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* HYPERTENSION

MAIMUN SYUKRI
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.
*Batasan Hipertensi
*Blood Pressure Classification
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80

Prehypertension 120139 or 8089

Stage 1 140159 or 9099


Hypertension

Stage 2 >160 or >100


Hypertension
WHO/ISH 2003.
ESC/ESH 2003 .
* Classification
Classification of
of blood
blood pressure
pressure levels
levels of
of the
the British
British Hypertension
Hypertension Society
Society

Category Systolic blood pressure Diastolic blood pressure


(mmHg) (mmHg)

Optimal <120 <80


Normal <130 <85
High-normal 130139 8589

Hypertension
Grade 1 (mild) 140159 9099
Grade 2 (moderate) 160179 100109
Grade 3 (severe) 180 110

Isolated Systolic Hypertension


Grade 1 140 - 159 <90
Grade 2 >160 <90

Brit Med J 2004 328:634-40.


AUSTRALIA 2003
Method Brief Description
In-office Two readings, 5 minutes apart,
sitting in chair. Confirm elevated
reading in contralateral arm.
Ambulatory BP Indicated for evaluation of white-
monitoring coat HTN. Absence of 1020% BP
decrease during sleep may indicate
increased CVD risk.
* BP Measurement Techniques
Self-measurement Provides information on response
to therapy. May help improve
adherence to therapy and evaluate
white-coat HTN.
JNC 7 2003
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.

*Office BP
Measurement
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 50 Juta dari total Penduduk


( 1 dari 4 orang dewasa)

Indonesia Baliem 0,65%


Sukabumi 28,6%
*Primary hypertension
* 95% of all cases
*Secondary hypertension
* 5% of all cases
* Chronic renal disease most common

*Etiology
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome

*Identifiable
Pheochromocytoma
Coarctation of the aorta
Causes of
Thyroid or parathyroid disease

Hypertension
* 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.


Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
*
Chronic kidney disease

Target Organ Damage


Peripheral arterial disease
Retinopathy
*Categories of
hypertensive
end-organ
Origin damage
Category
Large arteries Loss of compliance
(Dissecting) aneurysm
Peripheral occlusive arterial disease

Kidney Nephrosclerosis

Birkenhger and de Leeuw (1992)


Hipertensi & Kerusakan Organ Target

20
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

*Laboratory Tests
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
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Classification and management of BP for adults
Followup and monitoring
*Treatment
Overview
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.

*
Goals of Therapy
* 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)

*Sign and Symptoms


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

* Symptomatic associated with


malignant HTN
*Consequences of Malignant
HTN
End Organ Complications

Aorta Aortic disection


Brain Hipertensive encepahlopathy
Cerebral Infarction or Haemmorharge
Heart Cardiac failure
Myocardial ischemic or infarction

Kidney Renal failure


Haematuria
Gastrointestinal Anorexia,nausea,vomiting,abdominal
pain
Placenta Eclampsia
Other 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%
* Essential hypertension
(primer/idiopathic hypertension
remain uncertain
(genetic and environmental factors
contribute to development of hypertension)

* Secondary hypertension
*Aetiology of
hypertension
* Renal parenchymal disease, causes :
- the glomerulonephritides
- diabetic nephropathy
- analgesic nephropathy
- adult polycystic kidney disease
* Renal artery stenosis
* Primary hyperaldosteronism
* Secondary hypertension
* 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
* Sign and symptoms
* Pointers to secondary hypertension
* Features of malignant hypertension
* End organ damage
* Hypertensive nephropathy
* Left ventricular hypertrophy
* Hypertensive retinopathy

* Clinical assesment of
hypertension
* Grades of hypertension retinopathy
Grade Features
I Mild narrowing or sclerosis of the retinal
arteriole, no symptoms,
Good general health
II Venous compression at artriovenous
crossing (A-V nipping) no symptoms,
good general health
III Retinal oedema, cotton wool spots,
hemmorhages, often symptoms
IV All above
Papiloedema,Symptomatic
Cardiac and renal function often
impaired, reduced survival
* Non Pharmacotherapy
(lifestyle modification)
* Pharmacotherapy

*Treatment
*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
JNC:
* Preventif
* Deteksi
* Evaluasi
* Pengobatan
JNC VI, 1997

*Strategi
Penatalaksanaan
Hipertensi
* Untuk mencegah atau memperlambat terjadinya Hipertensi

