Rasionalisasi Terapi

Hipertensi
Dr. Suryono,SpJP.FIHA
Bagian-SMF Kardiologi & Kedokteran Vaskular
FK UNEJ / RSD dr. Soebandi
JEMBER

Definisi Hipertensi (JNC VII)

Klasifikasi tekanan darah pada seseorang berumur 18 dan lebih

Category

Systolic
(mm Hg)

Diastolic
(mm Hg)

Normal
Pre Hipertensi
Hipertensi
Stage 1
Stage 2

<120
120-139

dan
atau

<80
80-89

140-159
> 160

atau
atau

90-99
>100

Prevalensi dari Hipertensi

Hipertensi salah satu dari penyakit yang sering dijumpai di klinik
prevalence of hypertension (%)

70
60

SBP > 140 mm Hg

DBP > 90 mm Hg

65

70-79

80+

54

50

44

40
30
20

64

21
4

11

18-29

30-39

10
0
age (yrs)

40-49

50-59

60-69

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension Prevalence and

Treatment:
North America and Europe
Prevalence of Hypertension
55
50

US
Canada
Italy
Sweden
England
Spain
Finland
Germany

100
90
80

45
40
%

Patients on Therapy

70

35

% 60
50

30
25

40
30

20
15

20
10

10
5

0
Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.

Country

New Criteria (WHO-ISH 1999) 140 / 90 mmHg

22 % of American adults 18 to 70 years of age have hypertension
20 % of Indonesian adults have hypertension
Hypertensive patients
who are treated
and controlled

Hypertensive patients
who are treated
but uncontrolled

23%
19%

Patients who are aware

but remain untreated
and uncontrolled
Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

16%
42%

Hypertensive patients
who are unaware

Presentasi pasien hipertensi

yang terkontrol
< 140/90 mmHg
USA
27

England
6

Canada
16

France
24

< 160/95 mmHg

Finland

Spain

20.5

20

Germany
22.5

Scotland

Australia
19

India

17.5

> 65 years

USA: JNC VI. Arch Intern Med 1997

Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998

Adapted from G. Mancia / L. Ruilope

Diagnosis of Hypertension
Hypertension is defined as:
- BP 140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit

Caused of Hipertension :
I. Primer / essential / idiopathic
II. Sekunder :
A. Renal
B. Endocrine
C. Coartation of the aorta
D. Pregnancy induced hypertension
E. Neurological disorder
F. Drug and other abused substancen

PATOPHYSIOLOGY
The factors affecting cardiac output:

- sodium intake, renal function, &

mineralocorticoids
- the inotropic effects occur via extracellular
fluid volume augmentation
- an increase in heart rate and contractility
Peripheral vascular resistance is dependent
upon the sympathetic nervous system,
humoral factors, and local autoregulation
(Sharma,
2003)

Neurohormonal control of blood pressure

Blood pressure = Cardiac output (CO) x Peripheral resistance (PR)
Hypertension =

Increased CO

Preload

and/or

Contractility
Fluid volume

Increased PR
Vasoconstriction

Fluid volume

Renal sodium
retention
Excess
sodium
intake

Sympathetic
nervous
system

Reninangiotensinaldosterone
system

Genetic
factors
(Adapted from Kaplan, 1994)

Acute neurohormonal effects on blood

pressure homeostasis
Perfusion

RAA

SNS
Heart rate and cardiac output

Sodium and water retention

Blood pressure

The Renin-Angiotensin System

Alternate Pathway
Local

Circulating
Liver

Renin inhibitors

Angiotensinogen
Renin

Tissue
Non Renin pathways
- t-PA
- Cathepsin G
- Tonin

Angiotensin I
ACE inhibitor

Converting enzyme
Angiotensin II

AII receptor blockers

Angiotensin
receptors

Non-ACE pathways
- Chymase
- CAGE
- Cathepsin G

Effects of Angiotensin II at AT1 and AT2

Receptors

AT1

AT2

Blocked by ARB s
-

Vasoconstriction
Aldosterone release
Oxidative stress
Vasopressin release
SNS activation
Inhibits renin release
Renal Na+ and H2O reabsorption
Cell growth and proliferation

Siragy H. Am J Cardiol. 1999;84:3S8S.

