Kuliah Blok CVS-Hipertensi

8/19/2019 Kuliah Blok CVS-Hipertensi

1/49

HIPERTENSI


2/49


3/49

B P = CO xB P = CO x

SVR SVR

SV x HR SV x HR BP-blood pressure-tekanan darah.BP-blood pressure-tekanan darah.SVR-systemic vascular-resistance-SVR-systemic vascular-resistance-

tahanan perifer.tahanan perifer.

SV-stroke volume-isi sekuncup.SV-stroke volume-isi sekuncup.HR-heart rate-denyut jantung.HR-heart rate-denyut jantung.


4/49

Framingham – Study

Blood pressure and Age

Women

Men

MenWomen

Systolic BP

Diastolic BP

36 41 46 1 6 61 66 !1 !6 "1 #ears age

16$

1$

14$

13$1%$

&$

"$

!$

B P m m '

g

(annel et al 1&!"


5/49

Defnisi danDefnisi dan

klasifkasi/kriteriaklasifkasi/kriteriamenurut WHO, ISH, JNCmenurut WHO, ISH, JNC


6/49

• Tekanan darah sistolik lebih besar

atau sama dengan 140 mmHg, dan /

atau• Tekanan darah diastolik lebih besar

atau sama dengan 90 mmHg, atau

• Pasien dalam pengobatan antihipertensi.

HIPETE!"I


7/49

)he *+, -. classi/ication o/ 0lood pressure)he *+, -. classi/ication o/ 0lood pressure

/or adults 1" years old/or adults 1" years old11

CategoryCategory Systolic bloodSystolic blood Diastolic bloodDiastolic bloodpressure (mmHg)pressure (mmHg) pressure (mmHg)pressure (mmHg)

OptimalOptimal22


8/49


9/49

!5 6II


10/49Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension is one o- t"e most -reuent clinical discorders+

0

10

20

0

%0

!0

&0

'0

1832$ 03$ %03%$ !03!$ &03&$ '03'$ 804

S,5 > 1%0 mm Hg

D,5 > $0 mm Hg

age (yrs)

p r e a

l e n c e o - " y p e r t e n s i o n ( 6 )

% 11

21

%%

!%

&% &!

Prevalence ofPrevalence of

HypertensionHypertension


11/49

10 %

90 %

"e3ondar+h+pertension

Primar+

h+pertension

enalenal

Paren3h+malParen3h+mal

6as3ular6as3ular

#thers#thers

Endo3rineEndo3rine

!eurogeni3 !eurogeni3 7is3ellaneous7is3ellaneous

8nknon8nknon

!o underl+ing 3ause


12/49

!ase Hi"ertensi!ase Hi"ertensi


13/49

#arl$ %r H$"erkinetiarl$ %r H$"erkineti&

'$"ertensi%n'$"ertensi%nlinical signs ! systolic bloodlinical signs ! systolic blood

pressure higher than normal"pressure higher than normal"

diastolic blood pressurediastolic blood pressurenormal.normal.

Pathophysiology ! high cardiacPathophysiology ! high cardiacoutput or tachycardia.output or tachycardia.

#oung adult patients. #oung adult patients.


14/49

C'r%ni& %r #sta(lis'edC'r%ni& %r #sta(lis'ed

H$"ertensi%nH$"ertensi%nlinical signs ! systolic andlinical signs ! systolic and

diastolic blood pressure elevated.diastolic blood pressure elevated.

Pathophysiogy ! higher vascularPathophysiogy ! higher vascularresistance" but cardiac outputresistance" but cardiac output

normal or little lo$er thannormal or little lo$er than

normal. %ortic compliancenormal. %ortic compliancenormal.normal.


15/49

Is%lated S$st%li&Is%lated S$st%li&

H$"ertensi%n )ISH*H$"ertensi%n )ISH*linical signs ! high systolic bloodlinical signs ! high systolic blood

pressure" diastolic blood pressurepressure" diastolic blood pressure

normal or lo$.normal or lo$.Pathophysiology ! &ecreasedPathophysiology ! &ecreased

aortic compliance caused byaortic compliance caused by

atherosclerotic in aortic andatherosclerotic in aortic andartery vascular system.artery vascular system.

