HipertensiHipertensi secarasecara KlinikKlinik

Edwin Edwin Setiabudi,dr.SpPDSetiabudi,dr.SpPD

JNC VII : Classification of hypertension

Systolic Diastolic

Normal

Prehypertension

Stage 1 hypertension

Stage 2 hypertension

< 120

120-139

140-159

≥160

< 80

80-89

90-99

≥100

and

or

or

or

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension is one of the most frequent clinical disorders.

0

10

20

30

40

50

60

70

18-29 30-39 40-49 50-59 60-69 70-79 80+

SBP > 140 mm Hg DBP > 90 mm Hg

age (yrs)

prev

alen

ce o

f hyp

erte

nsio

n (%

)

4 11

21

44

54

64 65

Prevalence of HypertensionPrevalence of HypertensionPrevalence of Hypertension

(BANNAN L; BEEVERS DG; JACKSON SHD; :ABC HYPERTENSION 1981(BANNAN L; BEEVERS DG; JACKSON SHD; :ABC HYPERTENSION 1981

HYPERTENSIONHYPERTENSION

50% DIAGNOSED50% DIAGNOSED

50% TREATED50% TREATED

50% WELL DIAGNOSED50% WELL DIAGNOSED

50% NOT DIAGNOSED

50% NOT TREATED

50% POORLY CONTROLLED

• KEGEMUKAN• AKTIVITAS FISIK• PSIKOSOSIAL• KONSUMSI ALKOHOL• KONSUMSI MAKANAN : - NATRIUM, KALIUM. MAGNESIUM

- LEMAK JENUH

FAKTOR-FAKTOR YANG MENENTUKAN TINGGI TEKANAN DARAH INDIVIDU

FAKTOR LUAR

TIPE GEN• KELAINAN HEREDITER• GANGGUAN PERTUKARAN KATION MELALUI MEMBRAN ERITROSIT• KEPEKAAN TERHADAP GARAM NATRIUM / DAPUR

MEKANISME PENGATURAN TEKANAN DARAH1. ORGAN TUBUH

• VOLUME VASKULER• SISTEM KARDIAK• SISTEM SARAF SENTRAL

• SISTEM ENDOKRIN• SISTEM RENAL

2. MEDIATOR KIMIAWI DAN HORMONAL• NOREPINEFRIN• KATEKOLAMIN• ANGIOTENSIN-II (SISTEMIK & LOKAL)• PROSTAGLANDIN & KININ• HORMON NATRIURETIK : DIGOXIN - LIKE

ATRIAL NATRIURETIC PEPTIDECIRCULATING SODIUM TRANSPORT INHIBITOR

• ENDOTHELIUM-DERIVED CONTRACTING & RELAXING FACTORS (EDCF & EDRF)

Box 1. Cardiovascular Risk FactorBox 1. Cardiovascular Risk Factor””

Major Risk FactorMajor Risk FactorHypertension Hypertension Cigarette smokingCigarette smokingObesity (BMI Obesity (BMI ≥≥ 30) 30) Physical inactivityPhysical inactivityDyslipidemiaDyslipidemiaDiabetes mellitus Diabetes mellitus MicroalbuminuriaMicroalbuminuria or estimated GFR < 60 or estimated GFR < 60 mLmL / min/ minFamily history of premature cardiovascular disease ( men < 55 yeFamily history of premature cardiovascular disease ( men < 55 years ars

or women 65 years)or women 65 years)

TargetTarget--Organ DamageOrgan DamageIleartIleart

Left ventricular hypertrophyLeft ventricular hypertrophyAngina or prior myocardial infarctionAngina or prior myocardial infarctionPrior coronary revascularization Prior coronary revascularization Heart failureHeart failure

BrainBrainStroke or transient ischemic attackStroke or transient ischemic attack

Chronic kidney diseaseChronic kidney diseasePeripheral arterial diseasePeripheral arterial diseaseRetinopathyRetinopathy

* BMI indicates body mass index * BMI indicates body mass index calclatedcalclated as weight in kilograms divided by the as weight in kilograms divided by the sqaresqareof height in meters; GFR, of height in meters; GFR, glomerularglomerular filtration ratefiltration rateComponents of the metabolic syndromeComponents of the metabolic syndrome JAMA 2003; 289 : 2560 – 2570.

PenyebabPenyebab HipertensiHipertensi

PrimerSekunder90 %

10 %

HipertensiHipertensi SekunderSekunder

GangguanGangguan padapada ginjalginjal

GangguanGangguan padapada pembuluhpembuluh darahdarah

KerusakanKerusakan Organ Organ akibatakibat HipertensiHipertensi

TerapiTerapi NonNon--farmakologisfarmakologis

Diet yang Diet yang sehatsehat

KontrolKontrol beratberat badanbadan

KurangiKurangi garamgaram

NonNon--alkoholalkohol

Stop Stop merokokmerokok

OlahOlah ragaraga

55

Table 3. Lifestyle Modifications to Management Hypertension *Table 3. Lifestyle Modifications to Management Hypertension *

ModificationModification RecommendationRecommendation

Weight reductionWeight reduction

Approximate Systolic BPApproximate Systolic BPReduction, RangeReduction, Range

Adopt DASH eatingAdopt DASH eatingplanplan

Maintain normal body weight (BMI, 18.5Maintain normal body weight (BMI, 18.5--24.9)24.9) 55--20 mmHg/1020 mmHg/10--kg weight loss kg weight loss 23,24

Consume a diet rich in fruits, vegetables, andConsume a diet rich in fruits, vegetables, andlowlow--fat dairy products with a reducedfat dairy products with a reduced

content of saturated and total fat.content of saturated and total fat.