Vasodilation
Antiproliferation
Apoptosis
Antidiuresis/antinatriuresis
Bradykinin production
NO release

Technique of blood pressure measurement

recommended by the British Hypertension Society
1.
Several time, rest 5
minutes before

2.
The patient should be relaxed
and the arm must be
supported. Ensure no tight
clothing constricts the arm

3.
The cuff must be level with
the heart. If the circumference
exceeds 33cm, a large cuff
must be used (2/3 of arm).
Place stethoscope diaphram
over brachial artery

4.
The column of mercury
must be vertical. Inflate
to occlude the pulse
(>30 mmHg). Deflate at
2-3 mm/s. measure
systolic ( first sound /
Korotkoff I ) & diastolic
(disappearence /
Korotkoff IV or V ) to
nearest 2 mmHg

(From British Hypertension Society 1985)

Recommended Technique
for Measuring Blood Pressure

Standardized technique:
Have the patient rest for 5 minutes
Use an appropriate cuff size
Use a mercury manometer or a recently
calibrated electronic device

Recommended Technique
for Measuring Blood Pressure (cont.)
Position cuff appropriately
Increase pressure rapidly
Support arm with antecubital fossa or heart
level
To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
Place stethoscope over the brachial artery

Recommended Technique
for Measuring Blood Pressure (cont.)
Drop pressure by 2 mmHg / beat:
- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
Take 2 blood pressure measurements, 1
minute apart

Pengukuran tekanan darah ambulatory

(ABPM)

Indikasi
1. Adanya variasi tekanan darah yang

besar

2. Office hypertension
3.Dicurigai adanya episode hipotensi
4. Hipertensi
yang
resisten
terhadap
pengobatan

Symptoms

Headache
Dizziness
Fatigue
Pounding of the heart
Symptoms of complications : heart
failure, chest pain, claudication, vision

Riwayat Klinik (Ax):

Lama, tingkat TD
Adanya Penyakit penyerta
Faktor risiko
obat-obatan
Faktor pribadi,psikososial dan
lingkungan.

Pemeriksaan Fisik :

Pemeriksaan fisik & TD yang teliti

TB, BB, & BMI
Sistim kardiovaskuler
Paru
abdomen.
Fundus optikus & sistim syaraf
(mengetahui kerusakan serebro-vaskuler).

Pemeriksaan penunjang
Laboratorium
EKG & Foto polos dada
Ekhokardiografi
Ultrasonografi vaskuler
Ultrasonografi renal Angiografi

Komplikasi Hipertensi
Eyes
retinopathy

Kidneys
renal failure

Brain
stroke

Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure

Peripheral arterial disease

Kerusakan Target Organ!!

Kerusakan yang disebabkan
oleh hipertensi tergantung :

Besarnya peningkatan
tekanan darah

Lamanya kondisi tekanan

darah yang tidak
terdiagnosis dan tidak
diobati

Hypertension :
The Disease Continuum
Early Paradigm

Natural History of CVD Progression

Elevated BP

Target Organ Damage

Elevated BP

Target Organ Damage

More Recent Paradigm

Vascular Dysfunction
A Proposed Future Paradigm

Endothelial
Dysfunction

Vascular
Dysfunction

Elevated BP

Target Organ
Damage

LVH
Renal
Damage

MI

Angina
Pectoris

Stroke

Risiko Infark Miokard dan Stroke

15

5-year risk (%)

10

5
MI

Stroke

0
0

100

200

300

Systolic blood pressure (mm Hg)

Brown, M.J., Lancet 2000;355:653-4

Cumulative Incidence of CHF : Normotensives

and Stage 1 and 2 Hypertensives
20

Stage 2+ hypertension

15
CHF
Cumulative
Incidence 10
(%)

Stage 1+ hypertension

5
Normal BP

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.

Effects of blood pressure on the risk

of cardiovascular disease
Average annual incidence rate per 10.000

100

CHD

90
80
70
60
50

Stroke

40
30

CHF

20
10
0

<100
120
140
180
Systolic blood pressure (mmHg)

>180

Source : Framingham study (after Gorlin)

Total Mortality and Continuous

Ambulatory Blood Pressure
Systolic Blood Pressure
events/100 pt/yrs

Diastolic Blood Pressure

5

5
4

2
1
< 140

mm Hg

mm Hg
140-159 160-179 180-199 200+

< 80

80-89

90-99

100-109

110+

Assessment of the 24-hour blood pressure load is

a good clinical method to identify high-risk patients
Khattar, R.S. et al. Circulation 1999; 100:1071-4

 NON-Farmakologis
Farmakologis

Non Pharmacologic
( lifestyle modification )
Modification

Approximate SBP
reduction (range)

Weight reduction

520 mmHg/10 kg loss

Adopt DASH eating plan

814 mmHg

Dietary sodium reduction

28 mmHg

Physical activity

49 mmHg

Moderation of alcohol
consumption

24 mmHg

 Dahulu : stepped care therapy

Kini

: individualized therapy

Taylored therapy

Therapy of Hypertension
( pharmacologic )
Goal of treatment
Improved endothel function
Decreased systemic vascular resistance
Maintain cardiac output & blood suply to organ
Life long therapy
Bad compliance failed of therapy

Benefits of Lowering BP
Average Percent Reduction
Stroke incidence

3540%

Myocardial infarction

2025%

Heart failure

50%

MORTALITAS / MORBIDITAS TETAP TINGGI

failed of therapy
Tenaga medis
Asuransi
Pemegang kebijakan
Penderita
bad compliance

Minimal BP Goal of Therapy

Recommendations (SBP/DBP mmHg)
Patient Type

JNC VI

Uncomplicated HTN

< 140/90

Hypertension with
diabetes mellitus

< 130/85
< 130/80*
< 130/85

Heart failure
Hypertension with
renal impairment

< 125/75

*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.

