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HYPERTENSION

SYAIFUL AZMI

Subdivision of Nephrology, Faculty of Medicine
Andalas University
Padang
Buku pegangan.
HARRISON : INTERNAL MEDICINE

SUPARTONDO : ILMU OENYAKIT DALAM

NORMAN KAPLAN : CLINICAL
HYPERTENSION
Section 1: Definition and Classification
of Hypertension
Definition and classification of
hypertension: ESH/ESC 2003
Hypertension is defined as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Optimal <120 <80
Normal 120-129 80-84
High normal 130-139 85-89
Grade 1 hypertension (mild) 140-159 90-99
Grade 2 hypertension (moderate) 160-179 100-109
Grade 3 hypertension (severe) 180 110
Isolated systolic hypertension 140 <90
ESH/ESC Guidelines 2003
J Hypertens 2003;21:1011-1053
When a patients systolic and diastolic blood pressures fall into different
categories, the higher category should apply
Definition and classification of
hypertension: JNC VII
Hypertension is defined as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Normal <120 and <80
Pre hypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 or 100
JNC VII. J AMA 2003;289:2560-2572
Definition and classification of
hypertension: WHO/ISH 1999/2003
Hypertension is defined as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Optimal <120 <80
Normal <130 <85
High-normal 130-139 85-89
Grade 1 hypertension (mild)
Subgroup: borderline
140-159
140-149
or 90-99
90-94
Grade 2 hypertension (moderate) 160-179 or 100-109
Grade 3 hypertension (severe) 180 or 110
Isolated systolic hypertension
Subgroup: borderline
140
140-149
<90
<90
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992; 1999 WHO/ISH Guidelines for the
Management of Hypertension. J Hypertens 1999;17:151-183
When a patients systolic and diastolic blood pressures fall
into different categories, the higher category should apply
Section 2: Prevalence of Hypertension
Prevalence of hypertension*:
North America and Europe
0
10
20
30
40
50
60
70
80
P
r
e
v
a
l
e
n
c
e

(
%
)

Men
Women
Total
Wolf-Maier K, et al. J AMA 2003;289:2363-2369
* BP 140/90 mmHg or treatment with antihypertensive medication
Prevalence of hypertension: Asia
0
10
20
30
40
50
60
70
80
P
r
e
v
a
l
e
n
c
e

(
%
)

Men
Women
Total
Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol
1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
Prevalence of hypertension:
Other countries
0
10
20
30
40
50
60
70
80
P
r
e
v
a
l
e
n
c
e

(
%
)

Men
Women
Total
Ordunez P, et al. Pan Am J Public Health 2001;10:226-231;
Cubillos-Garzon LA, et al. Am Heart J 2004;147:412-417; Amad S, et al. J Hum Hypertens 1996;10:S31-S33
TABEL 4 Prevalensi Hipertensi Pada Populasi,
Obese, TGT dan DM di SumBar 2005
N
O
KOTA POPULASI
(%)
OBESE
(%)
TGT
(%)
DM
(%)
1
2
3
4
5
6
7
8

P.Panjang
Bt.Sangkar
Solok
Pariaman
Payakumbuh
Painan
Bukittinggi
Padang
22.3
23.4
26.1
22.9
19.1
16.0
26.6
11.8
22.4
23.4
24.6
22.2
17.6
17.7
37.6
12.0
26.3
32.5
33.3
35.6
326.6
36.4
38.2
25.3
33.3
42.2
41.2
40.0
18.4
29.4
28.6
23.1
RERATA 21.1 22.2 30.4 30.0
Section 3 : Classification of
hypertension
CLASSIFICATION
PRIMARY ( 90 % )
SECUNDARY ( 10 % )
renovascular hypertension
renal parenchymal hypertension
hypertension with pregnancy
pheochromocytoma
primary aldosteronemia
drug induced or related causes

JNC 7 2003, Caplan, clinical hypertension 2002
Section 4 : Risk factors of
Hypertension
Table Cardiovaskuler risk factors
Major Risk Factors

