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PHARMACOLOGICAL

INTERVENTION
IN MANAGEMENT OF
HYPERTENSION

Yenny Kandarini

Div of Nephrology Dept of Medicine Faculty of


Medicine
Udayana University Sanglah Hospital Denpasar

Hypertension-We try hard but


it does not get much better

NHANES, JNC 7, 2003

INITIATING PHARMACOLOGICAL
MANAGEMENT OF HYPERTENSION
When to start

Whats the medicine


Mono therapy

Combination drugs

Whats the goal

WHEN TO START ?!
Is it definite hypertension

What
have to
evaluate

Stage of hypertension

Risk factors /
target organ
damage

LSE OR DEFINITE HYPERTENSION


BP in first
measurement
S > 140 / D > 90
Remeasured 3 X in 4
weeks
BP
decrease
False
If initially BP >
180 / 110
symptomatic
target organ
damage

BP consistent
Definite
Drug
treatment
should be
initiated

Kaplan,
2014

Classification of BP in US and European Adults:


JNC VII and ESHESC 2013 Guidelines

JNC VII
BP category

Normal

Systol
ic
(mmH
g)

ESHESC, 2013

<120

&

Diastol
BP
Systol
ic
catego
ic
(mmH
ry
(mmH
g)

g)
<80

Hypertension
Stage 1
Hypertension
Stage 2

120
139

or

Diastol
ic
(mmHg
)

Normal

120
129

&

8084

High
normal

130
139

or

8589

or

9099

140
159

Grade 2
(moderate
)

160
179

or

100
109

Prehypertensi
on

8089

140
159

or

>160

or

Grade 1
(mild)

9099

>100

Grade
3
Chobanian
et al. JAMA 2003;289:256072
Journal
(severe)
>1802013,or31:12811357
>110
of Hypertension

Risk factors & Target organ damage


Major risk
factors
Smoking
Diabetes
Dyslipidemia
Family
history
Obese

Target organ
damage
Heart diseases
Kidney diseases
Stroke
Retinopathy
Peripheral
Arterial Disease

WHEN?

When Do We Initiate DrugTreatment?


Most would agree that we use lifestyle changesfirst unless
blood pressure ismore than 20mmHgover target
JNC7; 140/90(130/85for DM/CKD)
HOT trial; no difference between 80/90DBP (except maybe
some CVDreduction in DM2)
AASK trial; no difference between 125/75and 140/90
(except maybe if proteinuria >300)
ACCORDtrial; no difference for SBP <135
ABCDtrial; no benefit for intensive SBP lowering(132v.
138achieved)
SHEP, SYS EURO, HOT, UKPDStrialsshowed 30 69%risk
reduction byreducing SBP to about 140

Initiation of lifestyle changes and


Other risk antihypertensive
Blooddrug
Pressure
(mmHg)
treatment

factors,
asymptomatic
organ damage
or disease

High normal
SBP 130139
or DBP 8589

Grade 1 HT
SBP 140159
or DBP 9099

Grade 2 HT
SBP 160179
or DBP 100
109

Grade 3 HT
SBP 180
or DBP 110

No other RF

No BP
intervention

Lifestyle
changes for
several
months
Then add BP
drugs
targeting
<140/90

Lifestyle
changes for
several weeks
Then add BP
drugs
targeting
<140/90

Lifestyle
changes
Immediate BP
drugs
targeting
<140/90

12 RF

Lifestyle
changes
No BP
intervention

Lifestyle
changes for
several weeks
Then add BP
drugs
targeting
<140/90

Lifestyle
changes for
several weeks
Then add BP
drugs
targeting
<140/90

Lifestyle
changes
Immediate BP
drugs
targeting
<140/90

3 RF

Lifestyle
changes
No BP
intervention

Lifestyle
Lifestyle
Lifestyle
changes for
changes
changes
several weeks
BP drugs
Immediate BP
Then add BP
targeting
drugs
drugs
<140/90
targeting
targeting
<140/90
<140/90
2013 ESH/ESC
Guidelines for the management of arterial hypertension

II. Indications for Pharmacotherapy

Usual blood pressure threshold values for initiation of


pharmacological treatment

Population
Diabetes
High risk (TOD or CV risk
factors)
Low risk (no TOD or CV risk
factors)
Very elderly
TOD=target organ damage

