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Messerli, F. H. N Engl J Med 1995
Target Organ Damage
Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
Brain
• Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
Diseases Attributable to
Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy Hypertension Chronic kidney failure
Hypertensive
Aortic aneurysm encephalopathy
Retinopathy
Peripheral vascular disease All
Vascular
© Continuing Medical Implementation …...bridging the care gap
Adapted from: Arch Intern Med 1996; 156:1926-1935.
Mortality in Hypertension
Harvard
Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005 Medical
School
Consequences of Hypertension
Consequences of
Hypertension
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Hypertensive nephropathy
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Retina Normal and Hypertensive
Retinopathy
A B
Systolic
pressure Dicrotic notch
125 (aortic valve closes)
Pressure (mm Hg)
Diastolic decay
curve
75 Diastolic
pressure
Time
DEFINISI
SV x HR
BP : blood pressure
SVR: systemic vascular-resistance
SV : stroke volume
HR : heart rate
Hemodynamic Components of
BP
MAP - STEADY COMPONENT (due to CO and SVR)
SBP
%
Change
mm Hg
MAP
DBP
Age (yr)
Franklin SS et al. Circulation. 1997;96:308-315.
1976-98 Cumulative Incidence of HTN
in Women and Men Aged 65 Years
Risk of Hypertension %
100
80
Men
Women
60
40
20
0
0 2 4 6 8 10 12 14 16 18 20
Years of Follow-up
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
JAMA. 2001;285:2486-2497.
Blood Pressure
Determining Factors
Cardiac Output:
Peripheral
Stroke Volume Resistance **
Heart Rate
Vasodilators
Force of Contraction
ACE Inhibitors
Beta Blockers
Calcium Channel
BP
Blockers
Blood Volume **
MULTIFAKTORIAL
PATOGENESIS
Hipertensi primer : Penyakit multifaktorial
Juxtaglomerular
Cells
Decreased BP
Renin Release
Formation of
Angiotensin
Increased Vasoconstriction
Increased Aldosterone
with Increased Na++ and
Fluid Retention
FAKTOR2 YANG BERPENGARUH PADA PENGENDALIAN TD
asupan Na jumlah stress perubahan obesitas faktor2 yg
berlebih nefron genetis berasal dari
Endotel
konstriksi hipertrofi
Preload kontraktilitas fungsional struktural
CV 5
mortality 4
risk
3
2
1
0
115/75 135/85 155/95 175/105
SBP/DBP (mm Hg)
Decreased
Arterial
Obesity Compliance Endothelial
Dysfunction
Abnormal
Abnormal Lipid
Glucose
Metabolism
Metabolism
LV Hypertrophy Renal-Function
and Dysfunction Changes
Abnormal Blood-Clotting
Insulin Mechanism
Metabolism Changes
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.
Routine steps for accurate measurement
of blood pressure
• Rest the patient (seated) for at least 5 mins in a quiet
confortable room
. Use a calibrated sphygmomanometer (a validated and recently
calibrated electronic device may may also be used)
. Choose cuff with appropriate width of bladder
. Record with cuff at heart level
. Deflate cuff at 2 mmHg/sec
. First sound = systolic reading, disappearance = diastolic
reading
. Repeat measurement at least x2 (first visit: x3) & take average
value
. Take BP in both arms at least once; record which arm is used;
patient position ( seated, supine, standing) & pulse rate.
. Measure BP at + 1 & 5 mins after standing ( especially in older
patients and those with diabetes).
BP Measurement Techniques
……… sphygmomanometer
Patient should be seated and relaxed, preferably for several minutes
prior to to the measurement and in a quiet room.
Appropriate cuff size.
Average the readings. If the first two readings differ by more than 10 mmHg
systolic or 6 mmHg diastolic or if the initial readings are high, take several
readings after five minutes of quiet rest, until consecutive readings do not
vary by greater than these amounts.
Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
…………………..
Australia, 2004
CV Mortality Risk Doubles with
Each 20/10 mm Hg BP Increment*
8
7
6
CV 5
mortality 4
risk
3
2
1
0
115/75 135/85 155/95 175/105
SBP/DBP (mm Hg)
HDFP HOT
UKPDS SCOPE
CONVINCE VALUE
VA EWPHE ALLHAT ASCOT
Cooperative MRC-1 Syst-Eur
ANBP2 ACCOMPLISH
Studies ANHBP-1 SHEP Syst-China LIFE TROPHY
MRC-2 INSIGHT
CAPPP
STOP-1 STOP-2 NORDIL
HAPPHY
MAPHY
TOMHS
VA MONORx
HR Black, 2003.
