TERAPI RASIONAL HIPERTENSI

Dr. med. Frans Santosa, MD, SpJP, EFMA, FACA, FICA, FASA, FIHA, SFGISA
Internist (SpPD) University of Giessen, Germany 1989 Cardiologist (SpJP) University of Giessen Max Planck Society Bad Nauheim, Germany 1991 Angiologist (SpKed.Vask) University of Essen, Germany 2000

PIT IDI Wil DKI Jakarta Hotel Sahid Jakarta, 10 Mei 2012

Normal Blood Pressure Values in Children

Systolic pressure (mmHg) 80 90 95 95 100 120 Diastolic pressure (mmHg) 45 55 60 60 65 70

Neonates 6 months 1 year 5 years 10 years 15 years

Cuff sizes
Neonates Infants School children Adults Size of cuff (cm) Width Length 2.5 4 5 10 68 9 10 12 13 12 13.5 17 22.5 22 23.5

Muscular Adults
Obese Adults

15.5
18

30
36

Nilai Target BP

Symptoms of Hypertensive Emergencies

General

Cerebral
Headache Vomitting Blurring of vision Agitation Decreased consciousness Temporary or permanent paresis Pyramidal signs Comma Generalized seizures

Palpitations Fear Dizziness Tinitus Diaphoresis

Dyspnoea at rest Cough Angina pectoris Asthma cardial Pulmonary oedema Myocardial infarction

Cardial

Classification of Hypertension
I. By Aetiology
I. Primary Hypertension (85 90%) = essential, idiopathic, genuine, neurogenic II.Secondary Hypertension (10 15%)
A. Renal hypertension
1. Renal vascular hypertension (1%) Renal artery stenosis Renal artery aneurysm Renal artery atherosclerosis 2. Renal parenchymal hypertension (8-12%) Glomerulonephritis Pyelonephritis Polycystic kidney Phenacetin kidney

B. Endocrine hypertension
Cushings syndrome Conns syndrome Pheochromocytoma Hyperthyroidism

C. Hypertension due to neurological diseases

Brain tumour Encephalitis Polyomyelitis

D. Hypertension in pregnancy, Thalium intoxication, Porphyuria, Polyneuritis E. Cardiovascular Hypertension

Aortic coarctation Aortic valve insufficiency Atherosclerosis (Diffuse endothelial dysfunction)

Classification of Hypertension
II. By haemodynamic criteria
1. Increased peripheral vascular resistance (resistance hypertension) 2. Minute volume hypertension 3. Due to loss of elasticity (elasticity hypertension)

III. By staging
1. Benign Hypertension which does not/has not manifested in organ damage 2. Malignant Persistent hypertension with a diastolic pressure >120 mm Hg, as manifested by changes in the fundi (KW III, IV)

Classification of Hypertension
V. By character 1. Labile Intermittently elevated blood pressure 2. Stable Persistently elevated blood pressure readings (systolic or diastolic) without the characteristics of malignant hypertension

White Coat Effect

Brown M, Buddle M, Martin A (2001) Is resistant hypertension really resistant? Am J Hypertens 14: 1263-1269 Der Internist 1, Band 50. Heft 1. Januar 2009 - Hal.8

The Correct Blood Pressure Measurement

1.
2. 3. 4. 5. 6. 7. 8.

No mental, nor physical exertion at least 10 minutes before the measurement The cuff must be placed tightly around the arm Look up the correct cuff size below The arm should not be restricted by clothes Inflate cuff until the radial pulse disappears Velocity of deflation: 2 mm Hg/ sec The systolic pressure is read on the first audible pulse The diastolic pressure is read when the audible pulse disappears

Mengapa Hipertensi harus diobati ?

Menghindarkan EOD Menurunkan morbiditas & mortalitas

Source : HOT, ALL HAT, LIFE, PROGRESS, HOPE, FEVER, ADVANCE, dll

Hubungan Nilai BP dan Komplikasi Kardiovaskuler

HOT STUDY
N 18790 (usia maks.80, min.50 th, mean 61,5 th) BP 105-115 mm Hg diastolis. mean 169,5 / 105,4 mm Hg. Masa Pengamatan : 3,8 th.

