Dr.

Ika Prasetya Wijaya SpPD-KKV, FINASIM, FACP

www.ipwijaya@gmail.com

Samarinda: 5 Januari 1968

Pendidikan :
S1
: FKUI 1992
Spesialis 1 : FKUI 2003
Spesialis 2 : KIPD/FKUI 2011
Fellow INASIM : PAPDI 2010
Fellow ACP : ACP, AS 2015
Pekerjaan:
KETUA Divisi Kardiologi, Departemen Ilmu Penyakit Dalam FKUI-RSUPNCM 2014
Editor Acta Medica Indonesiana/Indonesian Journal of Internal Medicine
Penulis Buku Ajar Ilmu Penyakit Dalam bidang Kardiologi

Kabid Humas, Publikasi dan Media PB PAPDI 2006-sekarang

Wakil Ketua PAPDI Cabang Jakarta 2010- sekarang
Ketua I PB IKKI 2009-sekarang

Peneliti dan Pengembangan:

Tim Karotis FKUI RSCUPNCM
Anggota Tim Stem Cell FKUI RSUPNCM
Tim Transplan Ginjal RSCM

CRE/062/Aug10-Aug11/MF

Organisasi:

UPDATE IN HYPERTENSION
JNC VIII
IKA PRASETYA WIJAYA, MD
CARDIOLOGY DIVISION, INTERNAL MEDICINE DEPARTEMENT
CIPTO MANGUNKUSUMO HOSPITAL/
UNIVERSITY OF INDONESIA SCHOOL OF MEDICINE

HYPERTENSION IS
Achronic medical conditionin which theblood
pressurein thearteriesis elevated

Firstly, hypertension is very

common In the adult population

NHANES 2011-2012

rly 1 in 3 Adults (29.1%) in the US Has Hypertension

HYPERTENSION IN INDONESIA

Nearly 1 in 4 Adults (25.8%) in the

Indonesia Has Hypertension

WHY IS THIS IMPORTANT?

Individuals with a normal BP
at age 55 yo have a
90% lifetime risk of developing hypertension.

Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in
middle-aged women and men: The Framingham Heart Study. JAMA. 2002;287:1003-10.

MOST CASES OF HYPERTENSION

Primary hypertension
Also called essential
Responsible for 90-95% of all hypertension diagnoses

Partners in Healthcare Education, LLC

2009

CONSIDER SECONDARY CAUSES OF HTN

Sleep apnea
Drug-induced or drug related
Including OTC medications

Chronic kidney disease

Polycystic kidneys

Renal artery stenosis

Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings disease
Pheochromocytoma
Coarctation of the Aorta
Thyroid or parathyroid disease
Partners in Healthcare Education, LLC
2009

JAMA. 2003:289:2560-2577.

HYPERTENSION IS ASSOCIATED
WITH VARIOUS COMPLICATION

Global Leading Risks for Death,

2010

Global Burden of Disease Study 2010 , Lancet 2012; 380: 222460

CV Disease Risk Doubles with

Each 20/10 mm Hg BP Increment*
8
7
6
5
CV
disease 4
3
risk
2
1
0

115/75

135/85
155/95
SBP/DBP (mm Hg)

175/105

*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.

CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure
1. Lewington S, Cardiovascular Issues in Ageing Pilots. et al. Lancet. 2002; 60:1903-1913
2. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,12
And Treatment of High Blood
Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08

COMPLICATIONS OF HYPERTENSION:
END-ORGAN DAMAGE
Hypertension
Hypertension

LVH, CHD, CHF

Hemorrhage,
Stroke

Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Peripheral
Vascular
Disease

Renal Failure,
Proteinuria

WHAT CAN WE DO?

