HIPERTENSI ESENSIAL

FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI 2011

DEFENISI

Hipertensi esensial adalah hipertensi yang tidak diketahui penyebabnya. Klasifikasi tekanan darah menurut JNC 7 :
Klasifikasi tekanan darah Normal Prahipertensi Hipertensi derajat 1 Hipertensi derajat 2 TDS (mmHg) < 120 120 139 140 159 160 TDD (mmHg) < 80 80 89 90 99 100

Classification of Blood Pressure

ESC-ESH 2007
Optimal : <120 and < 80 Normal : 120-129 and/or 80 - 84 High Normal : 130-139 and/or 85-89 Grade 1 : 140-159 and/or 90-99 Grade 2 : 160-179 and/or 100-109 Grade 3 : > 180 and/or > 110

JNC-VII
Normal Pre-hypertension Stage 1
H Y P E R T E N S I O N

Stage 2

JNC VII committee, JAMA 2003: 289;2560-2572

Epidemiology of Hypertension

90% lifetime risk of developing hypertension in people normotensive at age 55 People with lower educational and income levels tend to higher levels of blood pressure

American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006

Hypertension in Asia Pacific

Alexandra L.C. Martiniuk et.al J. Hypertension 2007 ; 25 : 88-92

Hypertension is Not Adequately Treated

Off all the USA people with high blood pressure:

11% are not on treatment regimen 25% are not on adequate treatment 34% are on adequate treatment

American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006

The Cardiovascular Continuum

Coronary thrombosis Myocardial ischaemia CAD Atherosclerosis LVH Myocardial infarction Sudden Death Arrhythmia & loss of muscle Remodelling

Ventricular dilatation
Congestive heart failure

Risk factors
Hypertension, smoking, cholesterol, diabetes

Death
Dzau V. Braunwald E, Am Heart J. 1991

PATOGENESIS
Faktor yang mendorong terjadinya hipertensi : 1. Diet & asupan garam, stress, ras, obesitas, merokok, genetis 2. Sistem saraf simpatis : - Tonus simpatis - Variasi diurnal 3. Keseimbangan antara modulator vasodilatasi & vasokonstriksi 4. Pengaruh sistem endokrin setempat yang berperan pada sistem renin, angiotensin & aldosteron

Consequences Structural Changes in Hypertension

Loss of buffering Function Increased blood pressure Structural changes in compliance arteries Transmits Systolic pressure Wave to small arteries Compliance Load on heart
Perpetuation of Hypertension Left Ventricular Hypertrophy Predisposes of Atherosclerosis

Shear stress on Artery wall

Endothelial dysfunction

Dzau VJ. Hypertension. 2001;37:1047-1052

The Progression from Hypertension to Heart Failure

LVH Diastolic dysfunction CHF Systolic dysfunction Death

Hypertension
MI

Normal LV Structure & Function Time (decades)

LV remodeling

Subclinical LV dysfunction

Overt Heart Failure

Time (months)

Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796

Cumulative Incidence of Heart failure in Normotensive and Hypertensive Patients

20 15
CHF Cumulative Incidence 10 (%)
Stage 1 hypertension Stage 2 hypertension

5
Normal BP

0
5 10 Years From Baseline Exam 15

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7. Data from Levy D et al. JAMA. 1996;275:1557-1562.

KERUSAKAN ORGAN TARGET

1. Jantung : - Hipertrofi ventrikel kiri - Angina atau infark miokardium - Gagal jantung Otak : - Stroke atau Transient ischemic attack Penyakit ginjal kronis Penyakit arteri perifer Retinopati

2.
3. 4. 5.

Faktor resiko penyakit kardiovaskuler pada hipertensi : Merokok Obesitas Kurangnya aktivitas fisik Dislipidemia DM Mikroalbuminuria Umur ( laki-laki > 55 thn, perempuan 65 thn) Riwayat keluarga dengan penyakit jantung kardiovaskuler prematur (lakilaki < 55 thn, perempuan < 65 thn)

EVALUASI HIPERTENSI
Tujuan : 1.Menilai pola hidup & identifikasi faktor-faktor resiko kardiovaskular lainnya 2.Mencari penyebab kenaikan tekanan darah 3.Menentukan ada atau tidaknya kerusakan target organ & penyakit kardiovaskular

Menentukan adanya penyakit penyerta sistemik, yaitu :

Aterosklerosis
Diabetes

Penyakit ginjal

PENGOBATAN
Tujuan pengobatan :

Target tekanan darah < 140/90 mmHg Penurunan morbiditas & mortalitas kardiovaskular

Menghambat laju penyakit ginjal proteinuria

Pengobatan hipertensi terdiri dari : 1. Terapi nonfarmakologis Berhenti merokok menurunkan berat badan mengurangi konsumsi alkohol berlebih latihan fisik menurunkan asupan garam meningkatkan konsumsi buah & sayur menurunkan asupan lemak

2. Terapi farmakologis Jenis-jenis obat yang dianjurkan :

Diuretika Beta blocker Calsium Channel Blocker atau Calcium antagonist Angiotensin Converting Enzyme Inhibitor Angiotensin II Receptor AT1 receptor antagonist/blocker (ARB) * Tunggal atau kombinasi

Possible Combinations of Antihypertensive Agents

Diuretics

Beta-blockers

Angiotensinreceptor blockers

Diltiiazem
Alpha-blockers Calcium channel blockers

ACE inhibitors
Guidelines Committee. J Hypertens 2003; 21: 1011-53.

LIFESTYLE MODIFICATIONS
Not Goal BP

INITIAL DRUG CHOICES

Without Compelling Indications

With Compelling Indications

Drug(s) for the compelling indications. Other antiHT Drugs (Diuretics, ACEI, ARB,

Stage 1 Thiazide-Type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination

Stage 2 Two Drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB

BB, CCB) as needed

US-JNC VII Report

Renal Protection
Strict BP Control Target BP: <130/85 mm Hg 130/80 (ADA guidelines)
<125/75 mm Hg (if proteinuria > 1g/24h)

Control of Proteinuria Ideally = 0 mg/24h Mikroalbumiuri (0-300mg/24h)

American Diabetes Association. Diabetes Care. 2002;25 (Suppl.1):S85-S89.

Pemilihan obat antihipertensi dipengaruhi oleh beberapa faktor, yaitu : Faktor sosio ekonomi Profil faktor resiko kardiovaskular Ada tidaknya penyakit penyerta Variasi individu thd obat antihipertensi Kemungkinan adanya interaksi obat yg digunakan pasien utk penyakit lain