Dietary sodiumDietary sodiumreductionreduction

Reduce dietary sodium intake to no more thanReduce dietary sodium intake to no more than100 100 mEqmEq/L (2.4 g sodium or 6 g sodium/L (2.4 g sodium or 6 g sodiumchloride)chloride)

8 8 –– 14 mmHg 14 mmHg 25,2725,27

Physical activityPhysical activity Engage in regular aerobic physical activityEngage in regular aerobic physical activitysuch as brisk walking (at least 30 minutessuch as brisk walking (at least 30 minutes

per day, most days of the week)per day, most days of the week)8 8 –– 14 mmHg 14 mmHg 28,2928,29

Moderation of alcoholModeration of alcoholconsumptionconsumption

Limit consumption to no more than 2 drinksLimit consumption to no more than 2 drinksper day (1 oz or 30 per day (1 oz or 30 mLmL ethanol [ ethanol [ egeg. 24 oz. 24 ozbeer, 10 oz wine, or 3 oz 80beer, 10 oz wine, or 3 oz 80--proofproofwhiskey]) in most men and no more thanwhiskey]) in most men and no more than 8 8 –– 14 mmHg 14 mmHg 3030

1 drink per day in women and1 drink per day in women andlighterlighter--weight persons.weight persons.

Abbreviations; BMI, body mass index calculated as weight in kiloAbbreviations; BMI, body mass index calculated as weight in kilograms divided by the square of height ingrams divided by the square of height inmeters; BP blood pressure; DASH, Dietary Approaches to Stopmeters; BP blood pressure; DASH, Dietary Approaches to Stop Hypertension.Hypertension.

* For overall cardiovascular risk reduction, stop smoking. The* For overall cardiovascular risk reduction, stop smoking. The effects of implementing these modifications are dose and time effects of implementing these modifications are dose and time dependent and could be higher for some individuals.dependent and could be higher for some individuals.

8 8 –– 14 mmHg 14 mmHg 25,2625,26

JAMA 2003; 289 : 2560 – 2570.

JNC 7 AlgorithmJNC 7 Algorithm

Not at goal BP (<140/90 mmHg) (<130/80 mmHg for diabetes or proteinuria

Drugs

Lifestyle

Stage 2 hypertension (SBP ≥160 or DBP ≥100)

Start 2 drugs, HCTZ +ACEI, or ARB, or BBL, or

CCB

Stage 1 hypertension(SBP 140–159 or DBP 90–99)

HCTZ May consider ACEI, ARB, BBL,

CCB,

Without other problems

Drug(s) for the problem ie.

Statin, Aspirin, Metformin etc.

HCTZ, ACEI, ARB, BB, CCB as needed

With other problems

Increase dose or add more drugs until goal BP is achieved

Consult with hypertension specialist

Not at goal BP

Chobanian AV et al.2003;42:1206–52

< 140/90

Rendah garamOlahragaBBStop rokok

MulaiMulai thth/ / dg dg

ThiazideThiazide

Diuretik

ARB

Antagonis

kalsium

ACE inhibitor

α- blocker

β- blocker

Kombinasi golongan obat anti hipertensi yang rasional

Box 3. Causes of Resistant HypertensionBox 3. Causes of Resistant HypertensionImproper blood pressure measurementImproper blood pressure measurementVolume overload and Volume overload and pseudotolerancepseudotolerance

Excess sodium intakeExcess sodium intakeVolume retention from kidney diseaseVolume retention from kidney diseaseInadequate diuretic therapyInadequate diuretic therapy

DrugDrug--induced or other causesinduced or other causes

NonadherenceNonadherenceInadequate dosesInadequate dosesInappropriate combinationsInappropriate combinationsNonsteroidalNonsteroidal antianti--inflammatory drugs; inflammatory drugs; cyclooxygenasecyclooxygenase 2 inhibitors2 inhibitorsCocaine, amphetamines, other illicit drugsCocaine, amphetamines, other illicit drugsSympathomimeticsSympathomimetics (decongestants, (decongestants, anorectiesanorecties))Oral contraceptivesOral contraceptivesAdrenal steroidsAdrenal steroidsCyclosporine and Cyclosporine and tacrolimustacrolimusErythropoietinErythropoietinLicorice (including some chewing tobacco)Licorice (including some chewing tobacco)Selected overSelected over--the counter dietary supplements and medicines the counter dietary supplements and medicines

((egeg, , ephedraephedra, ma , ma haunghaung, bitter orange), bitter orange)

Associated conditionsAssociated conditionsObesityObesityExcess alcohol intakeExcess alcohol intake

Identifiable causes of hypertension (see Box 2)Identifiable causes of hypertension (see Box 2)

JAMA 2003; 289 : 2560 – 2570.