CURRICULUM VITAE : dr.

Syafrizal Nst,Mked(PD),SpPDKGH
I . Pendidikan

SD Mardi Lestari Medan1980

SMP Amir Hamzah Medan 1983
SMAN 4 Medan 1986
Dokter FK USU1994
Internis FK USU 2007
Magister Kedokteran Penyakit Dalam FK USU 2012
Nephrology & Dialisis Course, Gold Coast University
Hospital,
Australia. 2013
Konsultan Ginjal dan Hipertensi 2015

III. Riwayat Pekerjaan

Dokter PTT di RSU Kutacane 1996-2000

PNS Dinkes Pemprov NAD 2000-2008
Staf Penyakit Dalam RSUP H Adam Malik Medan 2008sekarang

IV. Keanggotaan

Pengurus IDI Wilayah Sumatera Utara 2009-sekarang

Anggota IDI Cabang Medan 2007-sekarang
Pengurus PAPDI SUMUT 2008-sekarang
PUSKI Jakarta 2007-sekarang
PERNEFRI 2007-sekarang
Indonesian Society Of Hypertension (Ina SH) 2008sekarang

ANTI HYPERTENSIVE
DRUG: WHEN TO START
& COMBINATION
Syafrizal nasution

Medical Update IDI Sumut , Sabtu 11 April 2015

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINE ?
COMBINATION STRATEGIES

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
WHY TREAT?
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

Hypertension:
a major CV risk factor

Impact of high-normal BP on CV risk

16
14
Cumulative 12
10
incidence of 8
CV events
6
(%)
4
2
0
12
Cumulative 10
incidence of 8
CV events 6
4
(%)
2
0

High-normal BP

Men

Normal BP
Optimal BP

Women

High-normal BP
Normal BP

6
Years

10

12

Optimal BP

Optimal BP: <120/80 mmHg; normal BP: 120-129/80-84 mmHg;

high-normal BP: 130-139/85-89 mmHg
BP, blood pressure; CV, cardiovascular

Vasan RS, et al. N Engl J Med 2001;345:1291-1297

Uncontrolled hypertension carries the same

CV risk as untreated hypertension
Third National Health and Nutrition Examination Survey (NHANES III)

Not treated

BP
uncontrolled
BP controlled

48%
(n = 2,458)

Both are at equally

increased risk compared
with controlled BP
(p>0.05)

35%
(n = 1,756)
17%
(n = 872)
Gu Q, et al. Am J Hypertens 2010;23(1):38-45

The challenge of BP
control

% Adults

Hypertension Awareness,
Treatment,
and Control:
-2000
73 US 1976
68
69
51
%
31
%
10
%

%
55
%

%
54
%

29
%

27
%

%
58 Awareness
%
Treatment
31
%

Control

NHANES II NHANES III NHANES III NHANES

1976-1980 (Phase 1)
(Phase 2) 1999-2000
1988-1991 1991-1994
Burt et al. Hypertention. 1995;25:305-313; Hyman et al. N Engl J Med.
2001;345:479-486; National Center for Health Statistics. NHANES 1999-2000 (CDROM); NIH. The Sixth Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure; 1997. NIH
publication 98-4080.

Hypertension in the U.S.

Source:CDC/NHNS, National Health and Nutrition Examination

Survey, 2011-2012
Available at http://www.cdc.gov. Accessed 8/24/14.

Hypertension Awareness, Treatment, & Control In The Population &

Control In Treated Hypertensive Patients
Individuals (%)
Low treatment & control rates could contribute to a
higher burden of CV Risk

*
* Threshold of SBP/DBP 140/90 mm Hg

Wolf-Maier K,et al. Hypertension 2004;43:1017

More Than 80% Of hypertensive Patients have

additional Co-morbidities

BP control is particularly poor in hypertensive patients at high risk

Hypertension controlled (%)
Total n=4,646

CAD, coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease;
DM, diabetes mellitus; HTN, hypertension; PAD, peripheral arterial disease.
* Based on BP target <130/80 mmHg

Wong ND,et al. Arch Intern Med 2007;167:2431-2436

Sumut
(-)

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

PENGUKURAN TEKANAN DARAH

PERSIAPAN SEBELUM PENGUKURAN

Standardized Preparation:

Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before
measurement
8. Patient should stay silent prior and during the
procedure.

