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8/12/2019 Kulidfzsgdfhgjah Hdyfugihojpkl;T

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Dr. Suryono,SpJP.FIHA

Bagian-SMF Kardiologi & Kedokteran VaskularFK UNEJ / RSD dr. Soebandi

J E M B E R

HipertensiDiagnosis, Pencegahan dan Terapi


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>100atau> 160Stage 2

90-99atau140-159Stage 1

Hipertensi

80-89atau120-139

Pre Hipertensi


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

Hipertensi salah satu dari penyakit yang sering dijumpai di klinik

010203040506070

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

SBP >140 mm Hg

DBP > 90 mm Hg

age (yrs)

prevalenceofhyperten

sion(%)

4 11

21

4454

64 65

Prevalensi dari Hipertensi


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Hypertension Prevalence and

Treatment:

North America and Europe

0

5

10

15

20

25

30

35

4045

50

55

Country

%

USCanada

Germany

ItalySweden

EnglandSpainFinland

0

10

20

30

40

50

60

70

80

90

100

Country

%

Wolf-Maier K et al. JAMA.2003;289:2363-2369.

Patients on Therapy


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23% 16%42%19%

Hypertensive patients

who are treated

but uncontrolled


who are treated

and controlled


who are unaware

Patients who are aware

but remain untreated

and uncontrolled

22 % of American adults 18 to 70 years of age have hypertension

20 % of Indonesian adults have hypertension

New Criteria (WHO-ISH 1999) 140 / 90 mmHg

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102


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Presentasi pasien hipertensiyang terkontrol

Adapted from G. Mancia / L. Ruilope

USA: JNC VI. Arch Intern Med 1997

Canada: Joffres et al. Am J Hypertens 1997

England: Colhoun et al. J Hypertens 1998

France: Chamontin et al. Am J Hypertens 1998

< 140/90 mmHg

Canada

16

USA

27

England

6

France

24

Marques-Vidal P et al. J Hum Hypertens 1997

< 160/95 mmHg

Finland

20.5

Spain

20

Australia

19

Germany

22.5

> 65 years

Scotland

17.5

India

9


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Diagnosis of Hypertension

Hypertensionis defined as:

- BP 140/90 mm Hg- during 1-5 visits- with an average of 2 readings per visit


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Caused of Hipertension :

I. Primer / essential/ idiopathic

II. Sekunder:

A. RenalB. Endocrine

C. Coartation of the aorta

D. Pregnancy induced hypertension

E. Neurological disorder

F. Drug and other abused substancen


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PATOPHYSIOLOGY

The factors affecting cardiac output:- sodium intake, renal function, &

mineralocorticoids

- the inotropic effects occur via extracellular

fluid volume augmentation

- an increase in heart rate and contractility

Peripheral vascular resistance is dependentupon the sympathetic nervous system,

humoral factors, and local autoregulation

(Sharma, 2003)


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Acute neurohormonal effects on blood

pressure homeostasis

Heart rate and cardiac output

Perfusion

Sodium and water retention

Blood pressure

RAA SNS


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Renin inhibitors

AII receptor blockers

Angiotensin II

Renin

Converting enzyme

Angiotensin

receptors

Angiotensinogen

ACE inhibitor

Angiotensin I

Liver TissueCirculating Local

Non Renin pathways- t-PA- Cathepsin G

- Tonin

Non-ACE pathways- Chymase

- CAGE- Cathepsin G

The Renin-Angiotensin SystemAlternate Pathway


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Effects of Angiotensin II at AT1and AT2Receptors

Blocked by ARB s

AT2AT1

- Vasoconstriction

- Aldosterone release

- Oxidative stress

- Vasopressin release

-SNS activation

- Inhibits renin release

- Renal Na+ and H2O reabsorption

- Cell growth and proliferation

- Vasodilation

- Antiproliferation

- Apoptosis

- Antidiuresis/antinatriuresis

-Bradykinin production

- NO release

Siragy H.Am J Cardiol. 1999;84:3S8S.


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Technique of blood pressure measurement

recommended by the British Hypertension Society

2.

The patient should be

relaxed and the arm

must be supported.

Ensure no tight clothing

constricts the arm

3.

The cuff must be level withthe heart. If the circumference

exceeds 33cm, a large cuff

must be used (2/3 of arm).

Place stethoscope diaphram

over brachial artery

4.

The column of mercury

must be vertical. Inflate

to occlude the pulse(>30 mmHg). Deflate at

2-3 mm/s. measure

systolic ( first sound /

Korotkoff I ) & diastolic

(disappearence /Korotkoff IV or V ) to

nearest 2 mmHg

(From British Hypertension Society 1985)

1.