Preparation for measurement
• Patient should
abstain from eating,
drinking, smoking
and taking drugs
that affect the blood
pressure one hour
before
measurement.
Preparation for measurement
• Because a full
bladder affects the
blood pressure it
should have been
emptied.
Preparation for measurement
• BP take in quiet
room and
comfortable
temperature, must
record room
temperature and
time of day.
BLOOD PRESSURE: MEASUREMENT
Ascultatory method of
blood pressure measurement Nokolai Korotkoff, 1905
Blood Pressure Assessment:
Patient preparation and posture
Standardized Preparation:
Patient
√ 1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
√ 4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before
measurement
√ 8. Patient should stay silent prior and during the
procedure.
Measuring Blood Pressure
Slide 9-59
Complications of Hypertension:
Hypertension
is a risk factor
TIA, stroke LVH, CHD,
HF
Renal
Peripheral vascular failure
disease
TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease
HF = heart failure.
Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22.
Benefits of Lowering BP
CV Risk Profile
703
700
8 Year Probability Per 1,000
600
500 459
400
326
300
210
200
100 46
Systolic BP: 105 >>> 185 105 >>> 185 105 >>> 185 105 >>> 185 105 >>> 185
Cholesterol: 185 335 335 335 335
Glucose Intol.:0 0 + + +
Cigaretes: 0 0 0 + +
ECG-LVH: 0 0 0 0 +
Kannel, 1983
CXR:
Cardiomegaly
pleural effusions
interstitial edema
Pulmonary venous redistribution
Echocardiography
Adapted from Cushman et al. Endocrine Practice 1997;3:106 & Sacks, et al. NEJM 2001;334:3
DASH Fact Sheet
JNC 7 Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal
Blood Pressure
Brain Strokes
TIA (transient ischemic attack)
Retinopathy
72
Laboratory Tests
Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR, and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density
lipoprotein cholesterol, and triglycerides
Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated unless BP control is not
achieved
Classes of
Antihypertensive Drugs
• ACE inhibitors
• Adrenergic inhibitors
• Angiotensin II receptor blockers
• Calcium antagonists
• Direct vasodilators
• Diuretics
Combination Therapies
Vasodilation
? Attenuate growth and
disease progression
Long-Term Antihypertensive Therapy
Significantly Reduces CV Events
Myocardial
Stroke infarction Heart failure
0
–10
–20
Average
reduction –30 20%-25%
in events
(%) –40
35%-40%
–50
>50%
–60
USA Canada UK
India China
<140/90 mmHg
140/90 mmHg
II. 1-2 Risk Factors MED RISK MED RISK V. HIGH RISK
III. 1-2 Risk Factors or TOD HIGH RISK HIGH V. HIGH RISK
or Diabetes
IV. Associated Clinical V. HIGH RISK V. HIGH V. HIGH RISK
Condition RISK
Target:
BP: SBP < 130 – 140 mm Hg
DBP < 90 mm Hg
Diuretics
β - blockers
Calcium channel blocker
ACE inhibitor
AIIRA / ARB
88
Choice of the initial drugs
89
Thiazide Diuretics
mechanism of action
adjunct agent
Losartan (Cozaar)
competitive antagonist
Valsartan (Diovan)
non-competitive
Candesartan (Atacand)
non-competitive
Losartan
Irbesartan (Aprovel)
non-competitive
Therapeutic Uses
same uses as ACE inhibitors
no bradykinin effects
no cough
Patients Providers
Healthcare
System
Self-Measurement of BP
• Epidemiology Summary:
– Increasing prevalence; world wide problem
– Blood pressure as a moving target
– ↑ PVR in the young, ↑ stiffness in the elderly
– Predominantly isolated systolic hypertension
– Consider special populations at increased risk
– Hypertension as a part of absolute global CV
risk
– Population vs. high risk approaches for
prevention
- very important is the circadian rhythm of blood pressure!
- physiological profound nocturnal decline, mostly around 4
a.m. ("dipping"), acts as a protection against pathological
lesions of blood vessels, resp. reduces them
- also hypertensive patients with significant nightime BP
decrease have a more favorable prognosis ,as patients
whose blood pressure at night compared to daytime values
doesn´t decrease (worse prognosis)
- → according to it are patients diveded to „dippers“ versus
„non-dippers“
- ≅ improvement of diagnosis ← broader application of 24-
hour blood pressure monitoring
Strategies for Prevention of High Blood Pressure