SBP
130
140

DBP
80
90

160

100

160

NA

*This higher treatment target for the very elderly reflects current evidence and
heightened concerns of precipitating adverse effects, particularly in frail patients.
Decisions regarding initiating and intensifying pharmacotherapy in the very elderly
should be based upon an individualized risk-benefit analysis.
CHEP, 2014

Thresholds for Initiation of Drug Therapy in


Current
Guidelines
JNC 8
ASH/IS
ACC/AHA/C ESH/ES
CHEP
UK NICE
ISHIB
Level
of Risk

(James
et al,
2014)

H
(Weber
et al,
2014)

DC
(Go et al.,
2014)

C
(Mancia
et al.,
2014)

(Hackam
et al.,
2013)

(Krause
et al.,
2011)

(Flack
et al.,
2010)

Elderly

150/90
(60+ y)

150/90
(80 + y)

140/90

160
systolic
(80 + y)

150/90
(80 + y)

150/90
(80 + y)

Not
specified

General
no risk
factors of
organ
damage

140/90

140/90

140/90

150/90

160/100

140/90

135/85

General,
+ risk
factors of
organ
damage

140/90

140/90

140/90

140/90

140/90

140/90

130/80

Diabetes

140/90

140/90

140/90

130/80 140/90
Kaplan
Clinical Hypertension,
2014
140/90
130/80

CKD

140/90

140/90

140/90

140/90

140/90

140/90

130/80

Which drug

HOW ?!

Single drug /
combination

Present of compelling
indication

Which
Drugs?!

Diuretic
ACE Inhibitor
CCB
Angiotensin Receptor Blocker (ARB)
Beta Blocker

Johnson RJ, Feehally J, Floege J. 2015.


Comprehensive Clinical Nephrology. 5 th edition.

Clinical indications favoring the use of specific classes


of BP-lowering medications in hypertensive patients.
ACE Inhibitors

Heart failure
LV dysfunction
Postmyocardial infarction
Diabetic nephropathy
Nondiabetic nephropathy
LV hypertrophy
Carotid atherosclerosis
Proteinuria/microalbuminuria
Atrial fibrillation
Metabolic syndrome

Angiotensin Receptor Blockers

Heart failure
Postmyocardial infarction
Diabetic nephropathy
Proteinuria/microalbuminuria
LV hypertrophy
Atrial fibrillation
Metabolic syndrome
ACE inhibitorinduced cough

-Blockers

Angina pectoris
Postmyocardial infarction
Heart failure
Tachyarrhythmias
Glaucoma
Pregnancy

ACE, Angiotensin-converting enzyme; LV, left ventricular.

Calcium Antagonists (Verapamil,


Diltiazem)
Angina pectoris
Carotid atherosclerosis
Supraventricular tachycardia

Calcium Antagonists
(Dihydropyridines)

Isolated systolic hypertension (elderly)


Angina pectoris
LV hypertrophy
Carotid/coronary atherosclerosis
Pregnancy
Hypertension in blacks

Thiazide Diuretics
Isolated systolic hypertension (elderly)
Heart failure
Hypertension (blacks)

Diuretics (Antialdosterone)
Heart failure
Postmyocardial infarction

Loop Diuretics
End-stage renal disease
Heart failure
Johnson RJ, Feehally J, Floege J. 2015.
Comprehensive Clinical Nephrology. 5 th edition.

Compelling and possible contraindications


to specific classes of BP-lowering therapies.
Contraindications
Compelling
Possible

Pharmacologic
Therapy
Thiazide diuretics

-Blockers

Gout

1.Asthma
2.A-V block (grade 2 or
3)

Calcium antagonists
(dihydropyridines)

1.Metabolic syndrome
2.Glucose intolerance
3.Pregnancy
1.Peripheral artery disease
2.Metabolic syndrome
3.Glucose intolerance
4.Athletes, physically active patients
5.COPD
6.Asthma (use cardioselective blocker)
1.Tachyarrhythmias
2.Heart failure

Calcium antagonists 1.A-V block (grade 2 or


(verapamil,
3)
diltiazem)
2.Heart failure
3.-blocker therapy
Johnson RJ, Feehally J, Floege J. 2015.
Comprehensive Clinical Nephrology. 5 th edition.

