HIPERTENSI 123

8/13/2019 HIPERTENSI 123

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HYPERTENSION

MAIMUN SYUKRI


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Batasan Hipertensi

1. Bila tekanan sistolik >= 140 mmHg, danatau tekanan diastolik >= 90 mmHg,

atau sedang mendapat obatantihipertensi.

2. Dilakukan dua kali atau lebihpengukuran pada dua kali atau lebihkunjungan.


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Blood Pressure Classification

Normal 100

BPClassification SBPmmHg DBPmmHg


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WHO/ISH 2003.


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ESC/ESH 2003 .


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Classification of blood pressure levels of theBritish Hypertension Society

Brit Med J 2004 328:634-40.

Category Systolic blood pressure Diastolic blood pressure(mmHg) (mmHg)

Optimal


7/55AUSTRALIA 2003


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BP Measurement Techniques

Method Brief Description

In-office Two readings, 5 minutes apart,sitting in chair. Confirm elevatedreading in contralateral arm.

Ambulatory BPmonitoring

Indicated for evaluation of white-coat HTN. Absence of 1020% BPdecrease during sleep may indicateincreased CVD risk.

Self-measurement Provides information on responseto therapy. May help improveadherence to therapy and evaluatewhite-coat HTN.

JNC 7 2003


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Office BP Measurement

Use auscultatory method with a properly calibrated and validated

instrument.

Patient should be seated quietly for 5 minutes in a chair

(not on an exam table), feet on the floor, and arm supported at heartlevel.

Appropriate-sized cuff should be used to ensure accuracy.

At least two measurementsshould be made.

Clinicians should provide to patients, verbally and in writing,

specific BP numbers and BP goals.

JNC 7 2003


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sphygmomanometer

Patient should be seated and relaxed, preferably for several

minutes prior to the measurement and in a quiet room.

Appropriate cuff size.

Average the readings. If the firsty 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,

..

How to measure blood pressure accurately

Australia, 2004


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Box 2 Procedures for blood pressure measurement

When measuring blood pressure, care should be taken to .. to sit for several minutes in a quiet room before

beginning blood pressure measurements.

Take at least two measurements spaced by 1-2 min, .

Use a standard bladder . but have a larger and a smallerbladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of thepatient.

Use phase I andV .

Measure blood pressure in both arms at first visit to detectpossible differences ..

Measure blood pressure 1 and 5 min after assumption ofthe standing position in elderly subjects, diabeticpatients,..

Measure heart rate by pulse palpation (30 s) after the

second measurement in the sitting position.ESC/ESH 2003


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HIPERTENSI

Tekanan Darah :

Rata-rata dari 2 kali pemeriksaan Pengukuran pada waktu yang berbeda

Pengukuran pada waktu duduk

12


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TD kekuatan darah ketika melewatidinding arteri

Jenis Hipertensi

Hipertensi ResistenHipertensi Emergensi

Hipertensi Urgensi

Berdasarkan Penyebab

Hipertensi Primer idiopatik 90-95%Hipertensi Skunder Sistemik


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Prevalensi Hipertensi

USA 50 Juta dari totalPenduduk

( 1 dari 4 orangdewasa)

Indonesia Baliem 0,65%

Sukabumi 28,6%


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Etiology

Primary hypertension

95% of all cases

Secondary hypertension

5% of all cases

Chronic renal disease most common


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CVD Risk Factors

Hypertension*

Cigarette smoking

Obesity* (BMI >30 kg/m2)

Physical inactivity

Dyslipidemia*

Diabetes mellitus*

Microalbuminuria or estimated GFR


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IdentifiableCauses of Hypertension

Sleep apnea

Drug-induced or related causes

Chronic kidney disease

Primary aldosteronism

Renovascular disease

Chronic steroid therapy and Cushings syndrome

Pheochromocytoma Coarctation of the aorta

Thyroid or parathyroid disease


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Target Organ Damage

Heart

Left ventricular hypertrophy

Angina or prior myocardial infarction

Prior coronary revascularizationHeart failure

Brain

Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy


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Origin Category

Large arteries Loss of compliance

(Dissecting) aneurysm

Peripheral occlusive arterial disease

Kidney Nephrosclerosis

Categories of hypertensiveend-organ damage

Birkenhger and de Leeuw (1992)


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Hipertensi & Kerusakan Organ Target


