Crisis of Hypertension

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    HIPERTENSI : Problem kardiovaskuler : Stroke, GPDO, PJK,

    Aneurisma, Hipertensi krisis

    Komplikasi : - Memperpendek usia; - Harapan hidup

    INSIDEN : Tahun - tahun >>

    TGT : - Kesadaran masyarakat kesehatan- Check up rutin

    : 10 - 20% ( USA : 15 - 20%; JEPANG : 15 - 22%

    Singapura : 14%; India : 15%; Philiphina : 10,8%

    Indonesia : 15%)

    Perlu survei yg luas pada masyarakat

    - Case finding

    - Problem kesehatan masyarakat

    Pengobatan yang rasional : - Komplikasi dihindari

    - Umur >>- Kualitas hidup

    HIPERTENSI

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    H. + Komplikasi

    H. + Keluhan +

    Pengobatan tak baik

    H. + Keluhan +

    Pengobatan baik

    H. Tanpa keluhan

    Nomiotensi

    Border line

    FENOMENA GUNUNG ES

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    Piekerning : Tek Darah : - Umur- Sex

    - Lingkungan

    Hence : Tek darah PrognosaPenatalaksanaan

    Kaplan : O

    < 45 th : 130/90 mm HgO > 45 th : 140/95 mm HgO- segala umur : 160/95 mm Hg

    NYHA : Tek darah > 140/90 mmHg

    WHO (1993) : Tek darah > 140/90 mmHg

    JNC (1997) : Tek darah > 140/80 mmHg

    Kriteria : Diastole

    96 - 100 Std I100 - 109 Std II110 - 119 Std III> 120 Std IV

    Hipertensi sistolik : Tek sitole > 160 mmHg

    D E F I N I S I

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    1. Umur : >> umur Tek darah >>Kriteria 160/90

    Hipertensi Umur : Hipertensisistolik

    2. Sex : Muda Pria > Wanita> 45 tahun Pria = Wanita

    3. BB : Gemuk HipertensiHipertensi GemukHipertensi gemuk > BB ideal

    Kenaikan 10 kg dari BB ideal >> tensi, 3 mmHg4. Hiriditer: OT Anak

    Anak dengan OT (+) 2 Anat OT (-)5. Garam : NaCl Na air6. Stress : Stress Hipotal Catekol >> Sympatis >> Resistensi >>7. Sosio ekonomis : - Kota > didesa

    - Tegang, Makanan, Olah Raga

    8. Lain-Lain : Rokok, Kopi, Alkohol

    FAKTORPREDISPOSISI

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    - 80 -90 % Prevalensi Hipertensi

    - Faktor: Usia, Sex, BB, Heriditas, Stress, Garam

    - NaCl : 5 - 15 gr/hr Prevalensi > 15 - 20 %- Simpatis >> Parasimpatis >- Ginjal : Pengaturan air + garam

    Renin angiotensin sistem

    - Na >> Tek Darah >>- Simpatis >> Tek Darah >>

    - Atas dasar renin HE1. HE Tinggi Renin : - Muda

    - NOR Adrenalin >>

    - COP >>

    2. HE Normo Renin

    3. HE Rendah Renin : - Tua

    - Resistensi >>

    P E N Y E B A B1. PRIMER (IDIOPATIK) = ESSENSIAL

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    Renin

    Angistensin I

    Angistensin IIACE

    AldosteronVasokonstriksi

    Tek Darah

    R A A S

    Na

    Vol

    Aktivasi RAA

    COP Angiotensi I Angiotensi II

    Afterload Preload

    Vasokonstruksi Aldosteron

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    10% Prevalensi Hipertensi

    A. GINJAL : Parenchym : - GHA / GNC

    - PHA / PNC

    - Polikistik ginjal

    - Kimmel Stiel-Wilson

    - Peny Kollagen

    - DM

    - Tumor

    - BatuVaskuler : - Stenosis A. Renalis

    - Nephro Sklerosis

    - Fistula A - V

    - Obstruksi : Tumor

    B. HORMONAL : - Phaechromacytoma

    - Cushing S.

