Pendahuluan

 Hipertensi adalah suatu masalah kesehatan

masyarakat
 Insidensi nya bervariasi namun diperkirakan sekitar
29 – 31%
 95 % Hipertensi esensial
 Hipertensi tidak pernah berdiri sendiri
 Hypertension syndrome atau Atherosclerosis syndrome
 HYPERTENSION SYNDROME IS MORE
THAN JUST BLOOD PRESSURE

Decrease
Arterial
compliance Endothelial
Obesity Dysfunction

Abnormal
Abnormal lipid Glucose
Metabolism Metabolism

Accelerated Neurohormonal
Atherogenesis Dysfunction

Renal-function
LV Hypertrophy Changes
And Dysfunction
Abnormal Blood-clotting
Insulin Mechanism
Metabolism Change

Kannel WB. JAMA 1996, 275: 1571-1576; Weber MA et al. J Hum Hypertens 1991,
5: 417-423; Dzau VJ et al. J Cardiovasc Pharmacol 1993, 21 (Suppl 1): S1-S5
 WHO-ISH Guidelines Committee sudah sepakat untuk
mengadopsi batasan dan klasifikasi The Joint National
Committee on Detection, Evaluation, and Treatment of High
Blood Pressure (JNC VII)

 Definisi Hipertensi :
Tekanan darah ≥140 mmHg sistolik dan atau ≥ 90 mmHg
diastolik pada seseorang yang tidak sedang makan obat anti
hipertensi.
 HEREDITER-LINGKUNGAN
Umur

Pra-hipertensi 0 - 30 tahun

Normotensi Hipertensi dini 20 - 40 tahun

Hipertensi (klinis) 30 - 50 tahun

Tanpa komplikasi Dengan komplikasi

Hipertensi Jantung P. Darah besar Otak Ginjal

maligna Hipertrofi Aneurisma Iskemia Sklerosis
Gagal Diseksi Trombosis Gagal ginjal
Infark Perdarahan
Hipertensi Dengan Terapi

Terapi yang efektif telah mengubah

komplikasi hipertensi pada jantung (gagal
jantung kongestif), sebagai akibat
menurunnya tekanan yang meninggi, pasien
menjadi hidup lebih lama namun penyakit
koroner muncul

PJK tampaknya belum dapat ditekan dengan

menurunkan tekanan darah saja
Pola Penyakit Usia  55 th
1. Penyakit Kardiovaskuler 15,7
2. ,, Muskuloskeletal 14,5
3. ,, TBC 13,6
4. ,, Bronchitis, Asma 12,1
5. ISPA 10,2
6. Gilut & saluran cerna 10,2
( Survey Kesehatan RT, Depkes 1986)
 Cardiovascular disease (CVD)
 Range of illnesses affecting the heart and blood vessels
 Coronary heart disease, cerebrovascular disease, peripheral vascular disease
 Leading cause of death and disability worldwide
 ~17 million deaths from CVD each year, particularly heart attacks and strokes
 In the ageing population, increasing need for cardiovascular (CV) care will be accompanied
by higher costs
No. of CVD deaths

~25 million CV deaths/year predicted by 2020

Time

The World Health Report 2004; Ezzati M. Lancet 2003;362:271–280;

Yach D, et al. New Engl J Med 2004;291:2616–2620
 FAKTOR RISIKO UTAMA
- Hipertensi
- Merokok
- Obesitas (IMT ≥ 30 kg/m2)
- Kurangnya aktivitas fisik
- Dislipidemia
- Diabetes mellitus
- Mikroalbuminuria atau perkiraan LFG < 60 ml/men
- Umur > 55 tahun (laki-laki) atau > 65 tahun (wanita)
- Riwayat keluarga dengan PJK prematur (pria < 55 th, wanita <65 th)
( IMT: indeks massa tubuh, LFG: laju filtrasi glomerulus, PJK: penyakit jantung koroner)
KERUSAKAN ORGAN TARGET
• Jantung
- hipertrofi ventrikel kiri
- angina atau pernah infark miokard
- pernah revaskularisasi koroner
- gagal jantung
• Otak
- stroke atau Transient Ischemic Attack
• Penyakit arteri perifer
• Retinopati
 Kidney
Renal Insufficiency

Heart
Hypertension Brain
Left Ventricular Hypertrophy
Chronic Heart Failure
Myocardial Infarction
Congestive Heart Disease
Arrhythmia Stroke
Vessel
Arteriosclerosis
Peripheral Vascular Disease
Coronary Heart Disease
 Table. Classification and management of blood pressure for adults

Initial drug therapy

BP SBP DBP Lifestyle
Classification mmHg mmHg Modification
Without compelling With compelling
indications indications

