MANAGEMENT OF HYPERTENSION

IN PRIMARY CARE
Ria Bandiara

OBJECTIVES
To promote the primary prevention of hypertension
through the adoption and maintenance of healthy
lifestyles
To promotes early and accurate diagnosis of hypertension
To improve the quality of care of person with hypertension
To promotes the referral of person with hypertension

Global Mortality 2000:

Impact of Hypertension
High blood pressure
Tobacco
High cholesterol

High mortality,
developing region

Underweight

Lower mortality,
developing region

Unsafe sex
High BMI

Developed region

Physical inactivity
Alcohol
0

1000 2000 3000 4000 5000 6000 7000 8000

Attributable Mortality (in thousands; total 55,861,000)

BMI = body mass index.
Adapted with permission from Ezzati M, et al. Lancet. 2002;360:1347-1360.

Klasifikasi tekanan darah menurut

ASH/ISH 2013, JNC VII
(Chobanian,2003) & 2014
Hypertension Guideline (report
JNC 8)
Kategori

Tekanan Darah
Sistolik

Tekanan Darah
Diastolik

Normal

<120 mmHg

<80 mmHg

Pre-hipertensi

120-139 mmHg

80-89 mmHg

Stage 1

140-159 mmHg

90-99 mmHg

Stage 2

>160 mmHg

>100 mmHg

ESH/ESC 2013
Same with 2003, 2007
HT : BP 140/90

HYPERTENSION
Chronic medical condition in which blood pressure is elevated
Systemic, arterial hypertension
Essential (primary) hypertension
Secondary hypertension

PRIMARY HYPERTENSION

SECONDARY HYPERTENSION
High blood pressure is a result of another condition
Adrenal cortical abnormalities :

Cushings syndrome ( adrenal glands overproduce the hormone cortisol)

More than 85 % of patients with Cushings syndrome have hypertension
Primary aldosteronism ( overproduction of aldosterone by adrenal glands)
Aldosteronism causes sodium and water retention, potassium excretion in the
kidneys - arterial hypertension

Diseases of the kidney (polycystic kidney disease genetic disorder

of the kidneys)
Diseases of the renal arteries supplying the kidney
RENOVASCULAR HYPERTENSION
Neuroendocrine tumors (pheochromocytoma)
Medication side effects (NSAID)

Risk Factors for Hypertension

Known modifiable risk factors for hypertension are:
Obesity
Excessive intake of salt and calories
Inadequate physical activity
Uncontrolled hyperglycemic states
High alcohol consumption
Tobacco use
Low potassium intake
Sleep apnea
Psychosocial stress is often implicated but difficult to measure
Non-modifiable factors include:
Age
Race
Family history of hypertension or diabetes

REGULATION OF BLOOD PRESSURE

Baroreceptor reflex changes in arterial pressure medulla (brain

stem)

Renin angiotensin system (RAS)

Location : left and right carotid sinuses, aortic arch

Long term adjustment of arterial pressure

Kidney - compensation
Endogenous vasoconstrictor angiotensin I

Aldosterone release (adrenal cortex)

Stimulates sodium retention and potassium excretion by the kidney

Increases fluid retention and indirectly arterial pressure

SPHYGMOMANOMETER
Uses the height of a column of mercury to reflect the

circulating pressure
Blood pressure values millimeters of mercury (mm/Hg)
Aneroid and electronic devices do not use mercury

SIGNS AND SYMPTOMS

No symptoms many people unaware they have hypertension,

accidentally found; complications:

Nonspecific symptoms mild symptoms
Headache
Morning headache
Tinnitus ringing in ears
Dizziness
Confusion
Fatigue
Shortness of breath

Anxiety

Changes in vision - blindness

Nose bleeds

Nausea

Heart palpitations
Flushed skin
Pale skin
Chest pain

Consequences of Hypertension:
Organ Damage

Hypertension
Transient ischemic
attack, stroke

Retinopathy

LVH, CHD, CHF

Peripheral
arterial
disease

Chronic kidney disease

CHF=congestive heart failure; CHD=coronary heart disease; LVH=left ventricular hypertrophy.

Chobanian AV et al. JAMA. 2003;289:2560-2572.

SCREENING FOR HIGH BLOOD PRESSURE

Screening for hypertension should be a routine part of every
health care encounter for adults.
Blood pressure monitoring should be carried out regularly in
those at risk for hypertension.
This includes persons with a family history of hypertension,
stroke, heart disease or diabetes.