PERSIAPAN SEBELUM PENGUKURAN

Tehnik yang standard
Postur
Pasien harus duduk tegak dan posisi
lengan setentang letak jantung
Kedua telapak kaki harus menyentuh
lantai dan kedua kaki lurus (tdk boleh
disilangkan

HYPERTENSION
Diagnosis

: Because blood pressure is characterized by large spontaneous

(2004)

variations, the diagnosis of hypertension should be based on

multiple blood pressure measurements,
taken on several separate occasions.
.. Is based on two or more properly measured, seated BP
(2003)
readings on each of two or more office visits.

IA: Metode pengukuran tekanan darah.

(2007)

dilakukan sesuai dengan standar WHO dengan ala

standar manometer air raksa. Untuk menegakkan diagn
sis hipertensi, perlu dilakukan pengukuran tekanan dar
minimal 2 kali dengan jarak 1 minggu bila tekanan dara
<160/100 mmHg.

JNC VII Classification 2003

BP (mmHg)
Sistolic
Diastolic
<130
and
<80
130-139 and/or
85-89

Classification
Normal
Pre Hypertension

140-159 and/or

90-99

Hypertension Stage 1

160

100

Hypertension Stage 2

and/or

Klasifikasi Tekanan Darah (WHO/ISH/ESC/ESH) 2007

Category
Optimal
Normal
High-normal
Grade 1 hypertension (mild)
Subgroup : borderline
Grade 2 hypertension (moderate)
Grade 3 hypertension (severe)
Isolated systolic hypertension
Subgroup : borderline

WHO-ISH
WHO-ISH

Systolic

Diastolic

< 120
< 130
130 - 139
140 - 159
140 - 149
160 - 179
> 180
> 140
140 - 149

< 80
< 85
85 - 89
90 - 99
90 - 94
100 - 109
> 110
<90
< 90

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

ecisions on management of the hypertensive patien

depend on the initial level of total cardiovascular
(CV) risk

TINGKATAN RESIKO KV (WHO/ESC/ESH

2013)

Rekomendasi Awal terapi Hipertensi ( WHO/ESC/ESH 2013)

The Newest
Guideline!!!

Algoritme Managemen Hipertensi JNC

8 2014

Algoritme Managemen Hipertensi JNC 8

2014 (cont)

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINE ?
COMBINATION STRATEGIES

Highly adherent patients are more

likely to achieve BP control
BP Controlled (%)
Highly adherent patients were 45% more likely to achieve
BP control

Low
(n = 46)
MPR = Medication possession
ratio

Medium
(n = 165)

High

Adherence (MPR)

(n = 629)

* <140/90 mmHg or <130/85 mmHg for patients with diabetes

(Defined by
JNC 6)
Bramley
TJ,et
al.J

Manag Care Pharm 2006;12:23945

High adherent patients are at lower CV risk

Cox Proportional-Hazards Models (%)

High adherence to AHT is associated

with a 38% decreased risk of CVEs
compared with lower adherence

Low
(n = 9,666)

Medium
(n = 7,624)

High

Adherence (PDC)

(n = 1,516)

PDC = Proportion of days covered

Mazzaglia et al. Circulation 2009;120:1598-1605

The efficacy of antihypertensives often

described in terms of the trough : peak ratio of
their BP lowering effect1

Trough : Peak Ratio vs Smoothness Index

for defining drug effects on 24 hour BP2
1. Omboni S,et al.Journal of hypertension 1995;13:10

2. Parati G,et al.Hypertension Research 2013;145

Amlodipine The longest Half-life in Class

Plasma elimination halflife (h)