Normal <120 and <80 Encourage No antihypertensive Drug(s) for

drug indicated compelling
Pre- 120-139 or 80-89 Yes
indication
hypertension
Stage 1 140-159 or 90-99 Yes Thiazide-type Drug(s) for
Hypertension diuretics for most.
May consider ACEI,
the
ARB, βB, CCB, or compelling
combination indication.
Stage 2 ≥160 or ≥100 Yes Two-drug Other
combination for hypertensive
Hypertension
most (usually drugs
thiazide-type (diuretics,
diuretic and ACEI, ARB,
ACEI or ARB or βB, CCB) as
βB or CCB) needed
 Tabel. Faktor yang menentukan prognosis
terhadap risiko kardiovaskular
I. Menentukan stratifikasi II. Faktor lain yang mempengaruhi prognosis

Tinggi tekanan diastolik/sistolik HDL yang menurun

Laki >55 th, wanita >65 th LDL meningkat
Kolesterol total >250 mg% Mikroalbuminuria pada DM
Diabetes melitus IGT
Riwayat keluarga CVGD dini Obesitas
Hidup malas
Fibrinogen meningkat
III. Kerusakan organ sasaran IV. Kondisi klinik terkait

LVH (EKG, ekokardiografi, foto) CVD (strok, iskemia, perdarahan, TIA)

Proteinuria, kreatinin (1,2-2 mg%) Penyakit jantung (IM, AP, GJK, revaskular)
Plak aterosklerosis (foto/USG) Penyakit ginjal (ND, kreatinin >2 mg%)
Penyempitan a.retina umum/lokal Penyakit vaskular (diseksi, PPP)
Retinopati lanjut (perdarahan, papil edema)
Healthy Life Style Changes
Decrease your blood pressure by:
 Reducing body weight
 Restricting dietary salt
 Increasing fiber and decreasing fat in your diet
 Not smoking
 Avoiding excess alcohol
 Exercising regularly
 Developing relaxation techniques

It is very important to follow your physician’s

instructions and to take any medications as prescribed.
 Tabel 5 :
Petunjuk Pemilihan Obat Anti Hipertensi

Golongan OAH Indikasi Utama Indikasi Lain Kontraindikasi Kontraindikasi

Lain
Gagal jantung Diabetes Gout Dislipidemia
Diuretik Manula Laki-laki
Hipertensi seksual aktif
sistolik

Angina pectoris Gagal jantung Asma dan PPOM Dislipidemia

Beta-bloker Post infark Hamil (penyakit paru Atilit dan orang
miokard Diabetes obstruktif yang aktif olah
Takiaritmia menahun) raga PPV
Heart block (AV
blok gr 2 atau 3)
Gagal jantung Hamil
ACEI Disfungsi LV Hiperkalemia
Post infark Stenosis a.
miokard Renalis bilateral
Nefropati
Diabetik
 Tabel 5 :
Petunjuk Pemilihan Obat Anti Hipertensi
Golongan OAH Indikasi Utama Indikasi Lain Kontraindikasi Kontraindikasi
Lain
Angina pectoris PPV Heart block (AV Gagal jantung
Angagonis Manula blok grade 2 atau kongestif
Kalsium Hipertensi 3 dengan (Diltiazem atau
Sistemik verapamil atau verapamil)
diltiazem)
Hipertropi Intoleransi Asma dan PPOM Hipotensi
Alfa-bloker Prostat Glukosa (penyakit paru ortostatik
Dislipidemia obstruktif
menahun)
Heart block (AV
blok gr 2 atau 3)
Hamil
Antagonis All atuk pada ACEI Gagal jantung Stenosis a.
Renalis bilateral
Hiperkalemia
 Tabel. Obat antihipertensi untuk berbagai situasi klinik
Population Target Non Pharmacologic Pharmacologic
(mmHg) Intervention Treatment

General < 140/90 Low salt diet, exercise Beta blockers, Diuretics
Chronic renal insufficiency with < 125/75 Low salt diet ACE-Is, ARBs
proteinuria (> 1g/dl, including (Diuretics)
diabetic nephropathy)

Insufficiency without proteinuria (< 1 < 130/85 Low salt diet ACE-Is, ARBs
g/dl) (Diuretics)

End stage renal disease with < 140/90 Low salt and water diet, All agents except
hemodialysis ultrafiltration diuretics

End stage renal disease with < 140/90 Low salt and water diet, All agents except
peritoneal dialysis ultrafiltration diuretics

Renal transplant with proteinuria > 1 < 125/75 Low salt diet ACE-Is, ARBs, CCBs
g/dl (Diuretics)

Renal transplant without proteinuria < 130/85 Low salt diet ACE-Is, ARBs, CCBs
(or < 1 g/dl) (Diuretics)
Penyakit Kardiovaskuler
1. Hipertensi
2. Gagal Jantung
3. Penyakit jantung koroner
4. Stroke
SKRT ’72 : penyebab kematian ke 11
’86 : ,, ,, ,, 3
92 : ,, ,, ,, 1

( Lily R. Rilantono, 2001)