Compelling and possible contraindications


to specific classes of BP-lowering therapies.
Pharmacologic
Therapy
Angiotensinconverting enzyme
inhibitors

Contraindications
Compelling
Possible
1.Pregnancy
2.Angioneurotic edema
3.Hyperkalemia
4.Bilateral renal artery
stenosis

1.Pregnancy
Angiotensin receptor 2.Hyperkalemia
blockers
3.Bilateral renal artery
stenosis
Diuretics
(antialdosterone)

1.CKD stages 4 and 5


2.Hyperkalemia

Direct renin
inhibitors

1.Pregnancy
2.Hyperkalemia
3.Bilateral renal artery
stenosis
Johnson RJ, Feehally J, Floege J. 2015.
Comprehensive Clinical Nephrology. 5 th edition.

Antihypertensive drugs
Class

Mechanisms

Diuretics

Reducing renal sodium


absorption

Thiazide diuretics

Inhibiting sodium and


chloride cotransporter in
the renal distal
convoluted tubule; more
effective in BP control
than loop diuretics

Loop diuretics

Side Effects

Compelling
Indications
for
Comorbiditi
es
Heart failure,
high CAD risk,
diabetes, stroke

Hypokalemia,
hyponatremia,
hypomagnesemia,
hyperuricemia,
photosensitivity, and
metabolic effects
including dyslipidemia
and impaired glucose
tolerance
Inhibiting sodium,
Hypokalemia, but
potassium, and chloride fewer other metabolic
cotransporter in the
side effects
thick ascending limb of
the loop of Henle National Kidney Foundations Primer On Kidney

Antihypertensive drugs (cont)


Class

Renin-Angiotensin
System Blockers

Mechanisms

Side Effects

Compelling
Indications
for
Comorbiditi
es

Dampening arterial
Heart failure,
wave reflections,
post-MI, high
increasing aortic
CAD risk,
distensibility, and
diabetes, CKD,
venodilation
stroke
Angiotensin converting Blocking the conversion Cough, hyperkalemia,
enzyme (ACE) inhibitors of angiotensin I to
elevated creatinine,
angiotensin II
angioedema, and fetal
toxicity
Angiotensin II receptor
Blocking binding of
Similar to ACE
type I blockers (ARB)
angiotensin II to the
inhibitors, except no
type 1 angiotensin
cough
receptor
Direct renin inhibitors
Blocking the conversion
Similar
toFoundations
ARB;
National
Kidney
Primer On Kidney
of angiotensinogen to
diarrhea at high doses Diseases, 2014
angiotensin I

Antihypertensive drugs (cont)


Class

Calcium Channel
Blockers
Dihydropyridine
Diltiazem
Verapamil
Beta Blockers

Nonselective beta
blockers
Selective beta blockers
Combined alpha and

Mechanisms

Inhibiting the L-type


voltage-gated plasma
membrane channel
Vasodilation
Vasodilation and AV
nodal blockade
Vasodilation and AV
nodal blockade
Inhibiting adrenergic
receptors

Side Effects

Compelling
Indications
for
Comorbiditi
es
High CAD risk,
diabetes

Dependent edema,
gingival hyperplasia
Bradycardia
Bradycardia,
constipation
Reduced exercise
tolerance, depression,
and bronchospasm

Heart failure,
post-MI, high
CAD risk,
diabetes, stroke

Inhibiting both beta 1


More bronchospasm
and 2 receptors
Blocking beta 1
Less bronchospasm
receptors
National Kidney Foundations Primer On Kidney
Blocking both beta and

Antihypertensive drugs (cont)


Class

Aldosterone
Blocker
Spironolactone

Mechanisms

Side Effects

Blocking aldosterone
receptor

Eplerenone

Direct Vasodilators Smooth muscle


relaxant
Alpha-1 Blockers
Vasodilatation

Compelling
Indications
for
Comorbiditi
es
Heart failure,
post-MI

Androgen blocking
effect, including
irregular menses,
gynecomastia, and
impotence
Less potent, but
fewer side effects
related to androgen
blocking
Peripheral edema
Postural

National
Kidney Foundations Primer On Kidney
hypotension

Doses of Antihypertension Based on EvidenceAntihypertensive


Initial Daily
Target Dose in No, of Doses per
Based
Medication

ACE inhibitors
Captopril
Enalapril
Lisinopril
Angiotensin receptor
clockers
Eprosartan
Candesartan
Losartan
Valsartan
Irbesartan
-Blockers
Atenolol
Metoprolol
Calcium
channel
blockers
Alodipine
Diltiazem extended
release
Nitrendipine
Thiazide-type
diuretics

