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Consequences of Hypertension
Consequences of Hypertension
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Hypertensive nephropathy
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Fundoscopy/ Vascular
DEFINISI
SV x HR
BP : blood pressure
SVR: systemic vascular-resistance
SV : stroke volume
HR : heart rate
Blood Pressure
Determining Factors
Cardiac Output:
Peripheral
Stroke Volume Resistance **
Heart Rate
Vasodilators
Force of Contraction
ACE Inhibitors
Beta Blockers
Calcium Channel
BP
Blockers
Blood Volume **
MULTIFAKTORIAL
PATOGENESIS
Hipertensi primer : Penyakit multifaktorial
Juxtaglomerular
Cells
Decreased BP
Renin Release
Formation of
Angiotensin
Increased Vasoconstriction
Increased Aldosterone
with Increased Na++ and
Fluid Retention
FAKTOR2 YANG BERPENGARUH PADA PENGENDALIAN TD
asupan Na jumlah stress perubahan obesitas faktor2 yg
berlebih nefron genetis berasal dari
Endotel
konstriksi hipertrofi
Preload kontraktilitas fungsional struktural
Decreased
Arterial
Obesity Compliance Endothelial
Dysfunction
LV Hypertrophy Renal-Function
and Dysfunction Changes
Blood-Clotting
Abnormal Insulin
Mechanism
Metabolism
Changes
Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J
Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.
Routine steps for accurate measurement
of blood pressure
JNC 7 2003
How to measure blood pressure accurately
……… sphygmomanometer
Patient should be seated and relaxed, preferably for several
minutes
prior to to the measurement and in a quiet room.
Appropriate cuff size.
Average the readings. If the first two readings differ by more than 10 mmHg
systolic or 6 mmHg diastolic or if the initial readings are high, take several
readings after five minutes of quiet rest, until consecutive readings do not
vary by greater than these amounts.
Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
………………….. Australia, 2004
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)
• Because a full
bladder affects the
blood pressure it
should have been
emptied.
Preparation for measurement
• BP take in quiet
room and
comfortable
temperature, must
record room
temperature and
time of day.
BLOOD PRESSURE: MEASUREMENT
Ascultatory method of
blood pressure measurement Nokolai Korotkoff, 1905
Blood Pressure Assessment:
Patient preparation and posture
Standardized Preparation:
Patient
√ 1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
√ 4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
√ 8. Patient should stay silent prior and during the
procedure.
Measuring Blood Pressure
Slide 9-36
Complications of Hypertension:
Hypertension
is a risk factor
TIA, stroke LVH, CHD,
HF
Retinopathy Renal
Peripheral vascular failure
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.
Benefits of Lowering BP
Heart failure50%
Framingham Heart Study (1983)
CV Risk Profile
703
700
8 Year Probability Per 1,000
600
500 459
400
326
300
210
200
100 46
Systolic BP: 105 >>> 185 105 >>> 185 105 >>> 185 105 >>> 185 105 >>> 185
Cholesterol: 185 335 335 335 335
Glucose Intol.:0 0 + + +
Cigaretes: 0 0 0 + +
ECG-LVH: 0 0 0 0 +
Kannel, 1983
CXR:
Cardiomegaly
pleural effusions
interstitial edema
Pulmonary venous redistribution
Echocardiography
Adapted from Cushman et al. Endocrine Practice 1997;3:106 & Sacks, et al. NEJM 2001;334:3
JNC 7 Algorithm for Treatment of Hypertension
Lifestyle
Lifestyle Modifications
Modifications
Not
Not at
at Goal
Goal Blood
Blood Pressure
Pressure (<140/90
(<140/90 mm
mm Hg)
Hg)
(<130/80
(<130/80 mm Hg for those with diabetes or chronic
mm Hg for those with diabetes or chronic kidney
kidney disease)
disease)
Initial
Initial Drug
Drug Choices
Choices
Without
Without Compelling
Compelling With
With Compelling
Compelling
Indications
Indications Indications
Indications
Stage
Stage 11 Hypertension
Hypertension Stage
Stage 22 Hypertension
Hypertension Drug(s)
Drug(s) for
for the
the compelling
compelling
(SBP
(SBP 140-159
140-159 or
or DBP
DBP 90-99
90-99 mm
mm Hg)
Hg) (SBP
(SBP >160
>160 or
or DBP
DBP >100
>100 mmmm Hg)
Hg) indications
indications
Thiazide-type diuretics for most
Thiazide-type diuretics for most 2-drug combination for most (usually
2-drug combination for most (usually Other
Other antihypertensive
antihypertensive drugs
drugs
May
May consider
consider ACEI,
ACEI, ARB,
ARB, BB,
BB, CCB,
CCB, thiazide-type
thiazide-type diuretic
diuretic and
and (diuretics,
(diuretics, ACEI, ARB, BB, CCB)
ACEI, ARB, BB, CCB)
or
or combination
combination ACEI,
ACEI, or
or ARB,
ARB, or
or BB,
BB, or
or CCB)
CCB) as
as needed
needed
Not
Not at
at Goal
Goal
Blood Pressure
Blood Pressure
Optimize
Optimize dosages
dosages or
or add
add additional
additional drugs
drugs
until
until goal
goal blood
blood pressure
pressure is
is achieved
achieved
Consider
Consider consultation
consultation with
with hypertension
hypertension specialist
specialist
Vasodilation
? Attenuate growth and
disease progression
Modifikasi Gaya Hidup untuk
Pengendalian Hipertensi
Modifikasi Rekomendasi Penurunan Tekanan
Darah Sistolik
kurang lebih
Menurunkan berat badan Pelihara berat badan normal 5-20 mm Hg utk
(BMI 18.5-24.9)
setiap penurunan
10 kg BB
Menjalankan menu DASH Konsumsi makanan kaya 8-14 mm Hg
buah, sayur, susu rendah
lemak dan rendah lemak
jenuh
Beta Blockers
Diuretics
Sympatholytics
Centrally acting sympatholytics
Clonidine
α-methyldopa
Guanfacine
Guanabenz
Peripherally acting sympatholytics
Metyrosine
Guanethidine, Bretylium
Reserpine
Peripheral Sympatholytics
rarely used
Bretylium, Guanethidine
Reserpine
Hydralazine
liberates NO from vascular endothelium
decreases TPR
not used as monotherapy
bioavailability dependent on genetic
factors
adverse effects: tachycardia, hypotension,
fluid retention, lupus-like syndrome
only used in severe or refractory
hypertension
Direct acting vasodilators
Minoxidil
adjunct agent
Reduction in
total peripheral resistance
systolic and diastolic pressure
mean arterial pressure
aldosterone secretion
cardiac remodeling
Increase in
regional blood flow in vascular beds
large artery compliance
Types of ACE inhibitors
Active Molecules
Captopril (Capoten)
Lisinopril (Prinivil)
Enalaprilat
Prodrugs: Enalaprilat
Losartan (Cozaar)
competitive antagonist
Valsartan (Diovan)
non-competitive
Candesartan (Atacand)
non-competitive
Losartan
Irbesartan (Aprovel)
non-competitive
Therapeutic Uses
same uses as ACE inhibitors
no bradykinin effects
no cough