Hypertension

Dr. dr. Sahala Panggabean, SpPD-KGH

Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran
Universitas Kristen Indonesia
 Problem Magnitude

• Hypertension( HTN) is the most common

primary diagnosis in America.
• 35 million office visits are as the primary
diagnosis of HTN.
• 50 million or more Americans have high BP.
• Worldwide prevalence estimates for HTN may
be as much as 1 billion.
• 7.1 million deaths per year may be attributable
to hypertension.
 Hypertension
• Blood pressure levels are a function of
cardiac output multiplied by peripheral
resistance (the resistance in the blood
vessels to the flow of blood)
 Patophysiology
Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Hypertension = Increased CO and/or Increaced PR

 Preload  Contractility Functional Structural

Constriction hypertrophy
 Fluid Volume
Volume Redistribution
Sympathetic Renin- Cell Hyper
nervous over- Angiostensin Membran Insulinemia
Renal Decreased activity Excess Alteration
Sodium filtration
Retension surface

Stress Obesity

Excess Genetic Genetic Endothelium

Sodium Alteration Alteration derived
Intake factors
 Classification and management
of blood pressure for adults
(JNC VII)
INITIAL GRUG THERAPY

DBp*
BP SBp* mmH Lifestyle Without Compelling With Compelling
Classification mmHg g MODIFICATION Indication indication
Normal <120 And Encourage
<80
Prehypertension 120- Or 80- Yes No Antihypertension Drug(s) for comppelling
139 89 Drug indicated indication
Stage 1 140- Or 90- Yes Thiazide-type Drug(s) for the
Prehypertension 159 99 diuretics for most. compelling indications
May consider Other antihypertensive
ACEI,ARB,BB, CCB drugs (diuratics, ACEI,
or combination ARB, BB, CCB) as
needed
Stage 2 >160 Or Yes Two drug
Prehypertension >100 combination for most
(usually Thiazide-type
diuretics an ACEI or
ARB or BB or CCB)

DBP* diagnostic blood pressure, SBP* systotic blood pressure

Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.
 Hypertensive Crises

• Hypertensive Urgencies: No progressive

target-organ dysfunction. (Accelerated
Hypertension)

• Hypertensive Emergencies: Progressive

end-organ dysfunction. (Malignant
Hypertension)
 Types of Hypertension
• Primary HTN:
• Secondary HTN:
also known as
essential HTN. less common cause
of HTN ( 5%).
accounts for 95%
cases of HTN. secondary to other
potentially rectifiable
no universally
causes.
established cause
known.
 Causes of Secondary HTN

• Common • Uncommon
– Intrinsic renal disease – Pheochromocytoma
– Renovascular disease – Glucocorticoid excess
– Mineralocorticoid – Coarctation of Aorta
excess – Hyper/hypothyroidism
– Sleep Breathing
disorder
 Secondary HTN-Clues in Medical
History

• Onset: at age < 30 yrs ( Fibromuscular dysplasi)

or > 55 (athelosclerotic renal artery stenosis),
sudden onset (thrombus or cholesterol
embolism).
• Severity: Grade II, unresponsive to treatment.
• Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
• Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)
 Secondary HTN-clues on Exam

• Pallor, edema, other signs of renal disease.

• Abdominal bruit especially with a diastolic
component (renovascular)
• Truncal obesity, purple striae, buffalo hump
(hypercortisolism)
 Secondary HTN-Clues on Routine
Labs
• Increased creatinine, abnormal urinalysis
( renovascular and renal parenchymal
disease)
• Unexplained hypokalemia
(hyperaldosteronism)
• Impaired blood glucose
( hypercortisolism)
• Impaired TFT (Hypo-/hyper- thyroidism)
 Evaluation Objectives

 To identify know causes

 To assess presence or absence of target
organ damage and cardiovascular
disease
 To identify other risk factors or disorders
that might guide treatment
Evaluation Components

• Medical history
• Physical examination
• Routine laboratory tests
• Optional tests
 MEDICAL HISTORY

 Duration and classification of hypertension

 Patient history of cardiovascular disease
 Family history
 Symptoms suggesting causes of hypertension
 Lifestyle factors
 Current and previous medications
 Physical Examination

 Blood pressure readings (two or more)