Dose, mg

Say

50
5
10

RCTs Reviewed,
mg

150-200
20
40

400
4
50
40-80
75

25-50
50

600-800
12-32
100
160-320
300

100
100-200

1-2
1
1-2
1
1

1
1-2

2-5
120-180

10
360

1
1

10

20

1-2

10

2
1-2
1

Bendroflumethiazide
Johnson
RJ, Feehally J, Floege J. 2015. Comprehensive
Clinical
Nephrology. 5 th edition. Elseiver
Saunders;
Chlorthalidone
12.5
12.5-25
1

Single drug
or combination ?!

Multiple Antihypertensive Agents Are Often


Needed to Achieve Target BP
Trial

Target BP
(mmHg)

UKPDS1

DBP 85

ABCD2

DBP 75

MDRD3

MAP 92

HOT4

DBP 80

AASK5

MAP 92

IDNT6

SBP 135/DBP 85

ALLHAT7

SBP 140/DBP 90

DBP-diastolic blood pressure


MAP-mean arterial pressure
SBP-systolic blood prressure

No. of Antihypertensive Agents


1

1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703713


2. Estacio RO, et al. Am J Cardiol. 1998;82:9R14R
3. Lazarus JM, et al. Hypertension. 1997;29:641650
4. Hansson L, et al. Lancet. 1998;351:17551762
5. Kusek JW, et al. Control Clin Trials. 1996;16:40S46S
6. Lewis EJ, et al. N Engl J Med. 2001;345:851860
7. ALLHAT. JAMA. 2002;288:29983007

Also Guidelines Worldwide Acknowledge That Most


Patients Need Combination Therapy to Achieve BP
Goals
JNC VII

ESH/ESC

Many patients will require more than one drug to


achieve adequate BP control
Pathophysiological reasoning suggests that adding an
ACE-I/ARB to a CCB or a diuretic (or vice versa in the
younger group) are logical combinations

NICE
JSH

Most patients with hypertension will require two or


more antihypertensive medications to achieve their
BP goals
When BP is > 20/10 mmHg above goal, consideration
should be given to initiating therapy with two drugs
Combination treatment should be considered as first
choice when there is high CV risk
i.e., in individuals in whom BP is markedly above the
hypertension threshold (> 20/10 mmHg), or associated
with multiple risk factors sub-clinical organ damage,
diabetes, renal or CV disease

The Japanese Society of


Hypertension Committee
for Guidelines for the
Management of
Hypertension
2009

The use of two or three drugs in combination is often


necessary to achieve the target BP control
A low dose of a diuretic should be included in this
combination

Chobanian et al. JAMA. 2003;289:25602572; Mancia et al. Eur Heart J. 2007;28:14621536; http://www.nice.org.uk/
27
download.aspx?o=CG034fullguideline (accessed January 2010); Ogihara et al. Hypertens Res. 2009;32:3107.

ESH-ESC Use of Monotherapy or Combination Therapy


Guidelines 2013

ESH-ESC Use of Monotherapy or


Combination Therapy Guidelines 2013

Which combination ?!

ESH/ESC 2013 Guideline recommendation


for combining drugs to lower Blood Pressure
Thiazide
diuretics
Angiotensin
receptor
blockers

blockers

Other
antihyperten
sives

Calcium
antagonist

ACE

Preferred combinations
inhibitors
Useful combinations with limitation
Possible but less well tested
Not recommended

ESH/ESC,2013

Single pill combination-based treatment:

Leads to improved adherence (and


decreased medical resource utilization)
Taylor AA, Shoheiber O. Congest Heart Fail. 2003;9:324-

32

Leads to better blood pressure control


rates RD, et al. Hypertension.
Feldman
2009;53;646-653

Leads to reduced hypertension-related


CV complication rates
Corrao G, et al. Hypertension. 2011;58:566-72

CHEP, 2014

WHAT S THE GOAL OF TREATMENT

How Low Should We Go?


