Curiculum Vitae

Nama : Dr.dr.Hasyim Kasim SpPD,KGH,FINASIM

Tempat/Tgl Lahir : Makassar 24 oktober 1959
Keluarga: seorang Istri, 2 putri/2 putra
Pendidikan : SD-SMA makassar,FKUH 1987,SP2 interna 1996, S3.
2013
Jabatan: - Direktur penunjang medik RSUH
Ketua Divisi Ginjal Hipertensi Dep.Penyakit Dalam
Koordinator pendidikan SP 1 Penhy.Dalam
Sekertaris Alumni FKUH
Pengurus IDI wilayah Sulsel bidang Hukum
Ketua Alumni FKUH angkatan 1979/Dapur seni
Ketua PAPDI sulsel
Pengurus PERDOKHI
Management Hipertensive in
Primary Care
Hasyim Kasim
 Introduction
Hypertension is a major health problem throughout the
world because of its high prevalence and its association
with increased risk of cardiovascular disease
the prevalence of hypertension averages 26%
The higher the blood pressure, the greater the chance of
myocardial infarction, heart failure, stroke and kidney
disease
Individuals who are normotensive at age 55 years have a
90% lifetime risk for developing hypertension
For individuals aged 4070 years, each increment of 20
mmHg in systolic blood pressure or 10 mmHg in diastolic
blood pressure doubles the risk of cardiovascular disease
 Hypertension
Common, Responsible for the majority of
office visits
Number one reason for drug prescription
Simple and cheap detection
Established treatment
Significant preventable outcomes

Observational studies suggest detection &

treatment suboptimal
Health care professionals should know the blood pressure of all
of their patients and clients.

To screen for hypertension

To assess cardiovascular risk
To monitor antihypertensive treatment
 Office Blood Pressure Measurement
Correct methods for office blood pressure measurement
Before measurement
Timing
1 hour Avoiding coffee food, smoking, decongestants
30 minutes Avoiding exercise
5 minutes Sitting calmly
During measurement
Body position Seated, back supported, legs uncrossed, feet flat on floor, and
relaxed
Arm Supported, using the arm higher value
Cuff At heart level, using appropriate sized one
Measurement Taking two measurement, spaced 1-2 minutes apart, and additional
maesurement if needed,
For initial readings, take the blood pressure in both arms and
subsequently measure it in the arm with the highest reading
Other
No talk during the procedure, No acute anxiety, stress or pain, Bladder and bowel
comfortable, No tight clothing on arm or forearm, Quiet room with comfortable
temperature, Patient should stay silent prior and during the procedure
Blood Pressure Assessment:
Patient position

X
 Health consequences of high blood
pressure may include
Coronary artery disease
Heart attack
Heart disease
Congestive heart failure
Stroke
Kidney damage
Vision loss
Erectile dysfunction in males
 The common risk factors for
hypertension include the following
Family history of high blood pressure
Poor diet and having too much salt in your diet
History of smoking and second-hand smoke
exposure Drinking too much alcohol
Lack of physical activity
Having diabetes
Being overweight or obese
African American race
 What are the symptoms of
hypertension?
normally will not experience symptoms.but
Severe headache
Nosebleeds/epstaxix
Changes in vision
Nausea or vomiting
Shortness of breath
Confusion
Chest pain
 Blood pressure can be measured via
the following methods
1) Manually,
2) with an automated machine,
3) Ambulatory blood pressure monitoring,
4) Home blood pressure monitoring.
Ambulatory blood pressure monitoring
is indicated in
Suspected white-coat hypertension
Apparent drug resistance
Hypotensive symptoms with antihypertensive
medication
Episodic hypertension
Autonomic dysfunction
 Manual blood pressure measurement
1. Check the condition of the device and the cuff size to ensure the reading is
accurate.
2. Make sure patient is relaxed and has been seated comfortably for 5 minutes in a
chair (not exam table) with feet on the floor and arm supported at heart level.
3. Have the patient relax and sit with their arm slightly bent on the same level as
their heart and resting comfortably on a table or other flat surface.
4. Place the inflatable blood pressure cuff securely on the upper arm
(approximately one inch above the bend of the elbow).
5. Close the pressure valve on the rubber inflating bulb, and pump the bulb rapidly
to inflate the cuff.
6. If using a stethoscope, place the earpieces in your ears and the bell of the
stethoscope over the artery, just below the cuff.
7. Now slowly release the pressure by twisting or pressing open the pressure
valve, located on the bulb. Listen through the stethoscope and note on the dial
when you first start to hear a pulsing or tapping soundthis is the systolic blood
pressure.
8. Continue letting the air out slowly. Note on the dial when the sounds
completely stop this is the diastolic blood pressure
History
Physical Examination
 Recommended diagnostic testing
12 lead electrocardiogram
Complete blood count
Basic metabolic profile (serum sodium, potassium, creatinine with
estimated/measured glomerular filtration rate, calcium)
Lipid profile (total cholesterol, high density lipoprotein cholesterol,
low density lipoprotein cholesterol, triglycerides) after 9 to 12 hour
fast
Fasting blood glucose or Hemoglobin A1c
Urinalysis
Thyroid-stimulating hormone (TSH)
Urinary albumin excretion or albumin/creatinine ratio
Chest X-ray Heart Echocardiogram
 The classification of blood pressure and hypertension
WHO-ISH, WSH-ESC, BSH, JNC-7
WHO-ISH, ESH-ESC, BP BP JNC VII
BSH BP Classification (mmHg) (mmHg) Bp Classification

