Farmako Anti Hipertensi

Asupan garam

berlebih

Jumlah nefron

berkurangStress

Perubahan genetis

Obesitas

Bahan-bahan yang berasal dari

endotel

Retensi natrium ginjal

Aktivitas berlebih

saraf simpatis

Penurunan permukaan

filtrasi

Renin angiotensin

berlebih

Perubahan membran

sel

Hiper-insulinesmia

↑ Volume cairan

Konstriksi vena

↑ Preload ↑ KontraktilitasKonstriksi fungsionil

Hipertrofi struktural

CURAH JANTUNG

TAHANAN PERIFER

TEKANAN DARAH

↑ curah jantung ↑ tahanan periferHipertensi

Autoregulasi

= X

Blood pressure goals in hypertensive patients (ESH-ESC)

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

Recommendations

SBP goal for “most”•Patients at low–moderate CV risk•Patients with diabetes•Consider with previous stroke or TIA•Consider with CHD•Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly•Ages <80 years•Initial SBP ≥160 mmHg

140-150 mmHg

SBP goal for fit elderlyAged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP•≥160 mmHg

140-150 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

Lifestyle Modifications to Manage HTN

Modification Recommendations Approximate Systolic Blood Pressure

Reduction

Weight Reduction Maintain normal body weight (BMI 18.5-24.9)

5-20 mm Hg for each 10 kg weight loss

Adapt eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat

8-14 mm Hg

Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl

2-8 mm Hg

Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days)

4-9 mm Hg

Moderate alcohol consumption

Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women.

2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

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2013 ESH/ESC Guidelines for the management of arterial hypertension

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357

Monotherapy vs. drug combination strategies to achieve target BP

Moving from a less intensive to a more intensive therapeutic strategyshould be done whenever BP target is not achieved.

Choose between

Single agent Two–drug combination

Previous agentat full dose

Switch to different agent

Previous combinationat full dose

Add a third drug

Two drug combination at full doses

Mild BP elevationLow/moderate CV risk

Marked BP elevationHigh/very high CV risk

Three drug combination at full doses

Switch to different two–drug

combination

Full dosemonotherapy

BP, blood pressure; CV, cardiovascular.

Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

2013 ESH/ESC Guidelines for the management of arterial hypertension

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357

Possible combinations of classes of antihypertensive drugs

Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.

Thiazide diuretics

β-blockers Angiotensin-receptorblockers

Otherantihypertensives

ACE inhibitors

Calciumantagonists

Preferred hypertension treatment in specific conditionsCondition Drug

Asymptomatic organ damage

LVH LVH ACE inhibitor, calcium antagonist, ARB

Asymptomatic atherosclerosis Calcium antagonist, ACE inhibitor

Microalbuminuria ACE inhibitor, ARB

Renal dysfunction ACE inhibitor, ARB

Clinical CV event

Previous stroke Any agent effectively lowering BP

Previous myocardial infarction BB, ACE inhibitor, ARB

Angina pectoris BB, calcium antagonist

Heart failure Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists

Aortic aneurysm BB

Atrial fibrillation, prevention Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist

Atrial fibrillation, ventricular rate control BB, non-dihydropyridine calcium antagonist

ESRD/proteinuria ACE inhibitor, ARB

Peripheral artery disease ACE inhibitor, calcium antagonist

Other

ISH (elderly) Diuretic, calcium antagonist

Metabolic syndrome ACE inhibitor, ARB, calcium antagonist

Diabetes mellitus ACE inhibitor, ARB

Pregnancy Methyldopa, BB, calcium antagonist

Blacks Diuretic, calcium antagonist

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BB, beta-blocker; BP, blood pressure; CV, cardiovascular; ESRD, end-stage renal disease; ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy.

Compelling indications for hypertension treatmentClass Contraindications

Compelling PossibleDiuretics(thiazides)

Gout Metabolic syndromeGlucose intolerancePregnancyHypercalcemiaHypokalaemia

Beta-blockers AsthmaA–V block (grade 2 or 3)

Metabolic syndromeGlucose intoleranceAthletes and physically active patientsCOPD (except for vasodilator beta-blockers)

Calcium antagonists(dihydropyridines)

TachyarrhythmiaHeart failure

Calcium antagonists(verapamil, diltiazem)

A–V block (grade 2 or 3, trifascicular block)Severe LV dysfunctionHeart failure

ACE inhibitors PregnancyAngioneurotic oedemaHyperkalaemiaBilateral renal artery stenosis

Women with child bearing potential

Angiotensin receptor blockers PregnancyHyperkalaemiaBilateral renal artery stenosis

Women with child bearing potential

Mineralocorticoidreceptor antagonists

Acute or severe renal failure (eGFR <30 mL/min)Hyperkalaemia

A-V, atrio-ventricular; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; LV, left ventricular.

Oral antihypertensive drugs*

Oral antihypertensive drugs* (continued)

ACEIs, angiotensin converting enzyme inhibitors; BBs, beta blockers; CCBs, calcium channel blockers* In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval (trough effect).BP should be measured just prior to dosing to determine if satisfactory BP control is obtained. Accordingly, an increase in dosage or frequency may need to be considered. These dosages may vary from those listed in the Physician’s Desk Reference (57th ed.).† Available now or becoming available soon in generic preparations.Source: Physician’s Desk Reference. 57th ed. Montvale, NJ: Thompson PDR, 2003.