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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 testsMeasurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated

unless BP control is not achieved


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TreatmentOverview

Goals of therapy

Lifestyle modification

Pharmacologic treatmentAlgorithm for treatment of hypertension

Classification and management of BP for adults

Followup and monitoring


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Goals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP


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Sign and Symptoms

Essential HTN is usually

- asymptomatic

- undetected for many years- headache, BP elevated systolic

beyond 200 mmHg or BP rising

rapidly (can occur in malignantHTN)


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Symptomatic associated withmalignant HTN

Headache

Blurred vision

Chest pain Breathlessness

Nausea, vomiting

Anxiety, confusion, coma Seizures


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Consequences of Malignant HTN

End Organ Complications

Aorta Aortic disection

Brain Hipertensive encepahlopathy

Cerebral Infarction or Haemmorharge

Heart Cardiac failureMyocardial ischemic or infarction

Kidney Renal failure

Haematuria

Gastrointestinal Anorexia,nausea,vomiting,abdominalpain

Placenta Eclampsia

Other Micro-angiopathic haemolytic anemia


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Consequences of hypertension

Cardiac diseaseLeft ventricular failureAngina

Myocardial infarction

Cerebrovascular diseaseTransient ischemic attacks

StrokeMulti-infarct dementiaHypertensive encephalopathy


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Consequences of hypertension

Vascular disease

Aortic aneurysm

Occlusive peripheral vascular diseaseArterial dissection

OthersProgressive renal failure

Hypertensive retinopathy


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Risk of Hypertension

Advancing age

Positive family history of prematurecardiovascular disease

Smoking

Hypercholesterolemia


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Hypertension is thought to account for :

- Onehalf of all deaths due to stroke

- Up to one quarter of coronary heartdisease deaths


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Isolated Systolic hypertension increasethe risk of :

stroke and coronary heart disease byabout 40%

cardiovascular death by about 50%

heart failure by about 50%


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Aetiology of hypertension

Essential hypertension

(primer/idiopathic hypertension

remain uncertain(genetic and environmental factors

contribute to development of

hypertension)



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Renal parenchymal disease, causes :

- the glomerulonephritides

- diabetic nephropathy- analgesic nephropathy

- adult polycystic kidney disease

Renal artery stenosis Primary hyperaldosteronism

Phaeochromocytoma



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Aortic coarctation

Cushings syndrome

Drug induced hypertension

- the oral contraception pill

- steroids

- NSAID

- immunosuppressive

- sympathomimetics

- anabolic steroids- erythropoieti n

- monoamin oxidase inhibitors

Thyrotoxicosis

Rare monogenic syndrome


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Clinical assesment of hypertension

Sign and symptoms

Pointers to secondary hypertension

Features of malignant hypertension

End organ damage

Hypertensive nephropathy

Left ventricular hypertrophy Hypertensive retinopathy


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Treatment

Non Pharmacotherapy

(lifestyle modification)

Pharmacotherapy


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Tujuan:

ANGKA KESAKITAN

KERUSAKAN ORGAN TARGET

ANGKA KEMATIAN

Pengobatan


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Sasaran Pengelolaan

Menilai gaya hidup dan identifikasi faktorrisiko kardiovaskular lain atau gangguan

yang menyertai yang dapat

mempengaruhi prognosis & pengobatan

Mengetahui penyebab tekanan darah

yang tinggi

Menilai adanya kerusakan organ dan

penyakit kardiovaskular

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Strategi Penatalaksanaan Hipertensi

JNC:

Preventif

Deteksi

Evaluasi

PengobatanJNC VI, 1997


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Preventif

Untuk mencegah atau memperlambat terjadinyaHipertensi

Merupakan solusi jangka panjang masalah hipertensi

Mencegah terjadi komplikasi

Dapat menghentikan atau mengurangi biaya

pengobatan dan komplikasi

NHBPEP Working Group Report on Primary Prevention of Hypertension


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Preventif

Upaya preventif primer:

Terhadap individu yang potensialhipertensi:

TD normal tinggiRiwayat keluarga hipertensi

Obesitas

Konsumsi tinggi garam

Kurang aktifitas

Konsumsi tinggi alkohol

Diharapkan prevalensi Hipertensi turun


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Intervensi Preventif Primer

Terbukti Efektif

Turunkan BB

Kurangi Garam

Kurangi Alkohol

Olah Raga

Efektif terbatas

Manajemen Stres

Kalium

Minyak Ikan (Fish oil)