Hypertension*
Cigarette* (body mass index 30 kg/m
2
)
Physical inactivity
Dislipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR < 60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women under age 65)

Target Organ Damage

Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
GFR, glomerular filtration rate
* Components of the metabolic syndrome JNC VII 2003


Risk factors

Gender
Race
Age
Family history
Cigarette smoking
Obesity ( BMI 30 Kg/m2 )*
Physical activity
Dyslipidemia*
Diabetes Mellitus*
Microalbuminuria

* componen of metabolic syndrome

JNC 7 2003




Bahaya HIPERTENSI
(bila tdk dikendalikan)
Kerusakan pada Organ Target
Stroke
Retinopati
(buta)
LVH
Gagal
Jantung
PJK
Penyakit Ginjal
khronik
Gagal Ginjal
Terminal
Section 5 : Pathophysiology and
Pathogenesis of Hypertension
PATHOPHYSIOLOGY OF HYPERTENSION
Several hypothesis exists of the original
pathogenesis of hypertension
- Excess Na intake
- Renal Na retention
- RAS
- Stress & sympathetic activity
- Peripheral resistance
- Endothelial dysfunction
- Obesity
- Insulin resistance
Pathogenesis hipertensi
( Kaplan N, 2002 )
Angiotensinogen
Angiotensin I
Angiotensin II
Ellis ML, et al. Pharmacotherapy 1996;16:849-860;
Carey RM, et al. Hypertension 2000;35:155-163
AT
1
AT
2

Vasoconstriction
Aldosterone secretion
Catecholamine release
Proliferation
Hypertrophy
Vasodilation
Inhibition of cell growth
Cell differentiation
Injury response
Apoptosis
BP
(-)
Renin-angiotensin-aldosterone system
Renin
Angiotensin-
converting
enzyme
Bradykinin
Inactive kinins
BP, blood pressure
Section 6 : Diagnosis of Hypertension
SYMPTOMS
Headache
Nocturia
Palpitation
Dizziness
Tinitus
Epistaxis


Kaplan N , 2002


PHYSICAL EXAMINATION
25
TABLE. IMPORTANT ASPECTS OF THE PHYSICAL
EXAMINATION
ACCURATE MEASUREMENT OF BLOOD PRESSURE
GENERAL APPEARANCE : DISTRIBUTION OF BODY FAT,
SKIN LESSION,MUSCLESTRENGTH.
FUNDUSCOPY.
NECK : PALPATION AND AUSCULTATION OF CAROTIDS, THYROID.
HEART : SOUND, RHYTHM, SIZE.
LUNG : RALES.
ABDOMEN : RENAL MASSES, BRUIT OVER AORTA OR RENAL
ARTERIES, FEMORAL PULSES, WAIST CIRCUMFERENCE.
EXTREMITIES : PERIPHERAL PULSES, EDEMA.
NEUROLOGIC ASSESSMENT, INCLUDING COCNITIVE
FUNCTION.
LABORATORY TEST
ROUTINE LAB WORK UP
RISK FACTORS : BLOOD SUGAR, LIPID
PROFILE, ELECTROLYTES.
LAB OF TARGET ORGAN DEMAGE
PLASMA INSULIN, PLASMA RENIN
ACTIVITY
FUNDUSCOPY EXAMINATION :
RETINOPATHY



CARDIAC ASSESSMENT : LVH, ARYTHMIA

CEREBRAL ASSESSMENT :
ENCEPHALOPATHY

RENAL ASSESSMENT
Section 7 : Treatment Guidelines
Table Lifestyle modifications to manage hypertension *

























DASH, Dietary Approaches to Stop Hypertension.
* For overall cardiovascular risk reduction, stop smoking.
The effects of implementing these modifications are dose and time dependent, and could be greater for some
individuals
JNC VII 2003
Modification Recommendation Approximate SBP
Reduction (range)
Weight reduction Maintain normal body weight (body mass
index 18.5-24.9 kg/m
2
)
5-20 mmHg/10 kg weight
loss
23-24