JNC7; 140/90(130/85for DM/CKD)
HOT trial; no difference between 80/90DBP (except
maybe some CVDreduction in DM2)
AASKtrial; no difference between 125/75and 140/90
(except maybe if proteinuria>300)
ACCORDtrial; no difference for SBP <135
ABCDtrial; no benefit for intensive SBP lowering(132v.
138achieved)
SHEP, SYS EURO, HOT, UKPDStrials showed 30 69%risk
reduction byreducing SBP to about 140

Recommended Treatment Targets

Treatment consists of health behaviour pharmacological


management

Population
SBP
DBP
Diabetes
<130
<80
All others < 80 y.a.
<140
<90
(including CKD)
Very elderly ( 80
<150*
NA
*This
higher treatment target for the very elderly reflects current
years)

evidence and
heightened concerns of precipitating adverse effects, particularly in frail
patients. Decisions regarding initiating and intensifying
pharmacotherapy in the very elderly should be based upon an
individualized risk-benefit analysis.
CHEP, 2014

Guideline Comparisons of Goal BP


and Initial Drug Therapy for Adults With
Hypertension

JAMA, 2014, 311(5).507-520

GUIDELINE

Peningkatan TD ringan
Risiko KV rendah
/menengah

Pilihan di
antara

Obat tunggal

Penggantian
obat lain

Obat
sebelumnya
pada dosis
penuh

Dosis penuh
monoterapi

Kombinasi 2
obat pada
dosis penuh

Peningkatan TD dgn
jelas
Risiko KV tinggi/sangat
tinggi

Kombinasi 2
obat
Kombinasi
sebelumnya
pada dosis
penuh
Penggantian
menjadi
kombinasi 2
obat berbeda

Menambah
obat ketiga

Kombinasi 3
obat pd dosis
penuh

Monoterapi vs Terapi Kombinasi sebagai


Strategi untuk Mencapai Tekanan Darah

Konsensus Penatalaksanaan Hipertensi 2014, InaSH

Updated UK NICE Algorihtm for the treatment of


Essential hypertension
<55 years
Step 1

ACEI (or ARB*)

55 years or
black at any
age
CCB or
thiazide-type
diuretic

Step 2

ACEI (or ARB*) + CCB or


ACEI (or ARB*) + thiazide diuretic

Step 3

ACEI (or ARB*) + CCB + diuretic

Step 4

Add further diuretic therapy, -blocker, or blocker.


Consider seeking specialist advice

*If ACE inhibitor (ACEI) not tolerated

http://www.nice.org.uk/download.aspx?o=CG034fullguideline
Accessed June 2006

Adult aged 18 y with HT


Implemented lifestyle intervention (continue
throughout management)
Set blood pressure goal and initiate blood pressure lowering-medication based
on age, diabetes, and chronic kidney disease (CKD
General population (no diabetes or
CKD)

Diabetes or CKD
present

Age 60 years

Age< 60 years

All ages
Diabetes present
No CKD

All ages
CKD present with or
without diabetes

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Nonblac
k
Initiate thiazide-type
diuretic or ACEI or ARB or
CCB, alone or in
combination

Black
Initiate thiazide-type
diuretic or CCB, alone or in
combination

All races
Initiate ACEI or ARB, alone
or in combination with
other drug class

Select a drug treatment titration strategy


A. Maximize first medication before adding second or
B. Add second medication before reaching maximum dose or first medication
C. Start with 2 medication classes separately or as fixed-dose combination

Algoritme Manajemen Hipertensi

Adult aged 18 y with HT


Implemented lifestyle intervention (continue
throughout management)
Set blood pressure goal and initiate blood pressure lowering-medication based
on age, diabetes, and chronic kidney disease (CKD
General population (no diabetes or
CKD)

Diabetes or CKD
present

Age 60 years

Age< 60 years

All ages
Diabetes present
No CKD

All ages
CKD present with or
without diabetes

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Blood pressure goal


SBP < 150 mmHg
DBP < 90 mmHg

Nonblac
k
Initiate thiazide-type
diuretic or ACEI or ARB or
CCB, alone or in
combination

Black
All races
Initiate thiazide-type
diuretic or CCB, alone or in
combination

Initiate ACEI or ARB, alone


or in combination with
other drug class

Select a drug treatment titration strategy


A. Maximize first medication before adding second or
B. Add second medication before reaching maximum dose or first medication
C. Start with 2 medication classes separately or as fixed-dose combination
JAMA, 2014, 311(5).507-520
The US JNC 8 Committee Treatment

At goal BP?