Measuring blood pressure

Diagnosing hypertension
Assessing CV risk and Target Organ Damage
Lifestyle Intervention
Initiating and monitoring antihypertensive drug treatment
Choosing antihypertensive drug treatment
Patient education and adherence to treatment

MEASURING AND CONFIRM BLOOD

PRESSURE

Select the appropriate cuff size

Width of the bladder and cuff about to 40% of upper am
Length of the bladder and cuff about 80% of upper arm
circumference

Patient preparation

Avoid smoking or drinking caffeinated beverages

Rest
Arm free of clothing

Techniques
Position of the arm

MEASURING AND CONFIRM BLOOD

PRESSURE
BP Classification

Systolic BP

Diastolic BP

< 120

< 80

Pre-hypertension

120-139

80-89

Stage 1 HTN

140-159

90-99

Stage 2 HTN

> 160

> 100

Normal

Measuring blood pressure

Diagnosing hypertension
Assessing CV risk and Target Organ Damage
Lifestyle Intervention
Initiating and monitoring antihypertensive drug treatment
Choosing antihypertensive drug treatment
Patient education and adherence to treatment

DIAGNOSING HYPERTENSION
If the clinic blood pressure is 140/90 mmHg or
higher, offer ambulatory blood pressure
monitoring (ABPM) to confirm the diagnosis of
hypertension.
Ensure that at least two measurements per
hour are taken during the person's usual
waking hours (for example, between 08:00 and
22:00)

Measuring blood pressure

Diagnosing hypertension

Assessing CV risk and Target Organ Damage

Lifestyle Intervention
Initiating and monitoring antihypertensive drug treatment
Choosing antihypertensive drug treatment
Patient education and adherence to treatment

ASSESSING CARDIOVASCULAR RISK AND TARGET

ORGAN DAMAGE: UPDATED RECOMMENDATIONS
For all people with hypertension offer to:
test urine for presence of protein
take blood to measure glucose, electrolytes,
creatinine, estimated glomerular filtration
rate and cholesterol
examine fundi for hypertensive retinopathy
arrange a 12-lead ECG.

Measuring blood pressure

Diagnosing hypertension
Assessing CV risk and Target Organ Damage

Lifestyle Intervention
Initiating and monitoring antihypertensive drug treatment
Choosing antihypertensive drug treatment
Patient education and adherence to treatment

LIFESTYLE INTERVENTION
Intake of vegetables, fruits,
whole grains (DASH dietary
pattern)

Low fat dairy products

Poultry, fish
Legume
Limits intake of sweet, sugar
sweetened and red meats

Lower sodium intake

No more than 2,400 mg
sodium/day
Further reduction of sodium intake
to 1,500 mg/day

Physical Activity
Aerobic physical activity 3-4
session a week, lasting 40 min per
session; moderate to vigorous
intensity

Measuring blood pressure

Diagnosing hypertension
Assessing CV risk and Target Organ Damage
Lifestyle Intervention

Initiating and monitoring antihypertensive

drug treatment
Choosing antihypertensive drug treatment
Patient education and adherence to treatment

GUIDELINES FOR
HYPERTENSION
JNC VII vs JNC VIII

JNC 7: ALGORITHM FOR TREATMENT OF

HYPERTENSION
Prehypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg)
LIFESTYLE MODIFICATIONS
Not at Goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with
diabetes or chronic kidney disease)

Prehypertension

INITIAL DRUG CHOICES

Without Compelling Indications

Stage 1 Hypertension
(SBP 140-159 or DBP 90-99 mm Hg)

Stage 2 Hypertension
(SBP 160 or DBP 100 mm Hg)

Thiazide-type diuretics for most;

may consider ACEI, ARB, BB,
CCB, or combination.

2-drug combinations for most

(usually thiazide-type diuretics and
ACEI, or ARB, or BB, or CCB).

With Compelling Indications

Drug(s) for compelling indications

Other antihypertensive drugs
(diuretic, ACEI, ARB, BB, CCB)
as needed.

If not at goal BP, optimize dosages or add additional drugs until

goal BP is achieved. Consider consultation with hypertension specialist.
Adapted from NHBPEPCC. 2003. NIH Publication No. 03-5233.