3 Therapi Gol :

1. Diastolis 90 mm Hg 2. Diastolis 85 mm Hg 3. Diastolis 80 mm Hg

Hasil :
-Insident Kejadian Kardiovaskuler terendah pada BP 138,5 / 82,6 mm Hg -Mortalitas Kardiovaskuler terendah pada BP 138,8 / 86,5 mm Hg Ini berarti tambah kuat BP diturunkan tambah rendah mortalitas

-Insident kejadian miokard infark terendah pada BP sistolis 142,2 mm Hg -Insident kejadian stroke terendah pada BP diastolis < 80 mm Hg -68 % dari semua pasien membutuhkan minimal 2 jenis obat anti hipertensi.
Source : Hansson et al, Lancet 351, 1752-1762,1998

HYVET
HYpertension in the Very Eldery Trial

Study antihipertensi pertama yang menunjukan penurunan signifikant terhadap mortalitas!

Source: Der Internist Band 50, Heft 9, September 2009: 1170

Terapi: n = 1933 Placebo: n = 1912

n = 8123 n = 3845

Usia: 80 th s/d 104 th, x 84 th Kriteria: Usia 80 th, BP 160 mmHg TBP:<150/80mmHg Lama pengamatan: 2,1 th Goal of study: Primer : stroke Sekunder: - dead - dead e.c. kardial / vaskuler
Source: Bechett NS, Peters R, Fletchen AE et al; N. Engl J Med 2008, 358: 1887 - 1898

Diagnostik
Pemeriksaan BP Pemeriksaan DL, UL, K, Na, Kreatinin, Ureum EKG Echocardiografi Funduskopi

Ultrasound Findings in Renal Hypertension

Visible Changes Bilateral renal hypoplasia Unilateral renal hypoplasia Hypertrophic kidneys Hypertrophic kidney, parenchymal hyperplasia Hypertrophic polycystic kidney Renal pelvic dilatation Renal stones Renal tumour Possible Diagnosis Chronic glomerulonephritis Pyelonephritis, renal artery stenosis, renal infarction, primary renal hypoplasia Acute renal failure M. Kimmelstiel Wilson Cystic kidney Hydro- or pyelonephrosis, outflow obstruction -

Non-Pharmacological Therapeutic Measures

Hindari makanan berlemak dan terlalu asin Makan buah-buahan dan sayur-sayuran 5x/d Jaga berat badan agar tetap normal Jangan merokok dan hindari passive smoker Olah raga teratur proporsional

According TOMHS final results: JAMA 270, 713-724, 1993

Classification of Antihypertensive Drugs

Source: Evidence Based Treatment in Cardiology; D. Stroedter, F. Santosa, UNIMED Verlag AG 2009: 74

Classification of Beta-blockers

Source: Evidence Based Treatment in Cardiology; D. Stroedter, F. Santosa, UNIMED Verlag AG 2009: 74

Classification of calcium-antagonist

Source: Evidence Based Treatment in Cardiology; D. Stroedter, F. Santosa, UNIMED Verlag AG 2009: 74

Pertimbangan pemilihan Anti Hiperten

Kelompok Diuretika (Thiazide) Pro Murah Payah jantung Isolated Systolic Hypertension (ISH) Kontra Hipokalemi Hiperurikemi Manifestasi baru DM Non-compliance

Beta blocker

Post MCI Angina pectoris Payah jantung Graviditas Aritmia

ISH Hipertensi Angina Pectoris PJK stabil Payah jantung Post MCI Nefropati Risiko tinggi kardiovaskular Nefropati (terutama DM tipe 2) Payah jantung Post MCI Apoplex

COPD AV-block Manifestasi baru DM

Ca-Antagonis

AV-block (non-DHP) Oedema (DHP)

ACE Inhibitor

Graviditas Batuk Hiperkalemi Arteri renalis stenosis bilateral Mahal Graviditas Hiperkalemi Arteri renalis stenosis bilateral

AT-1 Inhibitor Renin Blocker

Common Pitfalls in Hypertension Management

Nature of Pitfall
5. Too high dosage of sedatives

Consequence
Patient cannot work, thus refusing compliance
Lack of compliance

Solution
Use less sedative agents or use combination therapy
Better patient education, pamphlets Furosemide diuretics

6. Insufficient patient education

7. Thiazide diuretics Insufficient blood given to patients with Cr pressure control > 2 mg

Combination therapy
I. Optimal combinations
ACE-I / Diuretics AT-I-DRB / Diuretics Beta blockers / Diuretics Cave : DM new manifestasi!!! ACE-I or AT-I-RCB / CCB / HCT Beta blockers / CCB (dihydropyridines) / hydralazine, etc Beta blockers / ACE-I or AT-IRCB

