PIT PDUI JAWA BARAT 2018

Bandung, 13 – 15 Juli 2018

HYPERTENSION
ABOUT PATHOGENESIS, THERAPY AND COMPLICATION

Pudji Rusmono Adi., dr., SpPD. K-KV. FINASIM

Section of cardiovascular of Internal Medicine
IMMANUEL Hospital. Bandung
 WHAT IS HYPERTENSION ?

 A Blood pressure high enough to be a danger to their well-being.

- The exact cutoff points to define stages of hypertension are somewhat
arbitrary. ¹
- The relationships between arterial pressure and mortality is
quantitative; the high the pressure, the worse the prognosis.(Pickering, 1972)²

 The operational definition of hypertension is the level at which the

benefits of action exceed those of inaction. (Rose 1980) ²

 Hypertension is now considered as a part of a complex syndrome of

changes in cardiac and vascular structure and function.³

¹ Lily LS. Pathophysiology of Heart Disease. 5th ed

³ Kalra S, Kalra B, AgrawaNavneet. Combination therapy in hypertension: An update. Diabetology & Metabolic Syndrome 2010, 2:44

² M. Kaplan. Kaplan’s Clinical Hypertension. 9ed, 2006

PATHOGENESIS OF HYPERTENSION

Oparil S, Zaman,MA, Calhoun DA. Pathogenesis of Hypertension. Ann Intern Med. 2003;139:761-776
Pathophysiologic mechanisms of hypertension.

Oparil S, Zaman,MA, Calhoun DA. Pathogenesis of Hypertension. Ann Intern Med. 2003;139:761-776.
DEFINITION

The Seven Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure, NIH
Publication, 2004.

Blood Pressure SBP DBP

Classification mmHg mmHg
Normal < 120 And <80
Prehypertension 120 - 139 And 80 – 89
Stage 1 140 - 159 And 90 – 99
Hypertension
Stage 2 > 160 > 100
Hypertension
2013 ESH/ESC Guidelines for the management of arterial
hypertension

European Heart Journal (2013) 34, 2159–2219

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline
for the Prevention, Detection, Evaluation, and Management of High Blood
Pressure in Adults . 2017

Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

MEASUREMENT OF BLOOD PRESSURE.

Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment,
Prevention, and Treatment of Hypertension in Adults

Canadian Journal of Cardiology 2017 33, 557-576DOI:

(10.1016/j.cjca.2017.03.005)

Copyright © 2017 Canadian Cardiovascular Society

TREATMENT RECOMMENDATION

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection,

Evaluation, and Management of High Blood Pressure in Adults . 2017
Atherosclerotic cardiovascular Risk Calculator

Non pharmacology therapy

........
 Non pharmacology therapy +
BP lowering medication (1 medication)
Paul K. Whelton et al. Hypertension. 2018;71:1269-1324
Detection of white coat hypertension or masked
hypertension in patients not on drug therapy

Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

Copyright © American Heart Association, Inc. All rights reserved.

Choice of initial drug.

Paul K. Whelton et al. Hypertension.

2018;71:1269-1324
Blood Pressure Goal.

Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

JNC 8
Diagnosis and management of a hypertensive crisis.

Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

Copyright © American Heart Association, Inc. All rights reserved.

Paul K. Whelton et al. Hypertension.
2018;71:1269-1324
ESH/ESC Guidelines for the management of arterial
hypertension, 2013

.
European Heart Journal (2013) 34 2159–2219
Cardiovascular Risk Stratification.
ESHESC Guidelines 2013

Mancia et al. Eur Heart J 2013;34(28):2159-219

Possible combination therapy of Hypertensive drugs

2013 ESH/ESC Guidelines for the management of arterial hypertension.

European Heart Journal (2013) 34 2159–2219
 Single - drug :

 Hypertension (HTN) guidelines recommend antihypertensive

drug classes, without detailing specific drugs.¹
 Although decreases in BP were overall similar among the
different pharmacologic families, the specific analysis of the
drugs used in monotherapy showed relevant differences¹.
 Most of the drugs achieved mean SBP reductions between
10 - 15 mmHg and 5 -10mm Hg for DBP.¹
Monotherapy normalizes BP in no more than 30 - 40 % of
patients, even those with mild hypertension, and it is not fully
effective in patients with high grade hypertension.²
¹ Paz et al. Treatment efficacy of anti-hypertensive drugs in monotherapy or combination. Medicine (2016) 95:30
²Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
Combi – Drug.

 In high/very high-risk patients another important goal

of antihypertensive treatment is rapid normalization of
BP.
 Combination therapy can induce a more rapid BP
reduction and/or normalization than can monotherapy.
 Combination therapy produces a significantly greater
reduction in global cardiovascular, coronary, and
cerebrovascular events versus mono therapy,
independent of BP control.
 There is solid evidence that combination therapy offers
important advantages over monotherapy.
Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI 10.1007/s40256-015-0116-5
 It is important to use a combination of antihypertensive
agents characterized by complementary mechanisms of
action.
 Good combinations include:
- A RAS blockers (ACE inhibitors, ARBs, beta- blockers) +
a drug that stimulates RAS (calcium antagonists,diuretics,
vasodilators)
- An agent activating the sympathetic nervous system
should be combined with one that blocks sympathetic
activity.
Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI 10.1007/s40256-015-0116-5
Kalra S, Kalra B, Agrawal N. Combination therapy in hypertension: An update Diabetology & Metabolic Syndrome 2010, 2:44
Number of Antihypertensive Agents Needed to Reach
Blood Pressure (BP) Goal
Trial (SBP achieved)

HOT (138 mmHg)

AASK (128 mmHg)

UKPDS (144 mmHg)

ASCOT-BPLA (136.9 mmHg)

ALLHAT (135 mmHg)

1 2 3 4
Average no. of antihypertensive medications
SBP: systolic blood pressure
Kjeldsen et al Hypertension 1998: 31: 1014-1020; UKPDS group Lancet, 1998: 352: 854-865; AASK research group Arch Intern Med 168: 832-839; Dahlöf et al. Lancet 2005;366:895–
906
ALLHAT research group 2002; 288: 2981-2997:

27
Effectiveness of combination therapy in clinical practice: odds ratio values (95
% confidence interval) for nonfatal cardiovascular outcomes overall, coronary
heart disease, or cerebrovascular events.

Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI 10.1007/s40256-015-0116-5
JNC 7
ABOUT COMPLICATION.

*WHO. Global brief on hypertension. 2013

*WHO. Global brief on hypertension. 2013
*WHO. Global brief on hypertension. 2013
*WHO. Global brief on hypertension. 2013
WHO 2013:*
 Globally cardiovascular disease accounts for
approximately 17 million deaths a year, nearly one third
of the total .

 Of these, complications of hypertension account for 9.4

million deaths worldwide every year .

 Hypertension is responsible for at least 45% of deaths

due to heart disease, and 51% of deaths due to stroke.

*WHO. Global brief on hypertension. 2013

 SUMMARY

 Hypertension is now considered as a part of a complex

syndrome of changes in cardiac and vascular structure
and function.
 Pathophysiologically there are many that play a role in
the development of hypertension.
 In mild cases required only single medication, but in the
more severe cases requires a combination of two drugs.
 If hypertension is not controlled with combination drugs or
complication arise it is better referred to a specialist.
 The main complication of hypertension are causing high
death rates from heart disease and stroke.
HATUR NUHUN