Partners in Healthcare Education, LLC

2009

FOLLOW UP AND MONITORING

Patients should return for followup and
adjustment of medications until the BP goal is
reached.
More frequent visits for stage 2 HTN or with
complicating comorbid conditions.
Serum potassium and creatinine monitored 12
times per year.

FOLLOW UP AND MONITORING

(CONTINUED)

After BP at goal and stable, followup visits at 3- to

6-month intervals.
Comorbidities, such as heart failure, associated
diseases, such as diabetes, and the need for
laboratory tests influence the frequency of visits.

SPECIAL CONSIDERATIONS
Compelling Indications
Other Special Situations

Minority populations
Obesity and the metabolic syndrome
Left ventricular hypertrophy
Peripheral arterial disease
Hypertension in older persons
Postural hypotension
Dementia
Hypertension in women
Hypertension in children and
adolescents

COMPELLING INDICATIONS FOR

INDIVIDUAL DRUG CLASSES
Compelling
Indication
Heart
failure

Postmyocardial
infarction

High CAD risk

Initial Therapy
Options
THIAZ, BB, ACEI,
ARB, ALDO ANT

BB, ACEI, ALDO

ANT

THIAZ, BB, ACE,

CCB

Clinical Trial
Basis
ACC/AHA
Heart
Failure Guideline,
MERIT-HF,
COPERNICUS,
CIBIS, SOLVD, AIRE,
TRACE, ValHEFT,
RALES
ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
ALLHAT, HOPE,

COMPELLING INDICATIONS
FOR
INDIVIDUAL DRUG CLASSES
Compelling
Indication
Diabetes

Initial Therapy
Options
THIAZ, BB, ACE,
ARB, CCB

Chronic kidney
disease

ACEI, ARB

Recurrent stroke
prevention

THIAZ, ACEI

Clinical Trial
Basis
NKF-ADA
Guideline, UKPDS,
ALLHAT
NKF Guideline,
Captopril Trial,
RENAAL, IDNT,
REIN, AASK
PROGRESS

REFERENCE CARD

JNC 8 2013

JNC 7 VERSUS JNC 8

Topic

JNC 7

JNC 8

Methodology

Nonsystematic literature review

by expert committee
Recommendations based on
consensus

Critical questions and review criteria

defined by expert panel with input from
methodology team
Initial systematic review by
methodologists restricted to RCT
evidence
Subsequent review of RCT evidence
and recommendations by the panel
according to standardized protocol

Definitions

Defined by hypertension and

prehypertension

Definitions of hypertension and

prehypertension not addressed, but
thresholds for pharmacologic treatment
were defined

Treatment goals

Separate treatment goals defined

for uncomplicated hypertension
and for subsets with various
comorbid conditions (diabetes and
CKD)

Similar treatment goals defined for all

hypertensive populations except when
evidence review supports different goals
for a particular subpopulation

Lifestyle

Recommended lifestyle

Lifestyle modifications recommended by

Topic

JNC 7

JNC 8

Drug therapy

Recommended 5 classes to be
considered as initial therapy but
recommended thiazide-type
diuretics as initial therapy for
most patients without compelling
indication for another class
Specified particular
antihypertensive medication
classes for patients with
compelling indications

Recommended selection among 4

specific medication classes (ACEI or
ARB, CCB or diuretics) and doses based
on RCT evidence
Recommended specific medication
classes based on evidence review for
racial, CKD, and diabetic subgroups
Panel created a table of drugs and
doses used in outcome trials

Scope of topics

Addressed multiple issues (BP

measurement methods, patient
evaluation components, 2nd
hypertension, adherence to
regimens, resistant hypertension,
and hypertension in special
populations) based on literature
review and expert opinion

Evidence review of RCTs addressed a

limited number of questions, those judged
by the panel to be of highest priority

Review process
prior to
publication

Reviewed by the National High

Blood Pressure Education Program
Coordinating Committee, a coalition

Reviewed by experts including those

affiliated with professional and public
organizations and federal agencies; no

THANK YOU