HYPERTENSION

MAIMUN SYUKRI

Batasan Hipertensi
1. Bila tekanan sistolik >= 140 mmHg, dan atau tekanan diastolik >= 90 mmHg, atau sedang mendapat obat antihipertensi.

2. Dilakukan dua kali atau lebih pengukuran pada dua kali atau lebih kunjungan.

Blood Pressure Classification

BP Classification Normal SBP mmHg <120 and or or DBP mmHg <80 8089 9099

Prehypertension 120139 Stage 1 Hypertension 140159

Stage 2 Hypertension

>160

or

>100

WHO/ISH 2003.

ESC/ESH 2003 .

Classification of blood pressure levels of the British Hypertension Society

Category

Systolic blood pressure (mmHg) <120 <130 130139

Diastolic blood pressure (mmHg) <80 <85 8589 9099 100109 110 <90 <90
Brit Med J 2004 328:634-40.

Optimal Normal High-normal

Hypertension Grade 1 (mild) 140159 Grade 2 (moderate) 160179 Grade 3 (severe) 180 Isolated Systolic Hypertension Grade 1 140 - 159 Grade 2 >160

AUSTRALIA 2003

BP Measurement Techniques
Method In-office Brief Description Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Indicated for evaluation of whitecoat HTN. Absence of 1020% BP decrease during sleep may indicate increased CVD risk. Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.

Ambulatory BP monitoring

Self-measurement

JNC 7 2003

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 heart level. Appropriate-sized cuff should be used to ensure accuracy.

At least two measurements should be made.

Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals. JNC 7 2003

How to measure blood pressure accurately

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, .. Australia, 2004

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 smaller bladder available for fat and thin arms, respectively. Have the cuff at the heart level, whatever the position of the patient. Use phase I and V . Measure blood pressure in both arms at first visit to detect possible differences ..

Measure blood pressure 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients,..
Measure heart rate by pulse palpation (30 s) after the second measurement in the sitting position.

HIPERTENSI
Tekanan Darah :
Rata-rata dari 2 kali pemeriksaan
Pengukuran pada waktu yang berbeda Pengukuran pada waktu duduk

12

 TD kekuatan darah ketika melewati dinding arteri Jenis Hipertensi Hipertensi Resisten Hipertensi Emergensi Hipertensi Urgensi Berdasarkan Penyebab Hipertensi Primer idiopatik 90-95% Hipertensi Skunder Sistemik

Prevalensi Hipertensi
USA Penduduk dewasa) 50 Juta dari total ( 1 dari 4 orang

Indonesia

Baliem 0,65% Sukabumi 28,6%

Etiology
Primary hypertension 95% of all cases Secondary hypertension 5% of all cases Chronic renal disease most common

CVD Risk Factors

Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65)

*Components of the metabolic syndrome.

Identifiable Causes 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

Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure

Brain Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

Categories of hypertensive end-organ damage

Origin
Large arteries

Category
Loss of compliance (Dissecting) aneurysm Peripheral occlusive arterial disease Nephrosclerosis

Kidney

Birkenhger and de Leeuw (1992)

Hipertensi & Kerusakan Organ Target

20

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 tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Treatment Overview
Goals of therapy

Lifestyle modification
Pharmacologic treatment Algorithm for treatment of hypertension

Classification and management of BP for adults

Followup and monitoring

Goals of Therapy
Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons >50 years of age.

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 malignant HTN)

Symptomatic associated with malignant HTN

Headache Blurred vision Chest pain Breathlessness Nausea, vomiting Anxiety, confusion, coma Seizures

Consequences of Malignant HTN

End Organ Aorta Brain Heart Kidney Gastrointestinal Placenta Other Complications Aortic disection Hipertensive encepahlopathy Cerebral Infarction or Haemmorharge Cardiac failure Myocardial ischemic or infarction Renal failure Haematuria Anorexia,nausea,vomiting,abdominal pain Eclampsia Micro-angiopathic haemolytic anemia

Consequences of hypertension
Cardiac disease Left ventricular failure Angina Myocardial infarction Cerebrovascular disease Transient ischemic attacks Stroke Multi-infarct dementia Hypertensive encephalopathy

Consequences of hypertension
Vascular disease Aortic aneurysm Occlusive peripheral vascular disease Arterial dissection
Others Progressive renal failure Hypertensive retinopathy

Risk of Hypertension
Advancing age Positive family history of premature cardiovascular disease Smoking Hypercholesterolemia

Hypertension is thought to account for : - Onehalf of all deaths due to stroke - Up to one quarter of coronary heart disease deaths

