Vidhia Umami

Prevalence of Hypertension
in Indonesia
Age group Prevalence
(year) (%)
18 24 12.2
25 34 19.0
35 44 29.9
45 54 42.4
55 - 64 53.7
65 74 63.5
> 75 67.3
Total 31.7
National Basic Health Survey, 2007
Hypertension is highly
prevalent in(%)elderly
Prevalence of hypertension

patients
80
The greatest
prevalence of
72

hypertension is in
60 53
patients aged >65
years
40
31

20
10

0
1839 4054 5564 >65
Age (years)
AHA 2007 Heart Disease & Stroke Statistics: *72 million extrapolated based on NHANES 19992004,
projected to US Census estimates for 2004; Equinox Hypertension Market Map, Sept 2007
From Lewington S, Clarke R, Qizilbash N, et al: Age-specific relevance of usual blood pressure
to vascular mortality: A meta-analysis of individual data for one million adults in 61
prospective studies. Lancet 360:19031913, 2002 Slide Source
Hypertension Online
www.hypertensiononline.org
Prevalence of isolated systolic and
diastolic blood pressure by age and
gender
Risk of Adverse Outcomes by Age and Blood
Pressure
CAD Risk Predictor; Diastolic,
Systolic or Pulse Pressure?
Age <50 Diastolic
50 59 Transition; Diastolic , Systolic
60 - 79 Diastolic or Pulse Pressure
 Complications of Hypertension:
End-Organ Damage

Hypertension
Hypertension

Hemorrhage, LVH, CHD, CHF

Stroke

Peripheral
Vascular
Disease Renal Failure,
Retinopathy
Proteinuria
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy Slide Source
Hypertension Online
Chobanian AV, et al. JAMA. 2003;289:2560-2572. www.hypertensiononline.org
 Drug Treatment of Essential
Hypertension in Older People

Drug treatment of hypertension in older

people saves lives and prevents
unnecessary morbidity.
Treating isolated systolic hypertension
also saves lives.
 Antihypertensive therapy reduces
mortality in elderly patients aged >80
years, with systolic hypertension
No. of events per 100 patients No. of events per 100 patients
30 5
Death from any cause Death from stroke
4
20
p=0.02 3 p=0.05

2
10
1
0 1 2 3 4 0 1 2 3 4
0 Follow-up (years) 0 Follow-up (years)
Placebo group (n=1912) Active-treatment group (n=1933)*

*Active treatment consisted of a thiazide diuretic, with or without

the addition of an ACEI as needed to achieve BP control Beckett NS, et al. 2008
 Achieving BP goal can be problematic in
elderly patients and becomes
increasingly difficult with advancing age

Proportion of patients with hypertension treated and controlled (%)

Treated Controlled*
80
70 67
62
60 53

40 37
31

20

0
Age 6069 Age 7079 Age 80

*Control defined as: BP<140/90 mmHg Ostchega Y, et al. 2007

 Drug Treatment of Essential
Hypertension in Older People

Antihypertensive treatments are most

cost-effective when targeted at older
patients.
There is evidence of under detection
and under treatment of hypertension.
Factors influencing patient adherence
with treatment are not well understood
and require further research.
ACE Inhibitor Side Effects
Cough (15% of patients, reversible)
Taste disturbance (reversible)
Angiodema
First-dose hypotension
Hyperkalaemia ( esp. in patients with
type II diabetes and renal dysfunction)
 Modifikasi gaya hidup untuk
pengendalian Hipertensi
Modifikasi Rekomendasi Penurunan Tekanan
Darah Sistolik kurang
lebih
Menurunkan berat Pelihara berat badan 5-20 mm Hg utk
badan normal (BMI 18.5- setiap penurunan
24.9) 10 kg BB
Menjalankan menu Konsumsi makanan 8-14 mm Hg
DASH kaya buah, sayur,
susu rendah lemak
dan rendah lemak
jenuh
Mengurangi asupan Kurangi natrium 2-8 mm Hg
garam/sodium sampai tidak lebih
dari 2.4 g/hari atau
NaCl 6 g/hari
Meningkatkan aktifitas Berolahraga erobik 4-9 mm Hg
fisik teratur seperti
misalnya berjalan
kaki
(30 men/hari 4-5 hari
seminggu)
Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
Main classes of antihypertensive drugs

Diuretics
Inhibit the reabsorption 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
Vasodilators/Centrally acting
Direct renin inhibitors
 Special consideration in Antihypertensive
Potential side effects
Thiazide diuretics should be used cautiously in gout or a history
of significant hyponatremia.
BBs should be generally avoided in patients with asthma, reactive
airways disease, or second- or third-degree heart block.
ACEIs should not be used in individuals with a history of
angioedema.
Aldosterone antagonists and potassium-sparing diuretics can
cause hyperkalemia.
Drug Treatment
Considerations for Drug Therapy,
Great caution on alterations in drug distribution
and disposal
and changes in homeostatic CV control,
as well as QoL factors
Initiation of Drug Therapy
Start at the lowest dose and gradually
Target 140 mm Hg, if tolerated, (< 80 year )
This document has been developed as an expert consensus document by the American College of Cardiology
Foundation (ACCF), and the American Heart Association (AHA), in collaboration with the American Academy of
Neurology (AAN), the American College of Physicians (ACP), theAmerican Geriatrics Society (AGS), the
American Society of Hypertension (ASH), the American Society of Nephrology (ASN), the American Society for
Preventive Cardiology (ASPC), the Association of Black Cardiologists (ABC), and the European Society of
Hypertension (ESH).
Drug Treatment
Uncomplicated Hypertension
The 2009 updated European Society of Hypertension
guidelines recommend initiating therapy in the elderly with
thiazide diuretics, CAs, ACEIs, ARBs, or beta blockers
based on a meta-analysis of major hypertension trials
Complicated Hypertension
Beta blocker; CAD with hypertension and stable angina or
prior MI
A long-acting dihydropyridine CA : in addition to the beta
blocker when the BP remains elevated or if angina persists.
An ACEI should also be given, particularly if LV ejection
fraction is reduced and/or if HF is present.
Drug Treatment
Angina; verapamil SRtrandolapril strategy.
Acute coronary syndromes, beta blockers and ACEI, with
additional drugs added as needed for BP control.
Verapamil and diltiazem should not be used with significant
LV systolic dysfunction or conduction system
Beta blockers with intrinsic sympathomimetic activity must
not be used after MI.
Do not go too low
ACCORD BP (Action to Control Cardiovascular
Risk in Diabetes Blood Pressure) trial found no
additional benefit; target SBP 120 mm Hg versus a
target of 140 mm Hg.
INVEST (International VErapamil SR/Trandolapril
Study) extended follow-up, diabetes cohort,
suggest an increase in mortality when on-
treatment SBP is 115 mm Hg or DBP 65 mm Hg.
 Some guidelines recommend reducing BP
to 130/80 mm Hg in CAD patients, there is
limited evidence to support this lower
target in elderly patients with CAD.

Observational data show the nadir BP for

risk (CAD) was:
135/75 mm Hg for 70 to 80 years of age
140/70 mm Hg for 80 years of age.
Target Hypertension in
the Elderly

TDS <140 mmHg (65 79 tahun)

TDS 140 145 mmHg ( > 80 tahun )

JNC 8: <150/90

ACCF/AHA 2011
Kesimpulan
Hipertensi pada usia lanjut;
Prevalensi tinggi
Kebanyakan isolated systolic
Resiko KV tinggi
Pengobatan bermanfaat
bahkan pada yang > 80 tahun
Prinsip start low go slow
Target Pengobatan