'lderly patients'lderly patients


16/49

Is%lated S$st%li&Is%lated S$st%li&

H$"ertensi%nH$"ertensi%n)ISH*)ISH*

diastolic blood pressurediastolic blood pressure

Sti(ness )atherosclerotic* of aortic andSti(ness )atherosclerotic* of aortic and

arteryartery

organ damage )morbidity + mortality*organ damage )morbidity + mortality*


17/49

,risis 'ypertensi2e,risis 'ypertensi2e

• H+pertensie

en3ephalopath+.

• :3ute aorti3 disse3tion.

• Pulmonar+ edema.

• Pheo3hromo3+toma 3risis.

• 7:# inhibitor ; t+ramine

intera3tion.

• E3lampsia.

H+pertensie emergen3+

• H+pertension asso3iatedith 5:


18/49

Hem%d$nami& &'an+es inHem%d$nami& &'an+es in

H$"ertensi%nH$"ertensi%n


19/49

C%nseuen&es %-C%nseuen&es %-

'$"ertensi%n'$"ertensi%n


20/49

C%nseuen&esC%nseuen&es

,eft Ventricular Hypertrophy,eft Ventricular Hypertrophy

-angina-angina

-arrythmias-arrythmias-myocardial infarction-myocardial infarction

-contributes to congestive heart-contributes to congestive heart

failurefailure


21/49

C%nseuen&es &%nt.C%nseuen&es &%nt.

oronary %rtery &iseaseoronary %rtery &isease

-accelerated atherosclerosis-accelerated atherosclerosis

-decrease in oygen supply-decrease in oygen supply-in addition to high stystolic $ork-in addition to high stystolic $ork

load also contributes to risk ofload also contributes to risk of

myocardial infarctionmyocardial infarction


22/49

C%nseuen&es &%nt.C%nseuen&es &%nt.

StrokeStroke

-Hypertension induced strokes-Hypertension induced strokes

result from hemorragic )rupture ofresult from hemorragic )rupture of

microaneurysms in cerebral vessels*microaneurysms in cerebral vessels*

or atherothrombotic )plaues inor atherothrombotic )plaues in

carotids or major cerebral arteriescarotids or major cerebral arteries

break o( and emboli/e in smallerbreak o( and emboli/e in smaller vessels conditions.* vessels conditions.*


23/49

ar+et Or+an Dama+e inar+et Or+an Dama+e in

H$"ertensi%nH$"ertensi%nOr+an S$stemOr+an S$stem 0ani-estati%ns0ani-estati%ns

HeartHeart -1e-t 2entri&ular1e-t 2entri&ular'$"ertr%"'$ '$"ertr%"'$

-Heart -ailureHeart -ailure

-0$%&ardial is&'emia and0$%&ardial is&'emia andin-ar&ti%nin-ar&ti%n

Cere(r%2as&ular Cere(r%2as&ular Str%keStr%ke

3%rta and "eri"'eral 3%rta and "eri"'eral 2as&ular 2as&ular

- 3%rti& aneur$sm and/%r 3%rti& aneur$sm and/%rdisse&ti%ndisse&ti%n

- 3rteri%s&ler%sis 3rteri%s&ler%sis

4idne$ 4idne$ -Ne"'r%s&ler%sisNe"'r%s&ler%sis

-Renal -ailureRenal -ailure

RetinaRetina - 3rterial narr%5in+ 3rterial narr%5in+

-Hem%rr'a+es, exudates,Hem%rr'a+es, exudates,


24/49

3R6# OR63N3R6# OR63N

D3036#D3036#


25/49


26/49

Rek%mendasi "en+%(atanRek%mendasi "en+%(atan

'i"ertensi'i"ertensi

Pemilihan obatPemilihan obat

anti hipertensianti hipertensi

berkaitan denganberkaitan dengan

kerusakan targetkerusakan target

organ" penyakitorgan" penyakit

kardiovaskulerkardiovaskuler

dan ada+tidak adadan ada+tidak ada

&0.&0.


