Dr. Trisulo, HT Dan Metabolik Sindrome

5/23/2018 Dr. Trisulo, HT Dan Metabolik Sindrome'

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DAFTAR RIWAYAT HIDUP

1. Nama : Dr.H.Trisulo Wasyanto, Sp JP (K), FIHA

2. Tempat & tanggal lahir : Poso , 8

2 - 1956

3. Pangkat / Golongan : Pembina Utama Muda / IV C

4. Perguruan Tinggi Strata I : Fak.Kedokteran UNDIP , lulus 1982

Strata II : Program Pendidikan Dokter Spesialis I

Jantung dan Pembuluh Darah FK UNAIR ,

lulus 1995

5. 1983 - 1990 Kepala Puskesmas Kec. Mojolaban Kab. SukoharjoJateng

6. 1990 - 1995 PPDS I Jantung di FK UNAIR / RSUD Dr. Soetomo Surabaya

7. 1996 - Sekarang SMF / Lab. Kardiologi RSUD Dr.Moewardi / FK UNS8. 1998 - 2006 Wakil Kepala Instalasi Perawatan Intensive RSUD Dr.

Moewardi Surakarta

9. 2004 - Sekarang Ketua Panitia Kredensial Komite Medik RSUD

Dr. Moewardi Surakarta

10. 2006- Sekarang Ketua PERKI Cabang Surakarta


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THE ROLE OF ANTIHYPERTENSIVE AGENTIN HYPERTENSION PATIENTS WITH METABOLIC SYNDROM

Dr.TRISULO WASYANTO,Sp JP (K),FIHADEPT OF CARDIOLOGY & VASCULAR MEDICINE

UNIV OF SEBELAS MARET / Dr MOEWARDI HOSPITAL

S U R A K A R T A


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The Metabolic Syndrome The metabolic syndrome is characterized by

the variable combination of visceral obesity

and alterations inglucose metabolism, lipid

metabolism, and BP.It has a high prevalence

in the middle age and elderly population. Subjects with the metabolic syndrome also

have a higher prevalence of microalbuminuria,

LVH and arterial stiffness than those without

metabolic syndrome. Their CV risk is highandthe chance of developing diabetes markedly

increased.

Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.

Eur Heart J 2007;28:1462-1536


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Vascular amage


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The presence of the Metabolic Syndrome is associated

with increased CAD and Total mortality


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Definition and Classification of

Hypertension : JNC VII

Hypertension is defined as blood pressure 140/90 mmHg

Category Systolic

(mmHg)

Diastolic

(mmHg)

Normal


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JNC VII : Management of Hypertension byJNC VII : Management of Hypertension byBlood Pressure ClassificationBlood Pressure Classification

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;

CCB = calcium channel blocker.ChobanianChobanian AV et al.AV et al. JAMA.JAMA. 2003;289:25602003;289:2560--2572.2572.

Drug(s) for the compellingindications; otherantihypertensive drugs(diuretics, ACE-I, ARB,BB, CCB) as needed

Drug(s) for the compellingindications; otherantihypertensive drugs(diuretics, ACE-I, ARB, BB,

CCB) as needed

BP Classification

Lifestyle

Modification

Initial Drug Therapy

Without Compelling

Indication

With Compelling

Indication

Normal


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Hypertension treatment strategy : JNC VIILifestyle modifications

Not at goal blood pressure (


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JNC VII & ESH/ESC 2003:

Treatment Considerations

Most patients with hypertensionwill require 2 ormore antihypertensive drugs to achieve BP goals

According to baseline BP and presence or absence

of complications, therapy can be initiated either with

a low dose of a single agent or with a low-dose

combination of 2 agents

When BP is>20/10 mm Hg above goal,

consideration should be given to initiating 2 drugs,either as separate prescriptions or in fixed-dose

combinations, one of which should be athiazide-

type diureticChobanian AV et al. JAMA. 2003;289:2560-2572.Guidelines Committee. J Hypertens.2003;21:1011-1053.


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Definitions and Classifications of

Blood Pressure : ESH/ESC 2007

Category Systolic DiastolicOptimal < 120 and < 80

Normal 120-129 and/or 80-84

High normal 130-139 and/or 85-89

Grade 1

hypertension

140-159 and/or 90-99

Grade 2

hypertension

160-179 and/or 100-109

Grade 3hypertension

180 and/or 110Isolated

systolic

hypertension

and < 90 140

Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.Eur Heart J 2007;28:1462-1536


