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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
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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)
Secondary hypertension
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Secondary hypertension
Renal parenchymal disease, causes :
- the glomerulonephritides
- diabetic nephropathy- analgesic nephropathy
- adult polycystic kidney disease
Renal artery stenosis Primary hyperaldosteronism
Phaeochromocytoma
Secondary hypertension
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Secondary hypertension
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
39
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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