Several time, rest 5

minutes before


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Recommended Technique

for Measuring Blood Pressure

Standardized technique:

Have the patient rest for 5 minutes

Use an appropriate cuff size

Use a mercury manometer or a recentlycalibrated electronic device


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Position cuff appropriately

Increase pressure rapidly

Support arm with antecubital fossa or heartlevel

To exclude possibility of auscultatory gap,

increase cuff pressure rapidly to 30 mmHg

above level of diseappearance of radialpulse

Place stethoscope over the brachial artery


for Measuring Blood Pressure (cont.)


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for Measuring Blood Pressure (cont.)

Drop pressure by 2 mmHg / beat:

- appearance of sound (phase I Korotkoff)

= systolic pressure

- disappearance of sound (phase V

Korotkoff) = diastolic pressure

Take 2 blood pressure measurements, 1minute apart


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Pengukuran tekanan darah ambulatory

(ABPM)

Indikasi

1.Adanya variasi tekanan darah yang besar2. Office hypertension

3.Dicurigai adanya episode hipotensi

4. Hipertensi yang resisten terhadappengobatan


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Symptoms

Headache

Dizziness

Fatigue Pounding of the heart

Symptoms of complications : heart failure,chest pain, claudication, vision


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Riwayat Klinik(Ax):

Lama, tingkat TD

Adanya Penyakit penyerta Faktor risiko

obat-obatan

Faktor pribadi,psikososial danlingkungan.


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Pemeriksaan Fisik :

Pemeriksaan fisik & TD yang teliti TB, BB, & BMI

Sistim kardiovaskuler Paru abdomen.

Fundus optikus & sistim syaraf(mengetahui kerusakan serebro-vaskuler).


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Pemeriksaan penunjangLaboratorium

EKG & Foto polos dadaEkhokardiografiUltrasonografi vaskuler

Ultrasonografi renalAngiografi


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Evaluasi Klinik Hipertensi :

Tujuan :

1. Konfirmasi hipertensi dan tingkatnya

2. Menyingkirkan & menemukan hipertensi sekunder3. Menentukan kerusakan organ target

4. Mencari faktor risiko kardiovaskuler dan kondisi

klinik lain


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Komplikasi Hipertensi

Kerusakan yang disebabkan

oleh hipertensi tergantung :

Besarnya peningkatantekanan darah

Lamanya kondisi tekanandarah yang tidak

terdiagnosis dan tidak

diobati

Kerusakan Target Organ!!Eyesretinopathy

Kidneysrenal failure

Brainstroke

Heartischaemic heart disease

left ventricular hypertrophyheart failure

Peripheral arterial disease


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Hypertension :

The Disease Continuum

Early Paradigm

Elevated BP Target Organ Damage

Natural History of CVD Progression

More Recent Paradigm

Vascular Dysfunction Elevated BP Target Organ Damage

A Proposed Future Paradigm

Endothelial

Dysfunction

LVH

Renal

DamageMI Stroke

Angina

Pectoris

Vascular

Dysfunction

Elevated BP Target Organ

Damage?


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Brown, M.J., Lancet 2000;355:653-4

Risiko Infark Miokard dan Stroke

Systolic blood pressure (mm Hg)

5-yearrisk(%

)

0

5

10

15

0 100 200 300

StrokeMI


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CHFCumulative

Incidence

(%)

Years From Baseline Exam

5 10 15

20

15

10

5

0

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.

Data from Levy D et al. JAMA. 1996;275:1557-1562.

Stage 2+ hypertension

Stage 1+ hypertension

Normal BP

Cumulative Incidence of CHF : Normotensives

and Stage 1 and 2 Hypertensives


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Effects of blood pressure on the risk

of cardiovascular diseaseAverage annual incidence rate per 10.000

Source : Framingham study (after Gorlin)

100

90

80

70

6050

40

30

20

10

0

180

Systolic blood pressure (mmHg)

CHD

Stroke

CHF


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Khattar, R.S. et al. Circulation 1999; 100:1071-4

Assessment of the 24-hour blood pressure load is

a good clinical method to identify high-risk patients

events/10

0pt/yrs

200+

mm Hg

< 140 140-159 160-179 180-199

1

2

3

4

5

6

7

Systolic Blood Pressure

Total Mortality and Continuous

Ambulatory Blood Pressure

1

2

3

4

5

Diastolic Blood Pressure

mm Hg

< 80 80-89 90-99 100-109 110+


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NON-Farmakologis

Farmakologis


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Non Pharmacologic

( lifestyle modification )

Modification Approximate SBP

reduction (range)

Weight reduction 520mmHg/10 kg loss

Adopt DASH eating plan 814 mmHg

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcohol

consumption24 mmHg


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Dahulu : stepped care therapy

Kini : individualized therapy

Taylored therapy


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Goal of treatment

Improved endothel function

Decreased systemic vascular resistance Maintain cardiac output & blood suply to organ

Life long therapy

Bad compliance failed of therapy

Therapy of Hypertension

( pharmacologic )


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Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 3540%

Myocardial infarction 2025%

Heart failure 50%


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Minimal BP Goal of Therapy

Recommendations (SBP/DBP mmHg)Patient Type

Uncomplicated HTN

Hypertension withdiabetes mellitus

Heart failure

Hypertension with

renal impairment

JNC VI

< 140/90

< 130/85< 130/80*

< 130/85

< 125/75

(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes ExecutiveCommittees Working Group.Am J Kidney Dis. 2000) (JNC VI.Arch Intern Med.1997)

*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.Proteinuria > 1 g/24h.