 The renin–angiotensin system (RAS)
Bradykinin/NO Angiotensin I

ACE ACE-independent
ACE
Inhibitor ANG II formation
by Chymase, etc.
Inactive fragments Angiotensin II

ARB

AT1 RECEPTOR AT2 RECEPTOR

Vasoconstriction Vasodilation
Sodium retention Natriuresis
SNS activation Tissue regeneration
Inflammation Inhibition of inappropriate cell growth
Growth-promoting effects Differentiation
Aldosterone Anti-inflammation
Apoptosis Apoptosis
ACE = angiotensin-converting enzyme; ARB = angiotensin II receptor blocker;
AT = angiotensin; SNS = sympathetic nervous system
Hanon S, et al. J Renin Angiotensin Aldosterone Syst 2000;1:147–150;
Chen R, et al. Hypertension 2003;42:542–547; Hurairah H, et al. Int J Clin Pract 2004;58:173–183;
Steckelings UM, et al. Peptides 2005;26:1401–1409
 Reasons for discontinuation from treatment with
ramipril, telmisartan, or telmisartan plus ramipril

Discontinuation, n (%) Ramipril Telmisartan Telmisartan 80 mg +

ramipril 10 mg
10 mg 80 mg
(n=8502)
(n=8576) (n=8542)

Total discontinuations† 2099 (24.5) 1962 (23.0) 2495 (29.3)

Reason for permanent

discontinuation

Hypotensive symptoms 149 (1.7) 229 (2.7)** 406 (4.8)**

Syncope 15 (0.2) 19 (0.2) 29 (0.3)*

Cough 360 (4.2) 93 (1.1)** 392 (4.6)

Diarrhea 12 (0.1) 19 (0.2) 39 (0.5)**

Angioedema 25 (0.3) 10 (0.1)* 18 (0.2)

Renal impairment 60 (0.7) 68 (0.8) 94 (1.1)**

† Multiple discontinuations were possible because patients could restart study medications after
discontinuation; vs. ramipril: * p<0.05, ** p<0.001
The ONTARGET Investigators. N Engl J Med 2008;358:1547–1559
 Reasons for Permanently
Stopping Study Medications

Ram Ram + Tel Ram + Tel vs. Ram

N=8576 N=8502 RR P
Hypotension 149 405 2.74 <0.0001
Syncope 15 29 1.95 0.032
Cough 359 392 1.10 0.176
Diarrhea 12 39 3.28 0.0001
Angioedema 25 18 0.73 0.30
Renal 59 93 1.59 0.0047
Impairment
Any 2098 2492 1.20 <0.0001
Discontinuation
FINAL SUMMARY OF
RECOMMENDATIONS

Within the population of approximately 50 million US

adults with systemic hypertension, a subpopulation of
several million with comorbid chronic pulmonary disease
merits special consideration of BP-lowering treatment that
takes the comorbid pulmonary disease into account.
Diuretics
Use of diuretics in hypertensive patients with
pulmonary disease is currently untested, and therefore
alternatives should be considered (levels B-2, C).
Calcium Antagonists
There are insufficient data for making a
recommendation regarding use of calcium antagonists in
the management of systemic hypertension in patients with
concomitant COPD or SDB. Most studies to date have
shown calcium antagonists to modestly decrease bronchial
reactivity (level B-2).
Angiotensin-Converting Enzyme Inhibitors
Cough assoiated with angiotensin-converting
enzyme inhibitors could be a moderate –to-serious
adverse reaction to this class of drugs in patients with
sensitive airway disease, decreased pulmonary function
or congestive heart failure. Cough and possible
bronchospasm could be an important factor in patient
noncompliance (level C).
Studies to date indicate the incidence of angiotensin-
converting enzyme inhibitor-associated cough to be 10
to 20%. There are no large randomized controlled trials
to indicate any higher incidence of cough or
bronchospasm in patients with bronchopulmonary
disease (levels A-2. B-1).
Angiotensin II Receptor Antagonist
The use of an angiotensin II Receptor-Antogonist maybe
considered when anngiotensin-converting enzyme
inhibitor-associated cough is a concern in patients with
congestive heart failure or pulmonary disease (level C).
ß Adrenergic Blocking Agents
ß Adrenergic blocking agents increase airway
resistance and should not be administrated to patients with
asthma or other reversible airways disease. Only in
selected instances of coexisting cardiac conditions, may ß-
adrenergic blocking agents be considered for trial (levels
b-1, C)
 Some studies support the concept that cardioselective
ß-adrenergic blocking agents exert less effect than
nonselective agents on pulmonary function in patients
with reversible airways disease. If an asthma patient with
severe systemic hypertension is unable to tolerate other
classes of antihypertensive medications, a trial of a
cardioselective ß-adrenergic blocker could be attempted
while maintaining optimal treatment with bronchodilators.
Cardioselectivity may be lost at higher doses of these
agents (levels B-1, C)
Sehat, Bahagia, Sejahtera, Produktif & Mandiri
Terima kasih,
Tuhan beserta
kita.