 Verification in contralateral arm.
 Height, weight, and waist circumference
 Funduscopic examination
 Examination of the neck, heart, lungs,
abdomen, and extremities
 Neurological assessment
Accurate Blood Pressure Measurement

• The equipment should be regularly inspected and

validated.
• The operator should be trained and regularly retrained.
• The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
• The auscultatory method should be used.
• Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
• An appropriately sized cuff should be used.
• At least two measurements should be made and the
average recorded.
• Clinicians should provide to patients their specific BP
numbers and the BP goal of their treatment.
 Laboratory Tests and Other
Diagnostic Procedure

• Determine presence of target organ

damage and other risk factors
• Seek specific causes of hypertension
Laboratory Tests Recommended
Before Initiating Therapy

 Urinalysis
 Complete blood count
 Blood chemistry: potassium, sodium,
creatinine, and fasting glucose
 Lipid profile: total cholesterol and HDL
cholesterol
 12-lead electrocardiogram
 Stratification of Risk Factors
on Patients with Hypertension
Major Risk Factors: Clinical Risk Factors
• Smoking ( Target Organ Damage):
• Dyslipidemia * Heart diseases (HHD or CAD )
• Diabetes mellitus * Stroke or TIA
• Age older than 60 years * Nephropathy ( CKD )
• Sex (men or * Peripheral arterial disease
postmenopausal women)
* Retinopathy
• Family history of
cardiovascular disease
 Risk Stratification
Risk Group A ( Low ) No risk factors
No target organ disease/clinical
cardiovascular disease
Risk Group B ( Moderate ) At least one risk factor, not including
diabetes
No target organ disease/clinical
cardiovascular disease

Risk Group C ( High ) Target organ disease /clinical cardiovascular

disease and/or diabetes.
With or without other risk factors
 Target Organs Damage

Untreated hypertension can result in:

Arteriosclerosis --Kidney damage
Heart Attack --Stroke
Enlarged heart --Blindness
 Effects On CVS
• Ventricular hypertrophy, dysfunction and failure.
• Arrhithymias
• Coronary artery disease, Acute MI
• Arterial aneurysm, dissection, and rupture.

Effects on The Kidneys

• Glomerular sclerosis leading to impaired kidney function
and finally end stage kidney disease.
• Ischemic kidney disease especially when renal artery
stenosis is the cause of HTN
 Effects on Nervous System
• Stroke, intracerebral and subaracnoid hemorrhage.
• Cerebral atrophy and dementia

Effects on The Eyes

• Retinopathy, retinal hemorrhages and impaired vision.
• Vitreous hemorrhage, retinal detachment
• Neuropathy of the nerves leading to extraoccular muscle
paralysis and dysfunction
 Treatment for Hypertension
Lifestyle Modification

• Maintain a healthy weight, lose weight if

overweight.
• Be more physically active.
• Moderation of alcohol consumption.
• Reduce the intake of salt and sodium in the diet
to approximately 2400 mg/day.
• Maintain adequate intake of Potassium, calcium
and magnesium.
• Stop smoking.
• Reduce dietary saturated fat and cholesterol.
 Treatment Strategies and
Risk Stratification
Blood Pressure
Stages (mmHg) Risk Group A Risk Group B Risk Group C
High-normal Lifestyle modification Lifestyle modification Drug therapy
(130-139/85-89) Lifestyle modification

Stage 1 Lifestyle modification Lifestyle modification Drug therapy

(140-159/90-99) (up to 12 months) (up to 6 months)** Lifestyle modification

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

(≥160/ ≥ 100) Lifestyle modification Lifestyle modification Lifestyle modification

Or those with heart failure, renal insufficiency, or diabetes

For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification
 Goals of Treatment
• Treating SBP and DBP to targets that are <140/90 mmHg
• Patients with diabetes or renal disease, the BP goal is <130/80
mmHg
• The primary focus should be on attaining the SBP goal.
• To reduce cardiovascular and renal morbidity and mortality

Benefits of Treatment
• Reductions in stroke incidence, averaging 35–40 percent
• Reductions in MI, averaging 20–25 percent
• Reductions in HF, averaging >50 percent.
 Lifestyle modifications

www.nhlbi.nih.gov
 The DASH Diet
The Dietary Approaches to Stop Hypertension clinical trial
(DASH)
 Diet rich in fruits, vegetables, and low fat dairy foods, can
substantially lower blood pressure in individuals with
hypertension and high normal blood pressure.