Adopt DASH eating plan Consume a diet rich in fruits, vegetables,
and lowfat dairy products with a reduced
content of saturated and total fat
8-14 mmHg
25-26
Dietary sodium reduction Reduce dietary sodium intake to no more
than 100 mmol per day (2.4 g sodium or
6 g sodium chloride)
2-8 mmHg
25-27

Physical activity Engage in regular aerobic physical
activity such as brisk walking (at least 30
min per day, most days of the week0
4-9 mmHg
26-27

Moderation of alcohol
consumption
Limit consumption to no more than 2
drinks ( 1 oz or 30 mL ethanol; e.g., 24
oz beer, 10 oz wine, or 3 oz 80-proof
whiskey) per day in most men and to no
more than 1 drink per day in women and
lighter weight persons
2-4 mmHg
30

THE IDEAL ANTIHYPERTENSIVE AGENT
- Effectively reduces BP
- Maintains BP control over 24 hours with
once-a-day dosing
- Effective in all hypertensive patients
- No adverse effects
- No negative metabolic side effects

History of antihypertensive drugs
Direct
vasodilators
Alpha-
blockers
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids
Central
2

agonists
Calcium
antagonists-
non-DHPs
Beta-
blockers
Thiazide
diuretics
Calcium
antagonists-
DHPs
ARBs
1940s 1950 1957 1960s 1970s 1980s 1990s 2000
ACE
inhibitors
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
Effectiveness and general tolerability
AASK MAP <92
Target BP (mmHg)
Multiple antihypertensive agents
are needed to achieve target BP
Number of antihypertensive agents
1
UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
Trial 2 3 4
DBP, diastolic blood pressure; MAP, mean arterial pressure;
SBP, systolic blood pressure
IDNT SBP <135/DBP <85
ALLHAT SBP <140/DBP <90
Bakris GL, et al. Am J Kidney Dis 2000;36:646-661;
Lewis EJ, et al. N Engl J Med 2001;345:851-860;
Cushman WC, et al. J Clin Hypertens 2002;4:393-404
Main classes of antihypertensive drugs
Diuretics
Inhibit the re absorption of salts and water from kidney
tubules into the bloodstream
Calcium-channel antagonists
Inhibit influx of calcium into cardiac and smooth muscle
Beta-blockers
Inhibit stimulation of beta-adrenergic receptors
Angiotensin-converting enzyme (ACE) inhibitors
Inhibit formation of angiotensin II
Angiotensin II receptor blockers (ARBs)
Inhibit binding of angiotensin II to type 1 angiotensin II
receptors
Clinical trial and guideline basis for compelling indications for individual drug
classes
RECOMMENDED DRUGS
+

COMPELLING INDICATION CLINICAL TRIAL BASIS
+

DIURETIC BB ACEI ARB CCB ALDO ANT

Heart failure ACC/AHA Heart Failure Guide-
line,
40
MERIT-HF,
41
COPERNI-
CUS,
42
CIBIS,
43
SOLVD,
44
AIRE,
45

TRACE,
44
ValHEFT,
47
RALES
48

Postmyocardial infarction ACC/AHA post-MI Guideline,
49

BHAT,
50
SAVE,
51
Capricorn,
52

EPHESUS,
53

High coronary disease risk ALLHAT,
33
HOPE,
34
ANBP
2
,
36

LIFE,
32
CONVINCE
31

Diabetes NKF-ADA Guideline,
31,32
UKPDS,
34

ALLHAT
33

Chronic Kidney disease NKF Guideline,
22
captopril Trial,
55

RENALL,
56
IDNT,
57
REIN,
58
AASK
59

Recurrent stroke prevention PROGRESS
35




JNC VII , 2003

Compeling indications for antihypertensive drugs are based on benefits from outcome studies or existing
clinical guidelines; the compelling indications is managed in parallel with the BP
+ Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB,angiotensin receptor blicker;
Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker
Conditions for which trials demonstrate benefit of specific classes of antihypertensive drugs.