Isolated Systolic hypertension increase the risk of : stroke and coronary heart disease by about 40% cardiovascular death by about 50% heart failure by about 50%

Aetiology of hypertension
Essential hypertension (primer/idiopathic hypertension remain uncertain (genetic and environmental factors contribute to development of hypertension)
Secondary hypertension

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

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

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

Grades of hypertension retinopathy

Grade I Features Mild narrowing or sclerosis of the retinal arteriole, no symptoms, Good general health Venous compression at artriovenous crossing (A-V nipping) no symptoms, good general health Retinal oedema, cotton wool spots, hemmorhages, often symptoms All above Papiloedema,Symptomatic Cardiac and renal function often impaired, reduced survival

II

III IV

Treatment
Non Pharmacotherapy (lifestyle modification) Pharmacotherapy

Pengobatan

Tujuan:
ANGKA KESAKITAN KERUSAKAN ORGAN TARGET ANGKA KEMATIAN

Sasaran Pengelolaan
Menilai gaya hidup dan identifikasi faktor risiko 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

Strategi Penatalaksanaan Hipertensi

JNC: Preventif Deteksi Evaluasi Pengobatan
JNC VI, 1997

Preventif
Untuk mencegah atau memperlambat terjadinya Hipertensi 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

Preventif
Upaya preventif primer: Terhadap individu yang potensial hipertensi: TD normal tinggi Riwayat keluarga hipertensi Obesitas Konsumsi tinggi garam Kurang aktifitas Konsumsi tinggi alkohol
Diharapkan prevalensi Hipertensi turun

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

Deteksi
Dilakukan di fasilitas kesehatan dengan alat ukur yang standar dan cara yang benar Pasien diberitahu tentang makna TDnya Pasien dianjurkan melakukan pemeriksaan periodik sesuai dengan TD pertama Diharapkan ditemukan kasus tahap awal

Evaluasi
Mencari penyebab hipertensi (sekunder) Memeriksa adanya kerusakan organ target dan penyakit lain Mencari faktor risiko Mengetahui respon pengobatan, efek samping dan kepatuhan pasien

WHO-ISH Guidelines for Management of Hypertension: Stratification of Cardiovascular Risk

Blood Pressure (mm Hg) Grade 1 Mild hypertension SBP 140159 or DBP 9099 Low risk Med risk High risk Very high risk Grade 2 Moderate hypertension SBP 160179 or DBP 100109 Med risk Med risk High risk Very high risk Grade 3 Severe hypertension SBP 180 or DBP 110 High risk Very high risk Very high risk Very high risk

Other risk factors and disease history

I No other risk factors

II 12 risk factors

III 3 or more risk factors or TOD or diabetes

IV ACC

TOD = Target-organ damage ACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH Guidelines. J Hypertens 1999;17:151-183.

BP TARGETS:

WITHOUT COMPLICATION : <140/80 mmHg

DIABETES : < 130/80 mmHg

CKD
PROTEINURIA > 1 g/d

: < 130/80 mmHg

: <125/75 mmHg

Lifestyle Modification
Modification Approximate SBP reduction (range) 520 mmHg/10 kg weight loss 814 mmHg 28 mmHg 49 mmHg 24 mmHg

Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcoholconsumption

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

F I T

Frequency

- Four or five times per week - Moderate - 45-60 minutes

Intensity
Time

Type

Dynamic exercise - Walking - Cycling - Non-competitive swimming

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

Treatment of Hypertension
Diuretic ACE-Inh ARB Beta blocker Alpha blocker Direct renin inhibitor

Treatment Algorithm for Adults with SystolicDiastolic Hypertension without another compelling indication
TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification therapy

Thiazide

ACE-I

ARB

Long-acting DHP-CCB

Betablocker

Alpha-blocker as initial monotherapy

Indications for Pharmacotherapy

Strongly consider 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

-blockers

AT1 receptor blockers

-blockers

Ca Antagonist

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 Blood Pressure Classification

Initial Drug Therapy BP Classification
Normal <120/80 mm Hg Prehypertension 120-139/80-89 mm Hg Stage 1 hypertension 140-159/90-99 mm Hg

Lifestyle Modification
Encourage

Without Compelling Indication

With Compelling Indication

Yes Yes

No drug indicated Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination 2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB)

Drug(s) for the compelling indications Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

Stage 2 hypertension 160/100 mm Hg

Yes

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.

Compelling Indications for Individual Drug Classes

Compelling Indication Diabetes Initial Therapy Options THIAZ, BB, ACE, ARB, CCB ACEI, ARB Clinical Trial Basis
NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

Chronic kidney disease

Recurrent stroke THIAZ, ACEI prevention

PROGRESS

JNC 7 2003