27/49

ULE OF

ULE OF

HALVES

ALVES

#nl+ H:=> o? all h+pertensie patients are#nl+ H:=> o? all h+pertensie patients are :@:E:@:E

#nl+ H:=> o? those aare are#nl+ H:=> o? those aare are TE:TE o? those treated hae their#nl+ H:=> o? those treated hae their AP 5#!T#==E


28/49


29/49

,lasses o/ antihypertensi2e agents,lasses o/ antihypertensi2e agents

&iuretics&iuretics thia/ides and relatedthia/ides and related

agentsagents loop diureticsloop diuretics 1 1 22-sparing diuretics-sparing diuretics

Sympatholytic drugsSympatholytic drugs centrally acting agentscentrally acting agents adrenergic neurone-adrenergic neurone-

blocking agentsblocking agents ββ adrenergic antagonistsadrenergic antagonists αα33 adrenergic antagonistsadrenergic antagonists

multiple-actionmultiple-actionneurohormonalneurohormonal

antagonistsantagonists

Vasodilators Vasodilators arterial dilatorsarterial dilators

arterial and venousarterial and venous

dilatorsdilators

aa4242 channel blockerschannel blockers

%' inhibitors %' inhibitors

%ngiotensin 55 %ngiotensin 55

receptor antagonistsreceptor antagonists

7oodman and 7ilman (1$$&)

8uidelines /or Selecting Drug )reatment o/8uidelines /or Selecting Drug )reatment o/


30/49


'ypertension'ypertensionlass of &ruglass of &rug ompellingompelling PossiblePossible ompellingompelling PossiblePossible

indicationindication indicationindication contraindicationcontraindication contraindicationcontraindication

&iuretic&iuretic Heart failureHeart failure &iabetes&iabetes 6out6out &yslipidaemia&yslipidaemia'lderly patients'lderly patients Seually activeSeually activemalesmales

Systolic hypertensionSystolic hypertension

Beta BlockersBeta Blockers %ngina %ngina Heart failureHeart failure %sthma and 7P& %sthma and 7P& &yslipidaemia&yslipidaemia %fter myocardial infarct %fter myocardial infarct PregnancyPregnancy Heart block Heart block

aa %thletes and %thletes and8achyarrhytmias8achyarrhytmias &iabetes&iabetes physically patients physically patients

Peripheral vascularPeripheral vascular diseasedisease

%' inhibitors %' inhibitors Heart failureHeart failure PregnancyPregnancy,eft ventricular,eft ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunction %fter myocardial %fter myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosis&iabetic nephropathy&iabetic nephropathy

alciumalcium %ngina %ngina PeripheralPeripheral Heart blockHeart block bb ongestive heartongestive heart antagonistsantagonists 'lderly patients'lderly patients vascular vascular

Systolic hypertensionSystolic hypertension disease disease

%lfa Blockers %lfa Blockers Prostatic hypertrophyProstatic hypertrophy 6lucose6lucose7rthostatic7rthostatic

intoleranceintolerance&yslipidaemia&yslipidaemia hypotensionhypotension

%ngiotensine 55 %ngiotensine 55 %' inhibitors cough %' inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal


31/49

Ideal HypertensionIdeal Hypertension

Agent :Agent :

• Once DailyOnce Daily

• Smooth anti HT efectSmooth anti HT efect

• Well tolerated, minimal SEWell tolerated, minimal SE

• Benecial !" efect independent o# B$ lo%eringBenecial !" efect independent o# B$ lo%ering

Int’l Forum on Angiotensin Receptor Antagonism, Monte

Carlo 1999


32/49

9 95s to achieve the maimum5s to achieve the maimum

reduction in the total risk ofreduction in the total risk of

ardiovascular morbidity andardiovascular morbidity and

mortality:mortality:

8A9S F8A9S F

):;A)M;+)):;A)M;+)

edu3e 56< and renal morbidit+ and mortalit+.Treat to AP $140/90 mmHg or AP $1'0/&0 mmHg in

patients ith diabetes or 3hroni3 kidne+ disease.:3hiee "AP goal espe3iall+ in persons 2(0 +ears o?

age.