* Merupakan solusi jangka panjang masalah hipertensi


* Mencegah terjadi komplikasi

* Dapat menghentikan atau mengurangi biaya pengobatan dan


komplikasi

*Preventif
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


Terbukti Efektif
Efektif terbatas

*Turunkan BB * Manajemen Stres


*Kurangi Garam * Kalium
*Kurangi Alkohol * Minyak Ikan (Fish oil)
*Olah Raga * Kalsium
*Intervensi * Magnesium
* Serat
Preventif Primer
* Cegak makronutrien
*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


*Deteksi
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 Grade 2 Grade 3
Mild Moderate Severe
hypertension hypertension hypertension
Other risk factors and SBP 140159 SBP 160179 SBP 180
disease history or DBP 9099 or DBP 100109 or DBP 110
I No other risk factors Low risk Med risk High risk
II 12 risk factors Med risk Med risk Very high risk
III 3 or more risk factors High risk High risk Very high risk
or TOD or diabetes
IV ACC Very high risk Very high risk Very high risk

TOD = Target-organ damage Guidelines subcommittee. WHO-ISH


ACC = Associated clinical conditions Guidelines. J Hypertens 1999;17:151-183.
BP TARGETS:

WITHOUT COMPLICATION : <140/80 mmHg

DIABETES : < 130/80 mmHg

CKD : < 130/80 mmHg

PROTEINURIA > 1 g/d : <125/75 mmHg


*Lifestyle Modification
Modification Approximate SBP
reduction
(range)
Weight reduction 520 mmHg/10 kg weight loss

Adopt DASH 814 mmHg


eating plan
Dietary sodium 28 mmHg
reduction
Physical activity 49 mmHg
Moderation of 24 mmHg
alcoholconsumption
* Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four or five times per week

I Intensity - Moderate

T Time - 45-60 minutes

Type Dynamic exercise


T - Walking
- Cycling
- Non-competitive swimming

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
* Diuretic
* ACE-Inh
* ARB
* Beta blocker
* Alpha blocker
* Direct renin inhibitor

*Treatment of
Hypertension
* Treatment Algorithm for Adults with Systolic-
Diastolic Hypertension without another compelling
indication
TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Long-acting Beta-
Thiazide ACE-I ARB DHP-CCB blocker

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
Lifestyle Without Compelling With Compelling
BP Classification Modification Indication Indication

Normal Encourage
<120/80 mm Hg

Prehypertension Yes No drug indicated Drug(s) for the


120-139/80-89 mm Hg compelling indications

Stage 1 hypertension Yes Thiazide-type diuretics Drug(s) for the compelling


140-159/90-99 mm Hg for most; may consider indications; other
ACE-I, ARB, BB, CCB, or antihypertensive drugs
combination (diuretics, ACE-I, ARB, BB,
CCB) as needed
Stage 2 hypertension Yes 2-drug combination for most Drug(s) for the compelling
160/100 mm Hg (usually thiazide-type diuretic indications; other
and ACE-I, ARB, BB, or antihypertensive drugs
CCB) (diuretics, ACE-I, ARB,
BB, CCB) as needed
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 Initial Therapy Clinical Trial
Indication Options Basis

Diabetes THIAZ, BB, ACE, NKF-ADA


ARB, CCB Guideline, UKPDS,
ALLHAT
NKF Guideline,
Chronic kidney ACEI, ARB Captopril Trial,
disease RENAAL, IDNT,
REIN, AASK

Recurrent stroke THIAZ, ACEI PROGRESS


prevention
JNC 7 2003
THANK YOU
*HIPERTENSI
* Juniar Sianipar
* Lia Farista
* Muhammad Yusuf
Nasution
* Nurhanifah
* Pardamean
* Ramlah Melina
* Afrita Mahyuni Harahap
*Antoni Ardhi * Ruth Marliani Silalahi
*Ardhiansyah * Yola Safitri
*Arfaliza * Yogi Sugianto
*Delly Fadlianti * Yuyun Nailupar
*Desi Diana
*Devit Aprizal
*Handi Hendra
*Jenny
*Khairussaadah
hipertensi Yaitu penderita yang
adalah kondisi medis
di mana terjadi mempunyai tekanan
peningkatan tekanan darah yang melebihi
darah secara kronis
(dalam jangka waktu 140/90 mmHg saat
lama) istirahat.

* APA ITU HIPERTENSI?


tekanan yang dialami
darah pada pembuluh

TEKANAN arteri darah ketika


darah di pompa oleh
jantung ke seluruh
DARAH anggota tubuh manusia
Sphygmomanometer

*MENGUKUR TEKANAN
DARAH
1. Tidak 2. Secondary Hypertension (5 to
10%)
diketahui, 90- *Kidney Abnormalities
95 % kasus *Narrowing of certain
arteries
hipertensi *Rare tumors
tidak diketahui *Adrenal gland
abnormalities
penyebabnya
*PENYEBAB
*Pregnancy
( Primary
Hypertension)
HIPERTENSI
*
PATOGENIS
Mekanisme berbagai Vascular Growth Promotors dalam menimbulkan hipertensi
*Epidemiologi
Hipertensi diperkirakan menjadi penyebab kematian sekitar
7,1 juta orang di seluruh dunia, yaitu sekitar 13% dari total
kematian.
* American Heart Association
Recommended Blood Pressure Levels
*Lanjutan
..
* Mengapa Tekanan Darah Bisa Tinggi?