Yes

No
Reinforce medication and lifestyle adherence
For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use
medication class not previously selected and avoid combined use of ACEI and ARB).
For strategy C, titrate doses of initial medications maximum

At goal BP?

Yes

No
Reinforce medication and lifestyle adherence
Add and titrate thizide-type diuretic or ACEI or ARB or CCB (use medication class not
previously selected and avoid combined use of ACEI and ARB

At goal BP?

Yes

No
Reinforce medication and lifestyle adherence
Add additional medication class (eg, -blocker, aldosterone antagonist, or others)
And/or refer to physician with expertise in hypertension management

No

At goal BP?

Yes

JNC 8 (cont)

Continue current
treatment and monitoring

Strategies to Dose Antihypertensive Drugs

A. Start one drug, titrate to maximum dose,


and then add a second drug
B. Start one drug and then add a second
drug before achieving maximum dose of
the initial drug
C. Begin with 2 drugs at the same time,
either as 2 separate pills or as a single pill
combination
starting therapy with 2 drugs when SBP is >160
mm Hg and/or DBP is >100 mm Hg, or if SBP is
>20 mm Hg above goal and/or DBP is >10 mm Hg
above goal.
If goal BP is not achieved with 2 drugs, select a
third drug from the list (thiazide-type diuretic,
CCB, ACEI, or ARB), avoiding the combined use of
ACEI and ARB. Titrate the third drug up to the

Guidelines to Improve Maintenance of


Antihypertensive Therapy
Keep care inexpensive and simple
Do the least workup as needed
Obtain follow-up laboratory data only yearly unless indicated more
often
Use home BP readings
Use once-daily doses of long acting drugs
Use generic drugs and break larger doses of scored tablets in half
If appropriate, use combination tablets
Inspect all pill containers at each visit
If medications must be taken separately, provide clear, easily read
instructions
Use clinical protocols monitored by nurses and assistants

Prescribe according to pharmacologic principles


Add one drug or combination at a time
Start with small doses, aiming for 5- to 10-mmHg reductions at each
step, unless more rapid response is indicated
Have medication taken immediately on awakening in the morning
If morning surge of BP (above 160/100) persists, give at least some
Kaplans Clinical Hypertension,
drugs at 6 p.m. or at bedtime
2014

SUMMARY

BP in first measurement
BP 140/80

False

Definitive

Compelling
Indication

No treatment Initiate TherapyInitiate Therapy


Which Drug
Mono therapy

Combinatio
n Drugs
Target
BP

KASUS

Kasus 1

Laki-laki 38 thn, TD 145/95 mmHg, IMT


24,9
Ass: Hipertensi Stadium 1 ( risiko sedang )
1 factor risiko

INA SH ,2014

Model Stratifikasi Faktor Risiko Global


Kardiovaskular
Faktor risiko
Tekanan Darah (mmHg)
lain, kerusakan
organ target
atau penyakit

Normal Tinggi
TDS 130139
Atau TDD 85
89

Risiko
rendah

Tidak ada faktor


risiko lain

12 Faktor risiko

Risiko
rendah

3 Faktor risiko

Risiko
rendah
sampai
sedang

Kerusakan organ,
PGK derajat 3
atau DM

Risiko
sedang
sampai
tinggi

PKV Simptomatik,

HT St I
TDS 140159
Atau TDD 90
99

Risiko
Sedang
Risiko
sedang
sampai
tinggi

Risiko tinggi

HT St II
TDS 160179
Atau TDD 100
109

Risiko
Sedang
Risiko
sedang
sampai
tinggi

Risiko tinggi

Risiko tinggi

HT St III
TDS 180
Atau TDD 110

Risiko tinggi

Risiko tinggi

Risiko tinggi

Risiko tinggi
sampai
sangat tinggi

Konsensus Penatalaksanaan Hipertensi 2014, InaSH

Inisiasi pengobatan Hipertensi dgn Pengubahan Gaya Hidup dan


Obat Antihipertensi
Faktor risiko lain,
kerusakan organ
target atau
penyakit

Tekanan Darah (mmHg)

Normal Tinggi
TDS 130139
Atau TDD 8589

HT St I
TDS 140159
Atau TDD 9099

HT St II
TDS 160179
Atau TDD 100109

HT St III
TDS 180
Atau TDD 110

Perubahan gaya
hidup utk beberapa
minggu
Kemudian konsumsi
obat dg target TD
<140/90