Implications
• Combination diet affects comparable to pharmacological
trails in mild hypertension.
• Population wide reductions in blood pressure similar to
DASH results would reduce CHD by ~ 15% and stroke by
~27%
• Great potential in susceptible groups: high risk group and
elderly.
 Reducing Sodium in the Diet
• Use fresh poultry, fish and lean meat, rather than canned
or processed.
• Buy fresh, plain frozen or canned with “no salt added”
vegetables.
• Decrease or eliminate use of table salt.
• Choose ‘convenience’ foods that are lower in sodium.
When available, buy low- or reduced-sodium or ‘no-salt-
added’ versions of foods like:
– Canned soup, canned vegetables, vegetable juices
– cheeses, lower in fat
– condiments like soy sauce
– crackers and snack foods like nuts
– processed lean meats
 Pharmacologic Treatment
• Decreases cardiovascular morbidity and
mortality based on randomised controlled
trials
• Protects against stroke, coronary events,
heart failure, progression of renal disease,
progression to more severe hypertension,
and all-cause mortality
 Special Considerations
In Selecting Drug Therapy

• Demographics
• Coexisting diseases and Therapies
• Quality of life
• Physiological and biochemical measurements
• Drug interactions
• Economic considerations
 Drug Therapy

· A low dose of initial drug should be used

slowly titrating upward.
· Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least
50% of peak effect remaining at end of 24
hours
· Combination therapies may provide additional
efficacy with fewer adverse effects
 Classes of
Antihypertensive Drugs

· ACE inhibitors ( e.g captopril )

· Adrenergic inhibitors ( e.g bisoprolol )
· Angiotensin II receptor blockers ( e.g valsartan )
· Calcium antagonists ( e.g amlodipine , diltiazem )
· Direct vasodilators ( e.g nitrate )
· Diuretics ( e.g hydrochlorothiazide, furosemide )
 Combination Therapies

 β – adrenergic blockers and diuretics

 ACE inhibitors and diuretics
 Angiotensin II receptor antagonists and diuiretics
 Calcium antagonists and ACE inhibitors
 Other combinations
 Follow up
 Follow up within 1 to 2 months after initiating therapy
 Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
 Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
 Consider reducing dose and number of agents after 1
year at or below goal.
Causes for inadequate Response to
Drug therapy

 Pseudo resistance
 Non adherence to therapy
 Volume overload
 Drug-related causes
 Associated conditions
 Identifiable cause of hypertension
 Hypertensive Emergencies
and Urgencies

• Emergencies require immediate blood pressure

reduction to prevent or limit target organ
damage
• Urgencies benefit from reducing blood pressure
within a few hours
• Elevated blood pressure alone rarely requires
emergency therapy
• Fast-acting drugs are available.
 Drugs avaiblable for
hypertensive emergencies

Vasodilators : Adrenergic Inhibitors :

• Nitroprusside  Labetalol
• Nicardipine  Esmolol
• Fenoldopam  Phentolamine
• Nitroglycerin
• Enalaprilat
• Hydralazine
Algorithm for Treatment of Hypertension

Begin or Continue Lifestyle Modification

Not at Goal Blood Pressure

Initial Drug Choices

Not at Goal Blood Pressure

Notresponse or Inadequate response

Trpublesome side effect But well tolerated

Subtitute drug, from Add agent from

Different class Different class

Not at Goal Blood Pressure

Continue adding agents from other classes

Consider referral to a hypertension specialist
Algorithm for Treatment of
Hypertension
Initial Drug Choices *
Compelling Indications
* Heart failure
- ACE inhibitors
- Diuretics
* Mycardial infarction
- β-blockrs (non-ISA)
- ACE inhibitors (with systolic dysfunction)
* Diabetes Mellitus (Type 1) with proteinuria
- ACE inhibitors
* Isolated systolic hypertension (older persons)
- Diuretics preffered
- Long-acting dihydropyridine calcium antagonists

* Based on randomized controlled trials

THANK YOU