1. Controllable Risk
Factors
*Increased salt
intake
*Obesity
*Alcohol
*Stress
*Lack of exercise
2. Uncontrollable Risk
Factors
* Heredity
* Age
* Men between age 35 and 50
* Women after menopause
* Race
* 1 out of every 3 African
Americans
* Higher incidence in non-
Hispanic blacks and
Mexican Americans
* PENATALAKSANAAN
A. penatalaksanaan B. penatalaksanaan
nonfarmakologi atau farmakologi atau
perubahan gaya hidup dengan obat

Diuretik
Golongan penghambat
Penurunan berat badan simpatetik
penurunan asupan garam Penyekat Beta (-blocker)
menghindari faktor resiko Vasodilator
(merokok, minum alkohol, Penghambat ACE
hiperlipidemia dan stres) Antagonis kalsium
* Algoritma pengobatan hipertensi
* OBAT-OBAT ANTIHIPERTENSI
*Diuterika
Obat yang dapat mempertinggi sekresi urin. Secara umum
obat dalam golongan ini bekerja menghambat reabsorpsi
elektrolit pada sistem tubulus, dengan begitu osmolalitas
lumen dipertinggi, sehingga pengambilan cairan ditekan. Obat
yang termasuk golongan ini umumnya dapat menurunkan
tekanan darah.
Contoh:
- Asetozolamida - Furosemida - Manitol
- Hidroklortiazid - Triamteren
*GOLONGAN PENGHAMBAT SIMPATETIK
Penghambatan aktifitas simpatetik dapat
terjadi pada pusat vasomotor otak
( metildopa dan klonidin) atau pada ujung
saraf perifer (reserpin dan guanetidin)
Metil dopa mempunyai efek antihipertensi
dengan menurunkan tonus simpatis secara
sentral, serta mengganti norefinefrin di
saraf perifer dengan metabolit metil dopa
yang kurang poten
Efek samping: anemia hemolitik, gangguan
faal hati dan kadang-kadang hepatitis kronik.
*PENYEKAT BETA (-BLOCKER)
Mekanisme kerja adalah melalui penurunan curah jantung
dan penekanan sekresi renin, dibedakan atas 2 jenis:
= yang menghambat reseptor 1
= yang menghambat reseptor 1 dan 2

Efek samping terjadi karena obat tidak selektif terhadap


reseptor 2 sehingga menimbulkan bradikardi.

Kontraindikasi pada pasien asma bronkial, gagal jantung,


dan blok atrioventrikular. Hati-hati pada pasien diabetes
melitus.

Contoh: propanolol
*VASODILATOR
- Mekanisme obat dengan melepaskan nrogen oksida (NO)
akan mengaktifkan guanilat siklase dengan hasil akhir
defosforilasi berbagai protein termasuk protein kontraktil
dalam sel otot polos. Sehingga obat ini bisa merelaksasi
secara langsung otot polos arteriol atau vena, berakibat
penurunan resistensi pembuluh darah.

- Efek samping yang terjadi disebabkan oleh efek


antihipertensi yang berlebihan.
Contoh: Hidralazin
*PENGHAMBAT ACE
ACE (Angiotensin Converting Enzyme) mengubah
angiotensin I menjadi Angiotensin II yang aktif dan
mempunyai efek vasokontriksi pembuluh darah. Dengan
penghambat ACE maka Angiotensin II menurun. Yang
pertama digunakan dalam klinik adalah enalpril dan
kaptopril.
1. Ketahui tekanan darah anda
Apakah diperiksa secara teratur ?
2. Ketahui berat badan anda
Apakah proporsional?
3. Jangan gunakan garam yang berlebih pada makanan
Hindari makanan asin
4. Makan makanan yang diet rendah lemak

*
5. Jangan merokok
10 Cara untuk Mengontrol
Tekanan Darah
6. Minum obat seperti yang sudah diresepkan
7. Sering berkonsultasi dengan dokter
8. Rutin berolahraga
9. Ajak anggota keluarga anda untuk mengontrol tekanan darah
secara teratur
10. Hiduplah secara normal dan bahagia.