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Recomendation


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Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usually

thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.

May consider ACEI, ARB, BB, CCB,

or combination.

Without CompellingIndications

Not at Goal

Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.

Consider consultation with hypertension specialist.


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Compelling Indications for

Individual Drug Classes

Clinical Trial BasisInitial Therapy OptionsCompelling Indication

ALLHAT, HOPE,

ANBP2, LIFE,

CONVINCE

ACC/AHA Post-MI

Guideline, BHAT,

SAVE, Capricorn,EPHESUS

ACC/AHA Heart Failure

Guideline,MERIT-HF,

COPERNICUS, CIBIS,

SOLVD, AIRE, TRACE,ValHEFT, RALES

THIAZ, BB, ACE, CCB

BB, ACEI, ALDO ANT

THIAZ, BB, ACEI, ARB,

ALDO ANT

High CAD risk

Postmyocardial

infarction

Heart failure


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Compelling Indications for

Individual Drug Classes

Recurrent stroke

prevention

Chronic kidney disease

Diabetes

Clinical Trial BasisInitial Therapy OptionsCompelling Indication

PROGRESS

NKF Guideline,

Captopril Trial,

RENAAL, IDNT, REIN,

AASK

NKF-ADA Guideline,

UKPDS, ALLHAT

THIAZ, ACEI

ACEI, ARB

THIAZ, BB, ACE, ARB,

CCB


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Possible combinations of different classes of antihypertensive agents.The most rational combinations are represented as thick lines. ACE,

angiotensin-converting enzyme; AT1, angiotensin II type 1.

ACE inhibitors

Diuretics

1-blockers

-blockers AT1receptorblockers

Calcium

antagonists


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MATUR NUWUN

TERIMA KASIH

THANK YOU

SAKALANGKONG

Mba Marijan

KASOON


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Pengukuran Tekanan Darah :


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Karena adanya variasi yang besar TD, diagnosishipertensi harus berdasarkan beberapa kali pengukuran

yang diambil pada beberapa kesempatan (waktu) yangterpisah.

TD biasanya diukur secara tak langsung dengansphygmo-manometer air raksa atau alat noninvasiflainnya pada posisi duduk atau telentang.

sebelum pengukuran penderita istirahat 5 menitdiruangan yang tenang

ukuran manset lebar 12-13 cm serta panjang 35 cm,ukuran lebih kecil pada anak-anak dan lebih besar pada

penderita gemuk (ukuran sekitar 2/3 lengan) diperiksa pada fosa kubiti dengan cuff setinggi jantung

(ruang antar iga IV)

TD dapat diukur pada keadaan duduk atau telentang,

pada JNC VII dianjurkan pada posisi duduk


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TD dinaikkan sampai 30 mmHg (4.0 kPa) diatas tekanansistolik (palpasi), kemudian diturunkan 2 mmHg/detik (0,3

kPa/detik) dan dimonitor dgn stetoskop diatas abrakhialis.

tekanan sistolik ialah tekanan pada saat terdengar suaraKorotkoff I sedangkan tekanan diastolik pada saat

Korotkoff V menghilang. Bila suara tetap terdengar,dipakai patokan Korotkoff IV (muffling sound).

pada pengukuran pertama dianjurkan pada kedua lenganterutama bila terdapat penyakit pembuluh darah perifer.

kadang perlu pengukuran pada posisi duduk/telentangdan berdiri untuk mengetahui ada tidaknya hipotensipostural terutama pada orang tua, diabetes mellitus dankeadaan lain yang menimbulkan hal tersebut (pemberianpenyekat alfa).


Ri k St tifi ti d T t t


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Risk Stratification and Treatment(JNC-VI)

Risk Group B Risk Group C(At Least 1 Risk (TOD/CCD and/or

Risk Group A Factor, Not Including Diabetes, With or

Blood Pressure Stages (No Risk Factors Diabetes; No Without Other Risk

(mmHg) No TOD/CCD) TOD/CCD) Factors)

High-normal Lifestyle Lifestyle Drug therapy(130-139/89-89) modification modification

Stage 1 Lifestyle Lifestyle Drug therapy

(140-159/90-99) modification modification

(up to 12 months) (up to 6 months)

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

(> 160/> 100)

For example, a patient with diabetes and a blood pressure of 142/94 mmHg plus left ventricular

hypertrophy should be classified as having stage 1 hypertension with target organ disease (left

ventricular hypertrophy) and with another major risk factor (diabetes) This patient would be categorized

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