Dian Aristi Nugraheni,MD

 Hypertension is the most common condition in primary

care.

 1 in 3 patients have hypertension according to

the National Heart, Lung, and Blood Institute (NHLBI)

 Risk factor for MI, CVA, ARF, death

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Target
Organ
Damage
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Kemenkes 2015
5
6
Excess Reduced Endothelium
Genetic
sodium nephron Stress Obesity derived
alteration
intake number factors

Renal Decreased Sympathetic Renin- Cell

Hyper-
sodium filtration nervous angiotensin membrane
insulinemia
retention surface overactivity excess alteration

Increased
Venous
fluid
constriction
volume

Increased Functional Structural

contractability constriction hypertrophy
Increased
preload

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Hypertension = Increased Cardiac Output and/or Increased Peripheral Resistance

autoregulation Kaplan. Clinical Hypertension. 2006

 Primary hypertension (90-95% of cases)
 Secondary hypertension
* Renal
* Drugs
 Hormonal / oral contraceptive
 NSAIDs
* Endocrine
 Phaeochromocytoma
 Cusings syndrome
 Conn’s syndrome
 Acromegaly and hypothyroidism
* Coarctation of the aorta and aortitis
* Pregnancy-induced hypertension
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 Hypertensive Urgencies: No progressive target-organ
dysfunction. (Accelerated Hypertension)

 Hypertensive Emergencies: Progressive end-organ

dysfunction. (Malignant Hypertension)
 Severe elevated BP in the upper range of stage II
hypertension.
 Without progressive end-organ dysfunction.
 Examples: Highly elevated BP without severe headache,
shortness of breath or chest pain.
 Usually due to under-controlled HTN.
 Modestly lower BP in period of hours to days, target ≤160/100

 Rapidity based on individual risk for adverse event & probable duration of severe
HT

 Avoid overtreating & inciting hypotensive complications

 Treat with oral agent

 Agents: nitrate, captopril, clonidine, labetalol*

* Not available in Indonesia

 Severely elevated BP (>180/120mmHg).
 With progressive target organ dysfunction.
 Require emergent lowering of BP.

 Examples: Severely elevated BP with:

Hypertensive encephalopathy
Acute left ventricular failure with pulmonary
edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm
 Immediate but controlled reduction of MAP

 Treat with parenteral drug, in ICU

 ↓ MAP by 25% over minutes to 1 hr, then to 160/100 mm

Hg within the next 2 to 6 hr.

 Further reductions to <140/90 within 24-48 hr to allow

autoregulation to reset

 Exceptions: aortic dissection, LV failure and pulmonary

edema, needs faster reduction
1. Grading
2. Always measure the Heart Rate
3. Failure or Not (Rales? Edema?)
4. Comorbidity
5. Use 1 drug or combination
6. Risk Factors Limitation

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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)

Quit smoking

* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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  Anti RAAS
 Anti Remodelling
 Anti Fibrosis
 Main effect : Arterio-veno dilator

BP= Stroke.Volume X HR X Arterial Resistance

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Captopril : 3x (12,5 mg , 25 mg or 50 mg)
Lisinopril : 1x (2.5 mg , 5 mg, or 10 mg)
Ramipril : 1x (2.5 mg , 5 mg, or 10 mg)

Valsartan : 2x (80 mg or 160 mg)

Candesartan : 1x (8 mg or 16 mg)
Irbesartan : 1 x (150 mg or 300 mg)

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  Decrease contractility
 Decrease HR
 Particular Drug; Artery Dilatation/ NO donor

BP= Stroke.Volume X HR X Arterial Resistance

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 Bisoprolol : 1x (2.5 mg, 5 mg, 7.5 mg, 10 mg)
 Propanolol : 3 x (5 mg, 10 mg, 20 mg, 40 mg)
 Carvedilol : 2 x ( 3.125 mg, 6.25 mg, 12.5mg)
 Nebivolol : 1 (2.5 mg/ 5mg)

ESC recommendation : Carvedilol and Nebivolol has

arteri-dilator / donor NO property
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  Verapamil 3x 80mg, Diltiazem 3x (30mg or
60mg), Herbesser CD 1x (100mg or 200mg)
 Decrease HR
 Decrease Contraction
 Slight/ none  arterial dilatation

BP= Stroke.Volume X HR X Arterial Resistance

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  Nifedipine (not recommended unless
Pregnancy , due to tachycardia reflex)
 Adalat oros (still commonLong Acting
Nifedipine 1x30 mg)
 Amlodipine 1 x (5 mg or 10 mg)
 Strong arteri-dilator
 Slight decrease/none : HR and
Contraction

BP= Stroke.Volume X HR X Arterial Resistance

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  HCT 1x (12.5 mg or 25 mg)
 Furosemide ( tailor made)
 Spironolacton (not Essential HT’s
therapy)

BP= Stroke.Volume X HR X Arterial Resistance

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  Clonidine : 1 x 1tab or 2x 1 tab
(caution : Rebound phenomena)
 MetilDopa : 3 x (250 mg, 500 mg, 750
mg)
 Arteri-Dilator non direct (antagonis Alfa
central)
BP= Stroke.Volume X HR X Arterial Resistance

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