Reason
Diuretics increase Renin, which are influenced by ACE-I Synergism, blunting effects, decreased side effects due to lower dosages See above Synergism due to decreased cardiac output, PVR, avoidance of cardiac sensations (palpitations, AP) Synergism, blunting effects of RAAS

Combination therapy
II. Ocassionally optimal combinations
Reserpin / Methyldopa Beta blockers / Reserpin Beta blockers / CCB (verapamil)

Concerns
May cause depression May cause Bradycardia AV-block or more pronounced bradycardia

III. Not recommended combinations

Alpha blockers / beta blockers

Reasons
Similar pharmacodynamics, reduced cardiac output. Both result in bradycardia Reflex tachycardia, palpitations, flushing

Combination of Vasodilators

Differences in Opinion

End Organ Damage (EOD)

Definisi: Kerusakan pada organ akhir akibat hipertensi
Mikroalbuminurie UL Proteinurie UL LVH EKG dan Echokardiografi Fundus arteri (KW) Stadium hipertensi Aterosklerosis (Carotis stenosis, PJK, TIA, PAOD) Duplex

LVH

Ketebalan IVS = 8.4 mm LVPW = 7.8 mm

NORMAL
Ketebalan IVS = 13.6 mm LVPW = 14.2 mm

Stenosis Arteri Karotis

Post PTA
Pre PTA

Akibat Hipertensi Pada Organ

Hipertensi
Aterosklerosis Heart Failure Renal Failure

Stroke MI PAOD
Invalid dini Kualitas Hidup Kematian dini
s

Biaya Penyakit Kardiovaskuler

Tahun 2006 di Jerman
Urutan teratas dari segi biaya: 15,7% seluruh biaya penyakit yang ada, mencapai 35,2 Milliar (= 528 trilliun rupiah)

Source: Jahnsen K et al, Heft 43, Hipertonie, RKI: 12/2008

Biaya Yang Harus Dibayar

10 Golden Rules Untuk Pasien Hipertensi

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Kontrol Tekanan Darah teratur Batasi pemakaian Garam Usahakan Tidur mencukupi Batasi minum Alkohol Minum Obat Hipertensi secara teratur Olah raga teratur 3x/minggu 30 menit. Nikmati Istirahat dan cuti yang cukup Hentikan / Jangan merokok Hindari / turunkan berat badan Hindari stress dan ketergesa-gesaan
Sumber : Deutsche Blutdruckliga 1 juni 2008

Formula menuju Pembuluh Darah yang sehat

0 3 5 140 5 3 0
0 = Jangan merokok 3 = 30 menit olah raga proporsional setiap hari

5 = 5 kali makan Buah-buahan dan Sayur-sayuran setiap hari

140 = tekanan darah sehari-hari harus dibawah dari 140 mm Hg 5 = Kolesterol Total harus dibawah 5 mosmol (5x38) = 190 mg %

3 = Kolesterol Jahat LDL harus dibawah 3 mosmol (3x38) =114 mg %

0 = Berat badan harus normal

Key Messages
For persons over age 55, SBP is more important than DBP as CVD risk factor Normotensive individuals at age 55 have a 90% lifetime risk for developing hypertension Those with SBP of 120 mm Hg and DBP of 80 mm Hg should be considered prehypertensive; they may require lifestyle modifications to prevent CVD

Take Home Message I

Hipertonika diusahakan tepat, murah, dan aman Bila monoterapi kurang memuaskan, mulailah dengan kombinasi terapi

Terapi kombinasi bertujuan mendapat efek sinergism dan mereduksi efek samping obat

Take Home Message II

Pasien hipertensi usia sangat lanjut 80 th bukan argumen untuk tidak diberi obat antihipertensi

Pada pasien hipertensi usia sangat lanjut 80 th, menurunkan BP menjadi 150 / 80 mmHg selama 2 tahun terus menerus dapat menurunkan kematian, stroke dan payah jantung

Terima kasih !
Salam dari :
PB IDI IDI Wilayah DKI Jakarta Yayasan Pembuluh Darah (Angiologi) Indonesia Perhimpunan Angiologi Indonesia (PANGI) German Indonesian Society of Angiology Rekayasa Jaringan Sel Indonesia (REJASELINDO)