    C. COARCTATIO AORTA

    D. KEHAMILAN : Eklampsi

    E. KEL. SYARAF

    2. Hipertensi Sekunder (H.S.)

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    Gejala : Individual : - Pusing, mual, muntah

    - Kaku Kuduk- Iritable

    - Keluhan (-)

    1. H LVH Gagal Jantung2. H Atherosklerosis P.J.K

    LVH : Tingginya tekanan darah LVHGNA, Eklamspi, Phaechroma LVH LHF

    Frohliek : Kel Jantung OK H.I. Besar DBN EKG, X FotoII. LAH, Gallop (BJ 4)

    III. LVH, EKG X FotoIV. LVF

    KOMPLIKASI

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    Tek Darah LVHLV DELATL.V. Wall Tension

    L.V. O2 Consump

    Miokard Hypobia

    Diastolic Compliance LVEDP

    LVF

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    Atherosklerosis >>

    Atherom Plaque >>

    Trombus

    Lumen A. Coroner 50% Lumen)

    P.J.K

    AP MCI SD

    MC Kenna : PJK - H 22%

    ASPAC : 15%

    Boedi D. : 16%

    Sutanegara : 22%

    Antono E. : 28,6%D. Sargowo : 21,6%

    ATHEROSKLEROSIS

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    Mortality risk in relation to sex and B.P.

    8797

    98127

    128-137

    138-147

    148-157

    158-177

    178-197

    > 198

    Systolic blood pressure

    mmHg Standard risk

    48-68

    69-83

    83-88

    88-93

    93-98

    98-108

    108-118

    > 118

    Diastolic blood pressure

    0 100 200 300 400 500 600 700 800Mortality ratio in %

    woman

    men

    men

    woman

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    Klasifikasi hipertensi untuk umur 18th ( JNC VII )

    Klasifikasi Sistolik

    (mmHg)

    Diastolik

    (mmHg)

    Normal

    Prehipertensi

    Stadium 1

    Stadium 2

    < 120

    120 - 139

    140-159

    160

    < 80

    80 - 89

    90-99

    100

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    SevereHypertension

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    Patient assessment

    Complete cell blood count

    Complete metabolic panel

    ECG : ischemic, infarct ? Radiography :

    cardiomegaly,pulmonary edema,aortic

    abnormality

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    PENATALAKSANAAN (WHO)1. HIPERTENSI : 1. Non Farmakologik

    - Diet

    - OR

    - Stress (-)

    - Rokok (-)

    2. FakmakologikStepped care WHO I, II, III, IV.

    2. KOMPLIKASI :

    LVF : Kontraksi : InotropikPreload : DiuretikAfterload : - Vasodelator- Ace inhobitor

    PJK : - Suplai O2 : - VasodelatorNitrat, Acenning

    - Ca antagonis

    - Demand O2 : Blocker

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    MANAGEMENT HIPERTENSIPADA DIABETES

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    Ang II

    Vasokonstriksi Direct sel otot polos

    vaskuler HT, atheroschlerosis

    Faktor pertumbuhan (bFGFs, PDGF,

    TGF1, IL-6, PAF, Arachidonat)

    kardiomiosit: LVH , sel2 mesangial:

    glomeruloschlerosis, sel otot polosvaskuler: HT, atheroschlerosis

    Tonus saraf simpatik sel2 otot

    polos vaskuler : HT, kardiomiosit : LVH

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    In patients with proteinuria > 1g

    and renal insufficiency blood

    pressure goal < 125/75 mmHg

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    Dietary and Lifestyle Modifications

    Maintain weight loss (5 10%) Exercise 3045 min at least three times per

    week

    Reduced sodium intake to 100 mmol (2.4 g) per

    day Smoking cessation

    Adequate intake of dietary potassium, calcium,and magnesium

    Reduced alcohol intake to

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    Lifestyle Modification to Lower

    Blood Pressure

    Stults B. Diabetes Spectrum 2006; 19: 25

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    Pharmacologic Treatment

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    Advances in the Treatment of

    Hypertension

    Chobanian AV. N Engl J Med

    2009;361:878-87, 2009

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    Pharmacologic Therapy

    ACE Inhibitors(SOLVD Trial)

    Angiotesin II Receptor Blockers (ARB)

    (RENAAL, IRMA II, IDNT Study)

    -Blockers

    (UKPDS Study)

    Calcium Channel Blockers (CCB)

    (ABCD Trial) Diuretics

    (ALLHAT Study)

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    Effects of Hypertension Treatment

    on Morbid Events

    Comparative Drug Trials in Patients

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    Comparative Drug Trials in Patients

    with Hypertension

    Chobanian AV. N Engl J Med 2009;361:878-87, 2009

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    In patients with proteinuria > 1g

    and renal insufficiency blood

    pressure goal < 125/75 mmHg

    Algorithm for Management of Hypertension

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    Algorithm for Management of Hypertension

    Chobanian AV. N Engl J Med 2009;361:878-87, 2009

    Blood pessure

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    Management ofHypertension in

    Diabetes

    Recess for causes of resistant hypertens