Tabel No 2 Obat-obat parenteral untuk penanganan hipertensi emergensi pd edema paru dan sindroma koroner akut

Obat Golongan Dosis Onset kerja

Masa kerja

Efek samping

Sodiumnitroprusid

VasodilatorArteri & vena

0,25-10Mg/kg/mnt

Segera stlh distop

1-2 mnt

Mual, hipotensi,keracunan tiosianat, methemoglobinemia dan sianida.

Nitrogliserin Vasodilator:Arteri & vena

5-300 mcg/mnt

1-5 mnt 3-5 mnt

Sakit kepala, mual, takikardia, muntah toleransi

Isosorbid dinitrat

Vasodilator:Arteri & vena

1- 10 mg/jam

1-5 mnt 3-5 mnt

Sakit kepala,mual, takikardia, muntah, toleransi

Nikardipin Kalsiumantagonis

5-15mg/jam

5-15menit

30-40 menit

Hipotensi,takikardi,mual muntah, muka merah

Furosemide Diuretik loop

20-40 mg 10-20 mnt

4-6 jam

HipokalemiHipovolemia

17

Kelompok umur Hipertensi bermakna

Hipertensi berat

Neonatus 7 hari Td S > 96 Td S > 106

8 – 30 hari Td S > 104 Td S > 110

Bayi < 2 tahun Td S > 112Td D > 74

Td S > 118Td D > 84

Anak 3-5 tahun Td S > 116Td D > 76

Td S > 124Td D > 84

Anak 6-9 tahun Td S > 126Td D > 78

Td S > 84Td D > 130

Anak 10 –12 Td S > 126Td D > 82

Td S > 134Td D > 90

Remaja 13-15 tahun Td S > 136Td D > 86

Td S > 144Td D > 92

Remaja 16-18 tahun Td S > 142Td D > 92

Td S > 150Td D > 98

Tabel 1. Klasifikasi Hipertensi menurut kelompok umur

18

Obat Cara pembelian

Dosis Awal Respons Awal

Lamanya Respon

Efek Samping/ Komen

Diazoksid IV cepat (1-2 menit)

2-5 mg/kg, bila dalam 30 menit respons (-) ulangi

3-5 menit 4-24 jam Nausea, hiperglikemia rentsni natrium

Natrium Infus pompa 0,5 sampai 8 mikrogram/kg/menit

Segera Selama infus

Perlu monitor resiko ketatiosianat

Hidralazin

IV atau IM 0.1 - 0.2 mg/kg

10-30 menit 2-6 jam Takikardia, flushing, saku kepala

Reserpin IM 0.07 mg/kg, maksimal 2,5 mg

1,5 – 3 jam 2-12 jam Hidung tersumbat, respon lambat

Klonidin IMIV

0.002 mg/kg/kali. Ulangi 4-6 jam. Dapat dinaikan sampai 3 X lipat

IV : 5 menitIM :

beberapa menit lebih

lama

Beberapa jam

Mengantuk, bradikardia, kering. Hipertensi reboun

Tabel 2. Obat Antihipertensi untuk Penanggulangan Krisis Hipertensi

19

Klasifikasi/Nama Obat Dosis (oral/hari) Interval Dosis

Awal Maksimal

Diurettik

Hidroklorotiazid 1 mg/kg 2 mg/kg Sekali sehari

Klortalidon 1 mg/kg 2 mg/kg Sekali sehari

Spironolakson 1 mg/kg 3 mg/kg Tiap 12 jam

Furosemid 1 mg/kg 10 mg/kg Tiap 12 jam

Penghambar Adrenergik

Penghambat beta Propranolol

1 mg/kg 5 mg/kg Tiap 6 jam

Penghambat alfa Prazosin

0,05 mg/kg 0,5 mg/kg Tiap 8 jam

Tabel 3 a. Dosis Obat anti Hipertensi Oral pada Anak

20

Antiadrenergik sentral

Kolonidin 0,005 mg/kg 0,03 mg/kg Tiap 8 jam

Methildopa 5 mg/kg 40 mg/kg Tiap 6-12 jam

Bekerja pada ujung saraf simpatetik

Reserpin 0,02-0,07 mg/kg

2,5 mg kg Tiap 12 jam

Guanetidin 0,2 mg/kg 2 mg/kg Sekali sehari

Vasodilato langsung

Hidralazin 1 mg/kg 5 mg/kg Tiap 8-12 jam

Minosidil 0,1 mg/kg 1 mg/kg Tiap 12 jam

Calcium Channel Blocker

Nifedipin 0,25 mg/kg 1 mg/kg Tiap 12 jam

Diltiazem 2 mg/kg 3,5 mg/kg Tiap 12 jam

ACE Inhibiter

Captopril 0,3 mg/kg 6 mg/kg Tiap 6-12 jam

Tabel 3 b. Dosis Obat anti Hipertensi Oral pada Anak

21

1. Krisis hipertensi disertai gagal jantung maka pengobatan selain anti hipertensi, diuretika, digitalisasi juga diperlukan.

2. Krisis hipertensi disertai dengan gagal ginjal dengan ditandai uremia maka tindakan dilaisis perlu dilakukan[10]

Hal-hal yang memerlukan perhatian