Proteinuria > 1 g/24h.

(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive
Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)

Recomendation

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling
Indications

With Compelling
Indications

Stage 1 Hypertension

Stage 2 Hypertension

(SBP 140159 or DBP 9099

mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.

(SBP >160 or DBP >100 mmHg)

2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.

Drug(s) for the compelling

indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.

Compelling Indications for

Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
Heart failure

THIAZ, BB, ACEI, ARB,

ALDO ANT

ACC/AHA Heart Failure

Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES

Postmyocardial
infarction

BB, ACEI, ALDO ANT

ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS

High CAD risk

THIAZ, BB, ACE, CCB

ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE

Compelling Indications for

Individual Drug Classes
Compelling Indication

Initial Therapy Options

Clinical Trial Basis

Diabetes

THIAZ, BB, ACE, ARB,

CCB

NKF-ADA Guideline,
UKPDS, ALLHAT

Chronic kidney disease

ACEI, ARB

NKF Guideline,
Captopril Trial,
RENAAL, IDNT, REIN,
AASK

Recurrent stroke
prevention

THIAZ, ACEI

PROGRESS

Diuretics

-blockers

AT1 receptor
blockers

1-blockers

Calcium
antagonists

ACE inhibitors
Possible combinations of different classes of antihypertensive agents.
The most rational combinations are represented as thick lines. ACE,
angiotensin-converting enzyme; AT1, angiotensin II type 1.

Terapi Kombinasi

Potensiasi
Sinergisme
Saling melengkapi
Mengurangi efek samping
Fix kombinasi ---- mening kepatuhan

THANK YOU
TERIMA KASIH
MATUR NUWUN
SAKALANGKONG
KASOON
Mba Marijan

Pengukuran Tekanan Darah :

Karena adanya variasi yang besar TD, diagnosis hipertensi harus

berdasarkan beberapa kali pengukuran yang diambil pada beberapa
kesempatan (waktu) yang terpisah.
TD biasanya diukur secara tak langsung dengan sphygmo-manometer
air raksa atau alat noninvasif lainnya pada posisi duduk atau telentang.
sebelum pengukuran penderita istirahat 5 menit diruangan yang tenang
ukuran manset lebar 12-13 cm serta panjang 35 cm, ukuran lebih kecil
pada anak-anak dan lebih besar pada penderita gemuk (ukuran sekitar
2/3 lengan)
diperiksa pada fosa kubiti dengan cuff setinggi jantung (ruang antar iga
IV)
TD dapat diukur pada keadaan duduk atau telentang, pada JNC VII
dianjurkan pada posisi duduk

Pengukuran Tekanan Darah :

TD dinaikkan sampai 30 mmHg (4.0 kPa) diatas tekanan sistolik

(palpasi), kemudian diturunkan 2 mmHg/detik (0,3 kPa/detik) dan

dimonitor dgn stetoskop diatas a brakhialis.

tekanan sistolik ialah tekanan pada saat terdengar suara Korotkoff I

sedangkan tekanan diastolik pada saat Korotkoff V menghilang. Bila

suara tetap terdengar, dipakai patokan Korotkoff IV (muffling sound).

pada pengukuran pertama dianjurkan pada kedua lengan terutama

bila terdapat penyakit pembuluh darah perifer.

kadang perlu pengukuran pada posisi duduk/telentang dan berdiri

untuk mengetahui ada tidaknya hipotensi postural terutama pada

orang tua, diabetes mellitus dan keadaan lain yang menimbulkan hal
tersebut (pemberian penyekat alfa).

Risk Stratification and Treatment

(JNC-VI)

Risk Group B
(At Least 1 Risk
Risk Group A
Factor, Not Including
Blood Pressure Stages (No Risk Factors Diabetes; No
(mmHg)
No TOD/CCD)
TOD/CCD)

Risk Group C
(TOD/CCD and/or
Diabetes, With or
Without Other Risk
Factors)

High-normal
(130-139/89-89)

Lifestyle
modification

Drug therapy

Stage 1
(140-159/90-99)

Lifestyle
Lifestyle
modification
modification
(up to 12 months) (up to 6 months)

Drug therapy

Stages 2 and 3
(> 160/> 100)

Drug therapy

Drug therapy

Lifestyle
modification

Drug therapy

For example, a patient with diabetes and a blood pressure of 142/94 mmHg plus left ventricular
hypertrophy should be classified as having stage 1 hypertension with target organ disease (left
ventricular hypertrophy) and with another major risk factor (diabetes). This patient would be categorized
as Stage 1, Risk Group C, and recommended for immediate initiation of pharmacologic treatment.