitors, K sparing diuretics).
2. Evaluate causes of hyperkalemia.
3. Treat hyperkalemia with diuretics.
4. Continuo ACE-I or ARBs if K < 5.5 mmol/l.

 Monitor GFR
1. If GFR >30% within 4 weeks, evaluate.
2. Continuo ACE-I or ARBs if GFR < 30% from baseline over 4 months.
5. Hypertension in Dyslipidaemia:

 Common co-existence & demand aggressive management of both

conditions.

 High dose THIAZIDES, LOOPS DIURETICS & BETA BLOCKERS may transiently
increase total cholesterol, still has significant reduction CV morbidity &
sudden death. So should be used without hesitation.
6. Hypertension with ASTHMA & COPD:

 Ca++ channel blocker is the preferable drug.

 ACEi are safe in most patients with asthma.
 A-II receptor blocker may be used if cough is trouble some problem after using ACEi.
 Contraindications:
β-blocker, α-blocker should not be used in patient with asthma except in special
circumstances.
7. Hypertension with CVD:
 BP is actually raised after stroke. Unless end organ damage in present or
malignant HTN is present, elevated BP should not be lowered in acute
stage since it will always return towards normal within 24-28 hours.
 After 10 days gentle reduction of BP started as a part of secondary
prevention strategy of ischemic stroke.
 If hemorrhage stroke there is no value in reducing the high BP (except
very high) until at least some days after stroke.
8. Hypertension with LIVER DISEASE:

 ALL Antihypertensive drugs can be used except METHYLDOPA.

9. Hypertension with GOUT

 All hypertensive drugs can be used

 But all Diuretics can increase serum uric acid level but rarely
induced acute gout. So diuretics should be avoided if
possible.
 Contraindications: NO DIURETICS
10. Hypertension with peripheral vascular disease

 Better to use Ca++ channel blocker & Vasodilators.

11. Hypertension with Renal parenchymal disease

 Goal BP 130 / 85 or <125 /75 mm Hg.

 Unless contraindicated ACEi + Diuretic should be used.

 Loop diuretics should be used & potassium sparing diuretics should be avoided.

 Thiazide diuretics are not effective with advanced renal insufficiency.

 ACEi used with caution if serum creatinine> 3 mg / dl

12. Adjuvant drug therapy

 Aspirin: Anti Platelet therapy is a powerful means of reducing cardiovascular risk.

 Indications: Age 50 or more, who have well controlled BP and either

target organ damage, Diabetes, or a 10 year coronary heart disease- Risk
of > 15%
 Statins: Treating hyperlipidaemia & also produce a reduction of cardiovascular risk.

 Indications: Established vascular disease or hypertension with a high risk

of developing coronary heart disease.
13. Hypertensive crises
Hypertensive crises

A) Emergency B) Urgency
i) Malignant HTN
ii) Accelerated HTN
Goal of reducing BP 160/100 mm of Hg with in 24 hrs
Drugs of Choice:
Oral Drugs are better than I/V
ORAL I/V
1. Clonidine 1. Nitroprusside
2. Labetalol 2. Nitroglycerin
3. Captopril 3. Labetalol
4. Prazosine 4. Hydralazine
Follow up & Monitoring

 serum potassium and creatinine monitored 1-2 times per year.

 after BP at goal and stable, follow up visits at 3 to 6 months interval.
 [ref: JNC 7]
Recommendations for Improving Outcomes

Physician Patient

 Establish treatment goals  Self-Monitor BP

 Maintain adherence  Keep diary of BP therapy
 Minimize side effects  Make life-style changes
 Conclusion:
 Hypertension is a very common disorder, particularly past
middle age.
 It is not a disease in itself, but is an important risk factor
for cardio-vascular mortality & morbidity.

55
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