Treatment strategy: WHO/ISH 2003
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992
Compelling indication Preferred drug
Elderly with isolated systolic
hypertension
Diuretic, DHPCCB
Renal disease
Diabetic nephropathy type 1 ACE-I
Diabetic nephropathy type 2 ARB
Non-diabetic nephropathy ACE-I
Cardiac disease
Post-myocardial infarction ACE-I, beta-blocker
Left ventricular dysfunction ACE-I
Congestive heart failure (diuretics
almost always included)
Beta-blocker,
spironolactone
Left ventricular hypertrophy ARB
Cerebrovascular disease ACE-I + diuretic, diuretic
DHPCCB, dihydropyridine calcium-channel blocker;
ACE-I, angiotensin-converting enzyme inhibitor;
ARB, angiotensin II receptor blocker; CCB, calcium-channel blocker
Treatment initiation: JNC VII
Normal

Pre-
hypertension
Stage 1
hypertension
Stage 2
hypertension
Lifestyle
modification
Encourage

Yes

Yes

Yes

Initial drug therapy
Without
compelling
indication

No antihypertensive drug
indicated

Thiazide-type
diuretics for most;
may consider
ACE-I, ARB, BB,
CCB, or
combination
Two-drug
combination for
most (usually
thiazide-type
diuretic and
ACE-I or ARB
or BB or CCB)
With
compelling
indications
Drug(s) for compelling
indications
Drug(s) for compelling indications;
other antihypertensive drugs
(diuretics, ACE-I, ARB, BB, CCB)
as needed
ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII. J AMA 2003;289:2560-2572
Goals of treatment: JNC VII
The SBP and DBP targets are
<140/90 mmHg
The primary focus should be on achieving the
SBP goal
In patients with hypertension and diabetes or
renal disease, the BP goal is <130/80 mmHg
JNC VII. J AMA 2003;289:2560-2572
SBP, systolic blood pressure; DBP, diastolic blood pressure;
BP, blood pressure
Hypertension treatment strategy: JNC VII
Lifestyle modifications
Not at goal blood pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes or chronic kidney disease)
Initial drug choices
Without compelling
indications
With compelling
indications
Stage 1 hypertension
(SBP 140-159 or DBP
90-99 mmHg)
Thiazide-type diuretics
for most. May consider
ACE-I, ARB, BB, CCB
or combination
Stage 2 hypertension
(SBP 160 or DBP 100 mmHg)
Two-drug combination for
most (usually thiazide-type
diuretic and ACE-I or
ARB, or BB, or CCB)
Drug(s) for the
compelling indications

Other antihypertensive
Drugs (diuretics, ACE-I,
ARB, BB, CCB) as needed
Not at blood pressure goal
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
JNC VII. J AMA 2003;289:2560-2572
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
Circumstances in which ACE Inhibitors and ARBs Should Not Be
Used
Do Not Use Use with Caution

ACE Inhibitor Pregnancy(A) Women not practicing contraception (A)
History of angioedema (A) Bilateral renal artery stenosis*
Cough due to ACE inhitors (A) Drugs causing hyperkalemia (A)
Allergy to ACE or ARB (A)


ARB Allergy to ACE inhibitor or ARB (A) Bilateral renal artery stenosis*
Pregnancy (C) Drugs causing hyperkalemia (A)
Cough dua to ARB (C) Women not practicing contraception (C)
Angioedema due to ACE inhibitors (C)

K-DOQI AJKD, 2004

* Including renal artery stenosis in the kidney transplant or in a solitary kidney.
Letters in parentheses denote strength of recommendations.
Diuretik : Hati hati pada :
- gangguan elektrolit
- dislipidemia

Beta bloker hati hati pada :
- Asma bronkhial / spasme bronkhus
- Diabetes melitus