Patient Evaluation
1. Two consecutive blood pressure measurements
2. Assess lifestyle and identify other CV risk factors or

concomitant disorders that affects prognosis and guides

treatment
3. Reveal identifiable causes of high BP
4. Assess the presence or absence of target organ damage

and CVD

Risk factors influencing

outcome
CVD risk factors
Increased

SBP and

DBP

Left

Advanced

age (>55
years for men, >65
years for women)

Smoking
Dyslipidaemia
Family

history of
premature CVD

Abdominal

Target organ
damage

obesity

ventricular
hypertrophy

Ultrasound

evidence of
arterial wall
thickening or a
plaque
Slight

increase in
serum creatinine

Microalbuminuria

Increased

C-reactive
protein level

CVD, cardiovascular disease; DBP, diastolic blood pressure; MI, myocardial

infarction; SBP, systolic blood pressure; TIA, transient ischaemic attack.

Clinical disease

Cerebrovascular

disease:
ischaemic stroke,
cerebral
haemorrhage, TIA
Heart

disease:
MI, angina, coronary
revascularisation, CHF

Renal

disease:
diabetic nephropathy,
renal impairment

Peripheral

vascular

disease
Advanced

retinopathy:
haemorrhages or
exudates,

Stratification of Total CV Risk

18

European Heart Journal doi:10.1093/eurheartj/eht

Laboratory Investigations

19

ESTABLISHING THE DIAGNOSIS AND

RECOMMENDATIONS FOR FOLLOW-UP
I.

Patients with pre-hypertension but without diabetes, chronic renal failure

or cardiovascular disease are treated with non-pharmacologic therapies such
as weight reduction, sodium restriction and avoidance of excess alcohol.
They should also have their blood pressure measured every six months
since they are of significant risk of developing hypertension overtime.

II. If persons with Stage 1 levels have no evidence of end organ damage,
repeated BP measurements over three months are necessary.
III. If persons with Stage 2 levels have no evidence of end-organ damage, BP
measurements should be repeated on at least one other occasion within
one month.
IV. Persons with Stage 3 levels with no evidence of end-organ damage
should have their blood pressure measured within one week. In some
cases therapy should be started, if the risk level assessment so warrants.
Higher levels e.g. >210/120, if associated with complications may constitute
a Hypertensive Emergency

ESTABLISHING THE DIAGNOSIS AND

RECOMMENDATIONS FOR FOLLOW-UP
V. Labile hypertensives will show fluctuation of BP from normal to Stage or
higher hypertensive ranges and such patients should be monitored
regularly. Persistence of diastolic readings above 90 mm Hg will usually
indicate established hypertension.
VI. The diagnosis of hypertension can be established on the basis of a single
diastolic pressure > 100 mm Hg, if there is evidence of target organ
damage. The patient should be classified as hypertensive with specific target
organ disease, risk level assessed and treatment begun.
VII. Isolated systolic hypertension is diagnosed when there is an average of
four readings 140 mm Hg on two occasions with a diastolic BP < 90mm Hg
(JNC 7 criteria). Isolated systolic hypertension should be carefully reevaluated at intervals.
VIII.White-coat hypertension may occur in patients whose BP is raised only in
the clinic but not at other times. A white-coat effect may further raise BP in a
patient with hypertension.

Managing
Hypertension

Managing Hypertension
Dietary factors
Dietary modifications are mainstay for prevention and
initial treatment of hypertension.
In hypertensive patients, in addition to a well-balanced
diet, the dietary sodium intake
Reduced salt intake
BP reduction was the highest in the group with the lowest
sodium levels.
Reduce the intake of salt and sodium in the diet to
approximately 2400 mg/day
Maintain a healthy weight, lose weight if overweight.
Be more physically active

When to start Anti-HT Rx

BP 140/90 after lifestyle change

BP 160/100: start drug promptly
Elderly: SPB 160 mmHg
Not recommend anti-HT drug for
High normal BP (130-139 / 85-89 mmHg)
ISH in young patient, but should close
F/U with lifestyle change
2007
Elderly: start drug if BP 140/90
DM, CKD, CVD: start drug if BP > 130 /
85

BP target
SBP < 140 mmHg
DM (I,B) Low-moderate CV risk (I,A)
Previous stroke/TIA, CHD, CKD (II A)

Elderly < 80 yr: SPB keep 140-150 mmHg

(I, A)
Elderly > 80 yr: 140-150 mmHg if good
physical and mental condition (I, B)
DBP < 90 mmHg for all
Except DM: DBP < 85 mmHg

ESH/ESC 2013

Initiation age
of lifestyle
changes
drug treatment.
Risk Fx: male,
55
(M)and
antihypertensive
65 (F), smoking,
dyslipidemia,
IFG, abnormal OGTT, obesity, abdominal obesity, FHx
premature CVD < 55 yr (M), < 65 yr (F)

DM: high to very high risk

CHOICE OF
ANTIHYPERTENSIVE DRUGS
The main benefits of antihypertensive treatment are due
to lowering of BP per se and are largely independent of
the drugs employed
Most patients need 2 drugs to achieve target BP.

diuretics (including thiazides, chlorthalidone and

indapamide), beta-blockers, calcium antagonists,
angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers are all suitable for the
initiation and maintenance of antihypertensive
treatment, either as monotherapy or in some
combinations

Some drugs should be preferred in specific conditions

Markedly high baseline BP or high CV risk: start two-drug

combination may be considered

Possible combinations of classes of antihypertensive drugs

ESC/ESH 2013

Only DHP-CCB
should normally be
combined
with beta-blockers

Report JNC 8

JAMA. doi:10.1001/jama.2013.284427

Recommendation 9
The main objective of hypertension treatment is to attain

and maintain goal BP.