Optimal <120 / <80 <120/<80 Normal

Normal 120-129 / 80-84 120-129 /80-84 Prehypertension

grade 1

High normal 130-139 / 85-89 130-139 / 85-89 Prehypertension

grade 2
Grade 1 Hypertension 140-159 / 90-99 140-159 / 90-99 Stage 1
(mild) Hypertension

Grade 2 Hypertension 160-179 /100- >160 / >100 Stage 2

(moderate) 109 Hypertension

Grade 3 Hypertension > 180 / >110

(severe)

Isolated Systolic > 140 / < 90 Isolated Systolic

Hypertension Hypertension
Stages of hypertension
 A meta-analysis of prospective observational
studies found a direct correlation between
CVD deaths and SBP down to a threshold of
115 mm Hg .
As many as 39% of male and 23% of female
patients have an SBP between 130 and 139
mm Hg and are at increased risk of developing
HTN
Interview guide to assess medication adherence
Actions to Improve Medication Adherence
 Blood pressure treatment goals based on
patients age, DM , and CKD status

**Adapted from the 8th report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure.
a Recommendation informed by the following trials: HYVET, Syst-Eur, SHEP, JATOS, VALISH, and CARDIO-
SIS.6-11
b Recommendation informed by the following trials: HDFP, Hypertension-Stroke Cooperative, MRC,
ANBP, and VA Cooperative.12-17
c Recommendation informed by the following trials: SHEP, Syst-Eur, UKPDS, and Accord-BP. 18-21
d Recommendation informed by the following trials: AASK, MDRD, and REIN-2.
lifestyle modifications
 Lifestyle Recommendations for
Hypertension: Dietary
Dietary Sodium

High in: Less than 2300mg / day

(Most of the salt in food is hidden and comes
Fresh fruits from processed food)
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre Dietary Potassium
Plant protein Daily dietary intake >80 mmol

Low in: Calcium supplementation

Saturated fat and cholesterol No conclusive studies for hypertension

Sodium
Magnesium supplementation
No conclusive studies for hypertension

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
 Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four to seven days per week

I Intensity - Moderate

T Time - 30-60 minutes

Type Cardiorespiratory Activity

T - Walking, jogging
- Cycling
- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

 Non-pharmacological Treatment
Intervention Recommendation Expected systolic blood
Pressure reduction (range)

Weight Reduction Maintain ideal body mass index 5-10 mmHg per 10 kg
(20-23 kg/m2) weight loss

DASH eating plan Consume diet rich in fruit, vegetables, 8-14 mmHg
low-fat dairy products with reduced
All put together reduce SBP by
content of saturated and total fat

Dietary sodium Reduce dietary sodium intake to 2-8 mmHg

restriction 20 to 55 mmHg
<100 mmol/day (<2.4 g sodium or
<6 g sodium chloride)