35
30

30
25
20
15

10
5

12

16

Abernethy et al. The new England Journal of Medicine 1999. 341(9):1447

OUTLINE

OUTCOME HYPERTENSION
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINE ?
COMBINATION STRATEGIES

Kombinasi anti Hipertensi JNC 8 2014

GUIDELINES WORLDWIDE ACKNOWLEDGE THAT MOST PATIENTS

NEED COMBINATION THERAPY TO ACHIEVE BP GOALS
JNC 8 ; 20141

Initiate therapy with 2 drugs simultaneously

If SBP is > 20 mmHg above goal and/or DBP is > 10
mmHg above goal
ESH/ESC 20132

Combination of two antihypertensive drugs at fixed doses

in a single tablet may be recommended and favoured,
because reducing the number of daily pills improves
adherence, which is low in patients with hypertension.
ASH/ISH Hypertension Guidelines
20133

If the untreated blood pressure is at least 20/10

mmHg above the target blood pressure, consider
starting treatment immediately with 2 drugs
1. James P et al. JAMA. 2013;289: E1-E14
2. Mancia et al. Jounal of Hypertension 2013. 31:1281-1357
3. Weber M et al. The Journal of Clinical Hypertension. 2013. 1-13

Approach To Mono or Combination Therapy

Mancia et al. Jounal of Hypertension 2013.

31:1281-1357

ARB+CCB (TWYNSTA) is one of the

preffered

UNDER VS OVER TREATMENT

Comparisons to Other Guidelines for BP Goal

BP
Goal
Age <
60
Age 6079
Age
80+
Diabete
s
CKD

JNC-7

JNC-8

<140/9
0
<140/9
0
<140/9
0
<130/8
0
<130/8
0

<140/9
0
<150/9
0
<150/9
0
<140/9
0
<140/9
0

ASH/IS
H
<140/9
0
<140/9
0
<150/9
0
<140/9
0
<140/9
0

ESC/ES
H
<140/9
0
<140/9
0
<150/9
0
<140/8
5
<130/9
0

Adapted from Salvo M et al. Ann Pharmacother

2014;48:1242-8.

CHEP
<140/9
0
<140/9
0
<150/9
0
<130/8
0
<140/9
0

Pros and cons of

Monotherapy and combination therapy

Monotherapy
1.Monotherapy can effectively reduce BP in only a limited number of
hypertensive patients1
Combination Therapy
2.The most patiens require the combination of at least two drugs to
achieve BP control1
3.The advantage of initiating with combination therapy is potentially
beneficial in high-risk patients1
4.A greater probability of achieving the target BP in patients with
higher BP values and a lower probability of discouraging patient
adherence with many treatment changes1
5.Lower drop-out rate than patients given any monotherapy1
6.Fewer side effects and provide larger benefits thant those offered
by a single agent. (e.g : RAAS + CCB reduces oedema) 1
7.Convinient once-daily administration of a single tablet, with
potential compliance benefits2
8.Effectively lowers BP in patients with an inadequate response to
monotherapy2

1. Mancia et al. Jounal of Hypertension 2013. 31:1281-13

2. Drugs The Perspect 2011;Vol.27. No

Loose Combination or
Single-pill Combination ?

Single-pill combination (SPC)

1.Reducing the number of pills to be taken daily improves
adherence/patient compliance (Simplify treatment regimens)
1,2,3

2.Provide superior BP-lowering Efficacy2

3.Increases the rate of BP control1
4.Enhanced patient adherence2
5.Reducing healthcare costs3
6.Improved tolerability profile2

1. Mancia et al. Jounal of Hypertension 2013. 31:1281-1357

2. Suarez C. Drugs 2011. 71(17):2295-2305
3. Drugs The Perspect 2011;Vol.27. No. 5

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Jangan sampai
ya !!!

Take Home Message

Hipertensi masih menjadi masalah global
Peningkatan TD sedikit saja akan meningkatkan
resiko morbiditas dan mortalitas KV
Pengurangan TD 2 mmhg saja akan menurunkan
resiko morbiditas dan mortalitas KV
Tatalaksana Hipertensi harus dimulai sedini mungkin
Dokter sebagai motor pelayanan kesehatan Tingkat
Pertama memegang peranan penting dalam usaha
menurunkan angka morbiditas dan mortalitas
hipertensi melalui tatalaksana yang tepat sesuai
tingkat resikonya

The Paradox of
Diseases
The majority of people
continuously complain of
allergic problems

are
frightened to
death of
cancer and
AIDSor
H1N1
and ultimately die
of cardiovascular
diseases

Thank You