33/49


34/49

&'! "I ( 'EW B$ )OA*S &'! "I ( 'EW B$ )OA*S


35/49

!5 6I

%,67R58H0 ;7R 8H' 8R'%80'


36/49

%,67R58H0 ;7R 8H' 8R'%80'


37/49

AP 5lassi?i3ationAP 5lassi?i3ation

"+stoli3"+stoli3APAP

mm Hgmm Hg


38/49

Strati=cation of Risk to CuantifyStrati=cation of Risk to Cuantify

PrognosisPrognosis

Blood Pressure mm'g

ther :is> Factors

Disease 'istory

8rade 1mild hypertension

SBP 14$71&

or DBP &$7&&

8rade %moderate hypertension

SBP 16$71!&

or DBP 1$$71$&

8rade 3se2ere hypertension

SBP 1"$

or DBP 11$

. no other ris> /actors

LOW RISK MED RISK HIGH RISK

.. 17% ris> /actors

MED RISK MED RISK VERY HIGH RISK

... 3 or more ris> /actors or )D or dia0etes HIGH RISK HIGH RISK VERY HIGH RISK

.- A,, VERY HIGH RISK VERY HIGH RISK VERY HIGH RISK

Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. Hypertens

TOD = Target Organ Damage

Initiation o? Treatment


39/49

Initiation o? Treatment

S,5 1%03180 mmHg or D,5 $03110 mmHg

on seeral occasions (7rades 1 2 "ypertension)

9ssess ot"er ris -actors :OD and CCD

nitate ;i-estyle easures

Strati-y 9bsolute =is

/ery Hig" Hig" edium ;o*

,egindrug

treatment

,egindrug

treatment

onitor ,5 andot"er ris -actors-or 3 & mont"s

onitor ,5 andot"er ris -actors-or & 3 12 mont"s

S,5 > 1%0 orD,5 > $0

,egin drugtreatment

S,5 < 1%0 orD,5 < $0

Continue tomonitor

S,5 > 1%0or D,5 > $0,egin drugtreatment

S,5 < 1%0or D,5 < $0Continue to

monitor

1. TOD - Taeget Organ Damage (precious WHO Stage 2 hpertension! "#$2. && - ssociate' &inica &on'ition incu'ing cinica car'io)ascuar 'isease an' rena 'isease

(pre)ious WHO Stage * hpertension! "#$


40/49

• =ose eight i? oereight. • =imit al3ohol intake to no more than 1)% drinks per da+

euialent to approFimatel+ 1()'0 m= ethanol per da+-.• In3rease aerobi3 ph+si3al a3tiit+ to '0 ) 4( minutes on

most da+s.• edu3e sodium intake to no more than 100 mmol per da+

%.4 g sodium or g sodium 3hloride per da+-.• 7aintain adeuate intake o? dietar+ potassium

approFimatel+ 90 mmol per da+-. Inadeuate intake ma+

in3rease blood pressure.

• 7aintain adeuate intake o? dietar+ 3al3ium and magnesium ?or general health. Inadeuate intake ma+ in3rease blood

pressure.• "top smoking and redu3e intake o? dietar+ saturated ?at and

3holesterol ?or oerall 3ardioas3ular health.