Physical Activity Engage in regular aerobic 4-9 mmHg

physical activity

Alcohol Men < 21 units per week

Women < 14 units per week 2-4 mmHg
moderation
BP Treatment Initiation Algorithm for Adults < 60 years
 The two drug initiation therapy strategy
involves initiating therapy with two different
antihypertensive drugs, either as 2 separate
drugs or a single pill combination.
When considering adding additional
medications, begin adding from within the
four classes of first-line medications:
thiazides, ACEI, ARBs, and CCB.
 Consider secondary causes of hypertension if
patient requires more than three
antihypertensive medications from three
different classes.
Refer to Appendix A for evaluation of secondary
causes of hypertension.
Management of secondary causes of
hypertension should be coordinated with the
primary care provider and appropriate specialist.
Strategies to Dose Antihypertensive Drugs
 Initiating Pharmacologic Therapy
First visit.
(1)
1. Patients with SBP 180 mmHg and/or DBP 110 mmHg, with or without
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) require immediate management (non-
pharmagological & pharmacological treatment)
2. If SBP is between 160179 mmHg and/or DBP 100109 mmHg with
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) require immediate management (non-
pharmagological & pharmacological treatment)
3. If SBP is between 160179 mmHg and/or DBP 100109 mmHg, without
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) a second visit within 1-2 week should be scheduled
for confirmation of HTN. Non-pharmacological treatment should be initiated.
4. If average BP levels is within stage 1 range, a second visit within 3-4 weeks
should be scheduled for the assessment of HTN. Non-pharmacological
treatment should be initiated.
 Criteria for Diagnosis of
Hypertension (2)
Second Visit.
1. Patients with macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus
(DM), or CKD (GFR<60 mL/min/1.73 m2) if SBP is 140 mmHg and/or DBP is
90 mmHg, pharmacological treatment should be initiated
2. Patients without macrovascular TOD, DM, or CKD and SBP is between 140
159 mmHg and/or DBP 9099 mmHg, third visit within 2-4 week should be
scheduled for confirmation of HTN

Third Visit
1. If SBP is 140 mmHg and/or DBP is 90 mmHg, pharmacological treatment
should be initiated.
Commonly used hypertension medications
Aspects of the treatment plan that should be emphasized with the
patient
The unique role of each drug
The importance of taking the drug as directed
and making sure that they are refilled
How often the drug should be taken When to
avoid taking the drug (e.g., before a meal, with
other medications, etc.)
Any possible side effects
Suggest ways to manage side effects
Emphasize danger of not taking medications as
prescribed
Address possible adherence issues that may arise
Pertinent lab tests to order at follow-up
Indications and contraindications of antihypertensive drugs

Shin et al. Clinical Hypertension (2015) 21:2

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Resistant Hypertension
Blood pressure that remains above goal (<140/90
mmHg in non-complicated patients & <130/80 mmHg in
high risk patients) in spite of the concurrent use of of
three antihypertensive agent of different classes
Ideally, one of the three agents should be diuretic and
all agents should be prescribed at optimal dose
amounts
Includes patient whose blood pressure is controlled
with use of more than three medications
In a compliant patient
 Refer/consult with appropriate specialists when necessary.
Initial systolic BP 180 Initial diastolic BP 110
Abnormal lab results Total cholesterol 200 LDL cholesterol
130 or 100 in a patient with diabetes HDL 40 Triglycerides
200
Creatinine 1.4 for women or 1.5 for men
Potassium 3.5 mEq or 5.5 mEq
Positive microalbuminuria
Extreme complications/side effects of therapy.
Patient does not respond to therapy.
Patient is pregnant.
Patient is 18 years old.
Patient has an abnormal ECG.
Patient has any abnormal physical examination findings.
 Suspect secondary causes of HT
Abrupt onset of symptomatic hypertension
Stage 2 hypertension
Hypertensive crisis
Sudden loss of blood pressure control after
many years of stability on drug therapy
Drug resistant hypertension
Individuals with no family history of HT
Differential diagnosis for secondary causes of HT
 Guidelines for the physician to improve
antihypertensive drug compliance
Educate the patient about hypertension and its treatment with clear
and accepted goals. Need to continue treatment, control does not
mean cure, one cannot tell if BP is elevated by feeling or
symptoms-> BP must be measured
Keep the treatment as simple and cheap as possible (using long-acting
once-daily dosing) with written information.
Combine efficient and well tolerated drugs in the same pill (fixed-dose
combination)

Treat to target.
Lifestyle modifications are effective in preventing HT,
treating hypertension and reducing cardiovascular risk.
Combinations of both lifestyle changes and drugs are
generally necessary to achieve target blood pressures