If goal BP is not reached within a month of treatment:
increase the dose of the initial drug OR
Add a second drug from one of the classes in recommendation 6
(thiazide-type diuretic, CCB, ACEI, or ARB).
The clinician should continue to assess BP and adjust the

treatment regimen until goal BP is reached.

Report JNC

Recommendation 9
If goal BP cannot be reached with 2 drugs:
Add and titrate a third drug from the list provided.
Do not use an ACEI and an ARB together in the same

patient.
If goal BP cannot be reached using the drugs in

recommendation 6 because of a contraindication or the

need to use more than 3 drugs to reach goal BP:
antihypertensive drugs from other classes can be used.

Report JNC

Recommendation 9
For patients in whom goal BP cannot be attained

using the above strategy OR

The management of complicated patients for

whom additional clinical consultation is needed.

Referral to a hypertension specialist may be

indicated

GUIDELINES FOR REFERRAL

Indication for referral to a higher level of care included
Clinical suspicious of secondary hypertension
All complicated hypertensions
Patient with severe retinopathy
Failure to respond to treatment ( Resistant hypertension) or
need combination treatment
Raised serum creatinin
Haematuria, proteinuria or cell in urine
Suspicion of white coat hypertension

DETECTION

Rujuk

DIAGNOSIS

Penunjang :
Rujuk Balik Pemerikssaan
Anamnesa/PD
Urin : microalb, eri,gula
Darah: Kreatinin,glukosa
EKG & Foto Toraks
TERAPI
Max 2 obat

TARGET
ORGAN

TIDAK ADA
ADA
terkont
rol

CV RISKS
HIPERTENSI
KRISIS
Terapi awal
Tidak
terkontrol

Tidak
terkontrol
> 3 bulan

RE-EVALUASI
TERAPI
Pemerikssaan Penunjang :

RENAL
DENERVASI
RENAL
ANGIOGRAFI
(stenting)

Tidak
terkontrol
3 bulan
3 obat
RE-EVALUASI
TERAPI

HIPERTENSI
SEKUNDER

ADA
Tidak
terkontrol

P
P
K
1

P
P
K
2
P
P
K
3

CLINICAL PATHWAY HIPERTENSI

PPK I

Jenis Aktivitas
Tindakan
Assessment
Penilaian Awal

Status Medical Record lengkap

Tanda vital
Anamnesis dan pemeriksaan fisik
lengkap
Identifikasi :

Etiologi
Hipertensi esensial
Hipertensi sekunder
Faktor risiko lain :
Diabetes melitus
Hiperlipidemia
Merokok
Hiperuricaemia
Kerusakan target organ
Stroke
Retinopati
LVH, PJK
Penyakit Ginjal Kronik

CLINICAL PATHWAY HIPERTENSI

Jenis Aktivitas

PPK I

Tindakan

Investigations
Pemeriksaan

o Urinalisis : proteinuria,
hematuria, glukosuria
o Kimia Darah : kreatinin,
gula darah
o Rontgen thorax
o EKG

CLINICAL PATHWAY HIPERTENSI

Jenis Aktivitas

PPK I

Tindakan

Treatment
Medications

Modifikasi gaya hidup :

oDiet : DASH diet
oAktivitas fisik
Farmakoterapi
oMonoterapi atau terapi kombinasi
Golongan obat :
oACE Inhibitor atau ARB
oCalcium antagonist
oBeta blocker
oDiuretik

CLINICAL PATHWAY HIPERTENSI

Jenis Aktivitas

PPK I

Tindakan

Diet

kebutuhan kalori 30-35

kkal/kgBB/hari; protein
1,0 g/kg/hari
Rendah garam, tinggi
serat

Penyuluhan

o Edukasi
Konsep terapi hipertensi:
modifikasi gaya hidup dan
farmakoterapi
Kerusakan target organ
dan konsekuensinya

CLINICAL PATHWAY HIPERTENSI

Jenis Aktivitas

PPK I

Tindakan

Rujuk / konsultasi

Rujuk ke PPK 2 bila didapatkan

Faktor Risiko kardiovaskular lain
yang tidak terkontrol
Adanya kerusakan target organ
Hipertensi sekunder
Hipertensi krisis

Outcome
Rencana Perawatan

Tekanan darah tidak terkontrol

dengan 2 macam obat maksimal
selama 3 bulan
Hipertensi terkontrol
Pencegahan kerusakan target organ

Rawat jalan