Perubahan gaya
hidup
Segera konsumsi obat
dg target TD < 140/90

Tidak ada faktor risiko


lain

Tidak ada intervensi


TD

Perubahan gaya hidup


utk beberapa bulan
Kemudian konsumsi
obat dg target TD <
140/90

12 Faktor risiko

Perubahan gaya
hidup
Tidak ada
intervensi TD

Perubahan gaya hidup


utk beberapa minggu
Kemudian konsumsi
obat dg target TD
<140/90

Perubahan gaya
hidup utk beberapa
minggu
Kemudian konsumsi
obat dg target TD
<140/90

Perubahan gaya
hidup
Segera konsumsi obat
dg target TD < 140/90

3 Faktor risiko

Perubahan gaya
hidup
Tidak ada
intervensi TD

Perubahan gaya hidup


utk beberapa minggu
Kemudian konsumsi
obat dg target TD
<140/90

Perubahan gaya
hidup
Konsumsi obat dg
target TD < 140/90

Perubahan gaya
hidup
Segera konsumsi obat
dg target TD < 140/90

Kerusakan organ, PGK


derajat 3 atau DM

Perubahan gaya
hidup
Tidak ada
intervensi TD

Perubahan gaya hidup


Konsumsi obat dg target
TD < 140/90

Perubahan gaya
hidup
Konsumsi obat dg
target TD < 140/90

Perubahan gaya
hidup
Segera konsumsi obat
dg target TD < 140/90

PKV Simptomatik,
PGK derajat 4 atau
DM dgn kerusakan
organ/faktor risiko

Perubahan gaya
hidup
Tidak ada
intervensi TD

Perubahan gaya hidup


Konsumsi obat dg target
TD < 140/90

Perubahan gaya
hidup
Konsumsi obat dg
target TD < 140/90

Perubahan gaya
hidup
Segera konsumsi obat
dg target TD < 140/90

Konsensus Penatalaksanaan Hipertensi 2014, InaSH

Strategi pengobatan dan pemilihan


obat

INA SH< 2014

Advice
Advice
Pastikan diagnosis hipertensi
Perubahan gaya hidup untuk
beberapa minggu
Kemudian konsumsi obat
antihipertensi
Target TD <140/90 mmHg
Pilihan obat :
diuretic thiazide/ACE/ARB/CCB/BB

CASE 2
Laki-laki 50 tahun, TD 170/110 mmHg, IMT
27, SC 1.2, GDP 178 mg/dL, 2JPP 238
mg/dL, LVH, Kardiomegali, proteinuria
Ass: Hipertensi stadium II, CKD, DM
risiko tinggi
Penatalaksanaan :
Perubahan gaya hidup
Konsumsi obat antihipertensi
Target < 140/90 mmHg

Peningkatan TD ringan
Risiko KV rendah
/menengah

Pilihan di
antara

Obat tunggal

Penggantian
obat lain

Obat
sebelumnya
pada dosis
penuh

Dosis penuh
monoterapi

Kombinasi 2
obat pada
dosis penuh

Peningkatan TD dgn
jelas
Risiko KV tinggi/sangat
tinggi

Kombinasi 2
obat
Kombinasi
sebelumnya
pada dosis
penuh
Penggantian
menjadi
kombinasi 2
obat berbeda

Menambah
obat ketiga

Kombinasi 3
obat pd dosis
penuh

Monoterapi vs Terapi Kombinasi sebagai


Strategi untuk Mencapai Tekanan Darah

Konsensus Penatalaksanaan Hipertensi 2014, InaSH

Obat yang mana? Monoterapi atau kombinasi?

Pilihan : ACE atau ARB


Atau kombinasi 2 klas obat yang berbeda
Peningkatan TD sangat jelas (Stadium 2)
dengan risiko CV tinggi disarankan
kombinasi 2 macam obat yang berbeda
Pilihan Kombinasi : ACE / ARB dengan
CCB

ESH/ESC 2013 Guideline recommendation


for combining drugs to lower Blood Pressure
Thiazide
diuretics
Angiotensin
receptor
blockers

blockers

Other
antihyperten
sives

Calcium
antagonist

ACE

Preferred combinations
inhibitors
Useful combinations with limitation
Possible but less well tested
Not recommended

ESH/ESC,2013

Thank you

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