The li?est+le modi?i3ations


41/49

H$"ertensi2e HeartH$"ertensi2e Heart

DiseasesDiseases


42/49

ar+et Or+an Dama+e inar+et Or+an Dama+e in

H$"ertensi%nH$"ertensi%nOr+an S$stemOr+an S$stem 0ani-estati%ns0ani-estati%ns

HeartHeart -1e-t 2entri&ular1e-t 2entri&ular'$"ertr%"'$ '$"ertr%"'$

-Heart -ailureHeart -ailure

-0$%&ardial is&'emia and0$%&ardial is&'emia andin-ar&ti%nin-ar&ti%n

Cere(r%2as&ular Cere(r%2as&ular Str%keStr%ke

3%rta and "eri"'eral 3%rta and "eri"'eral 2as&ular 2as&ular

- 3%rti& aneur$sm and/%r 3%rti& aneur$sm and/%rdisse&ti%ndisse&ti%n

- 3rteri%s&ler%sis 3rteri%s&ler%sis

4idne$ 4idne$ -Ne"'r%s&ler%sisNe"'r%s&ler%sis

-Renal -ailureRenal -ailure

RetinaRetina - 3rterial narr%5in+ 3rterial narr%5in+

-Hem%rr'a+es, exudates,Hem%rr'a+es, exudates,

- - -- - -t di hi t f t ll dt di hi t f t ll d


43/49

standing history of uncontrolledstanding history of uncontrolled

hypertension sho$ing left atrialhypertension sho$ing left atrial

enlargement and left ventricularenlargement and left ventricular

hypertrophy.hypertrophy.

'6 o a ?E-year-o man $it ong-o a -year-o man $ t ong-

http://www.emedicine.com/med/images/150072-162449-3547.jpg


44/49

6 o a E yea o a t o go a yea o a t o gstanding hypertension sho$ing left atrialstanding hypertension sho$ing left atrial

abnormality and left ventricularabnormality and left ventricular

hypertrophy $ith strain.hypertrophy $ith strain.

8$o-dimensional echocardiogram of a D@-8$o-dimensional echocardiogram of a D@-



45/49

8$o dimensional echocardiogram of a D@8$o dimensional echocardiogram of a D@

year-old $oman )parasternal long ais vie$* year-old $oman )parasternal long ais vie$*

sho$ing concentric left ventricularsho$ing concentric left ventricular




46/49

Short ais vie$ ! concentric leftShort ais vie$ ! concentric left

ventricular hypertrophic ventricular hypertrophic

6 i f th h t ith6ross specimen of the heart $ith



47/49

6ross specimen of the heart $ith6ross specimen of the heart $ith

concentric left ventricularconcentric left ventricular



http://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPG


48/49

g gg g'ypertension'ypertension

lass of &ruglass of &rug ompellingompelling PossiblePossible ompellingompelling PossiblePossibleindicationindication indicationindication contraindicationcontraindication contraindicationcontraindication

&iuretic&iuretic Heart failureHeart failure &iabetes&iabetes 6out6out &yslipidaemia&yslipidaemia'lderly patients'lderly patients Seually activeSeually activemalesmales

Systolic hypertensionSystolic hypertension

Beta BlockersBeta Blockers %ngina %ngina Heart failureHeart failure %sthma and 7P& %sthma and 7P& &yslipidaemia&yslipidaemia %fter myocardial infarct %fter myocardial infarct PregnancyPregnancy Heart block Heart block

aa %thletes and %thletes and8achyarrhytmias8achyarrhytmias &iabetes&iabetes physically patients physically patients

Peripheral vascularPeripheral vascular diseasedisease

%' inhibitors %' inhibitors Heart failureHeart failure PregnancyPregnancy,eft ventricular,eft ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunction %fter myocardial %fter myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosis&iabetic nephropathy&iabetic nephropathy

alciumalcium %ngina %ngina PeripheralPeripheral Heart blockHeart block bb ongestive heartongestive heart antagonistsantagonists 'lderly patients'lderly patients vascular vascular

Systolic hypertensionSystolic hypertension disease disease

%lfa Blockers %lfa Blockers Prostatic hypertrophyProstatic hypertrophy 6lucose6lucose7rthostatic7rthostatic

intoleranceintolerance&yslipidaemia&yslipidaemia hypotensionhypotension

%ngiotensine 55 %ngiotensine 55 %' inhibitors cough %' inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal


49/49

H3N4 9O8H3N4 9O8

Kuliah Blok CVS-Hipertensi

Documents

Transcript of Kuliah Blok CVS-Hipertensi