Kalsium

Magnesium

Serat

Cegak makronutrien


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Deteksi

Dilakukan di fasilitas kesehatandengan alat ukur yang standar dancara yang benar

Pasien diberitahu tentang maknaTDnya

Pasien dianjurkan melakukanpemeriksaan periodik sesuai denganTD pertama

Diharapkan ditemukan kasus tahapawal


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Evaluasi

Mencari penyebab hipertensi(sekunder)

Memeriksa adanya kerusakan organtarget dan penyakit lain

Mencari faktor risiko

Mengetahui respon pengobatan, efeksamping dan kepatuhan pasien

WHO-ISH Guidelines for Management


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WHO ISH Guidelines for Managementof Hypertension: Stratification ofCardiovascular Risk

Blood Pressure (mm Hg)

Grade 1 Grade 2 Grade 3

Mildhypertension

Moderatehypertension

Severehypertension

ther risk factors andisease history

SBP 140159

or DBP 9099

SBP 160179

or DBP 100109

SBP 180

or DBP 110

No other risk factors Low risk Med risk High risk

I 12 risk factors Med risk Med risk Very high risk

II 3 or more risk factors or TOD or diabetes

High risk High risk Very high risk

V ACC Very high risk Very high risk Very high risk

TOD = Target-organ damage

ACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH

Guidelines. J Hypertens1999;17:151-183.


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BP TARGETS:

WITHOUT COMPLICATION : 1 g/d :


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Lifestyle Modification

Modification Approximate SBP

reduction(range)

Weight reduction 520mmHg/10 kg weight loss

Adopt DASHeating plan

814 mmHg

Dietary sodiumreduction

28 mmHg

Physical activity 49 mmHg

Moderation ofalcoholconsumption

24 mmHg

f l d f


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For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Lifestyle Recommendations forHypertension: Physical Activity

Should be prescribed to reduce blood pressure

TypeDynamic exercise- Walking- Cycling- Non-competitive swimming

Time - 45-60 minutes

Intensity - Moderate

Frequency - Four or five times per weekF

I

T

T


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Treatment of Hypertension

Diuretic

ACE-Inh

ARB

Beta blocker

Alpha blocker

Direct renin inhibitor

Treatment Algorithm for Adults with Systolic-


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Diastolic Hypertension withoutanothercompelling indication

TARGET


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Indications forPharmacotherapy

Stronglyconsider prescription if: Average DBP equal or over 90 mmHg and:

Hypertensive Target-organ damage (or CVD) or

Independant cardiovascular risk factors

Elevated systolic BP

Cigarette smoking

Abnormal lipid profile

Strong family history of premature CV disease

Truncal obesity

Sedentary Lifestyle

Average DBP equal or over 80 mmHg and

diabetes

Diuretics


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Diuretics

-blockers AT1receptor

blockers

Ca Antagonist-blockers

ACE Inhibitors

2003 Guidelines for Management of Hypertension, J of Hypertension 2003

C.I. : Verapamil + Blocker ESH-ESC 2003

JNC 7: Management of Hypertension by


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JNC 7: Management of Hypertension byBlood Pressure Classification

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;CCB = calcium channel blocker.

Chobanian AV et al. JAMA. 2003;289:2560-2572.

Drug(s) for the compellingindications; otherantihypertensive drugs(diuretics, ACE-I, ARB,BB, CCB) as needed

Drug(s) for the compellingindications; otherantihypertensive drugs(diuretics, ACE-I, ARB, BB,CCB) as needed

BP Classification

Lifestyle

Modification

Initial Drug Therapy

Without Compelling

Indication

With Compelling

Indication

Normal


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Diabetes

Chronic kidneydisease

Recurrent strokeprevention

Compelling Indications forIndividual Drug Classes

CompellingIndication

Initial TherapyOptions

Clinical TrialBasis

NKF-ADAGuideline, UKPDS,ALLHAT

NKF Guideline,Captopril Trial,RENAAL, IDNT,

REIN, AASK

PROGRESS

THIAZ, BB, ACE,

ARB, CCB

ACEI, ARB

THIAZ, ACEI

HIPERTENSI 123

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