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Initiation of Antihypertensive treatment : ESC 2OO7Other risk

factors, OD, or

disease

Normal SBP

120-129 or DBP

80-84

High normal

SBP 130-139 or

DBP 85-89

Grade 1 HT

SBP 140-159 or

DBP 90-99

Grade 2 HT

SBP 160-179 or

DBP 100-109

Grade 3 HT

SBP 180 orDBP 110

No other risk

factors

No BP

intervention

No BP

intervention

Lifestyle

changes forseveral months

then drug

treatment if BP

uncontrolled

Lifestyle

changes forseveral weeks

then drug

treatment if BP

uncontrolled

Lifestyle

changes +immediate drug

treatment

1-2 risk factors Lifestyle

changes

Lifestyle

changes

Lifestyle

changes for

several weeksthen drug

treatment if BP

uncontrolled

Lifestyle

changes for

several weeksthen drug

treatment if BP

uncontrolled

Lifestyle

changes +

immediate drugtreatment

3 risk factors,MS or OD

Lifestyle

changes

Lifestyle

changes and

consider drug

treatment

Lifestyle

changes + drug

treatment

Lifestyle

changes + drug

treatment

Lifestyle

changes +

immediate drug

treatmentDiabetes Lifestyle

changes

Lifestyle

changes + drug

treatment

Lifestyle

changes + drug

treatment

Lifestyle

changes + drug

treatment

Lifestyle

changes +

immediate drug

treatment

Established CV

or renal

disease

Lifestyle

changes +


Lifestyle

changes +


Lifestyle

changes +


Lifestyle

changes +


Lifestyle

changes +



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Conditions favouring the use of some

Antihypertensive drugs versus otherSUBCLINICAL ORGAN DAMAGE

LVH ACEI, CA, ARB

Asymptomatic atherosclerosis CA, ACEI

Microalbuminuria ACEI, ARB

Renal Dysfunction ACEI, ARB

CLINICAL EVENT

Previous stroke Any BP lowering agent

Previous MI BB, ACEI, ARBAngina pectoris BB, CA

Heart failure Diuretics, BB, ACEI, ARB,

Anti - aldosterone agents

Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.

Eur Heart J 2007 28:1462-1536


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Continued..

Atrial fibrillation

Recurrent ARB, ACEI

Permanent BB, non - dihydropiridine CA

Tachyarrhytmias BB

ESRD / proteinuria ACEI, ARB, loop diuretics

Peripheral artery disease CA

LV dysfunction ACEI

Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial HypertensionAdapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.Eur Heart J 2007;28:1462-1536


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Continued..

CONDITION

ISH (elderly) Diuretics, CA

Metabolic syndrome ACEI, ARB, CA

Diabetes mellitus ACEI, ARB

Pregnancy CA, methyldopa, BB

Black people Diuretics, CA

Glaucoma

ACEI induced cough

BB

ARB



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Contra-indications to use certain

Antihypertensive drugs

Compelling contra-indications

Possible contra-indications

Thiazide diuretics Gout -Metabolic syndrome

-Glucose intolerance

-Pregnancy

Beta-blockers Asthma

A-V block (grade 2 or 3)

-Peripheral artery disease

-Metabolic syndrome

-Athletes and physically

active patients

-Chronic obstructive

pulmonary disease

Calcium antagonists

(dihydropiridine)

-Tachyarrhytmias

-Heart failure

Calcium antagonists

(verapamil, diltiazem)

A-V block (grade 2 or 3)

Heart failure



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Continued..

Compelling contra-

indications

Possible contra-

indications

ACE-inhibitors Pregnancy

Angioneurotic edema

HyperkalaemiaBilateral renal artery

stenosis

Angiotensin receptor

blockers

Pregnancy

Hyperkalaemia

Bilateral renal arterystenosis

Diuretics

(antialdosterone)

Renal failure

hyperkalaemia



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Diuretics

ARBs

CCBs

ACE-Inhibitors

-Blockers

-Blockers

European Society

of Hypertension

2007

Possible Combination of

Different Classes of Anti

Hypertension Drugs

Preferred

combinations

Proven bene-

ficial in trialsAdapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension


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Mild BP elevation

Low/Moderate CV risk

ConventionalBP Target

Marked BP elevation

High/very high CV RiskLower BP target

Choose between

Single Agent at

low Dose

Two Drugs Combination

at low Dose

Previous Agent

at Full Dose

Two Three drug combination

at full dose

Switch to different

agent

at low dose

Two-to

Three drug

Combination

at full dose

Full Dose

Monotherapy

Monotherapy versus combination therapy strategies

Previous

combination

at full dose

Add a Third drug

at low dose

If Goal BP

Not Achieved

If Goal BP

Not Achieved

Ada ted From 2007 ESH-ESC Guidelines for the Mana ement of Arterial H ertension


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Comparison of tight BP vs tight Glucose control

in UKPDS

5

-50

-40

-30

-20

-10

0

Tight glucose controlTight BP control

Microvascularendpoints

*

Stroke Any diabetes-related endpoint Diabetes-relateddeaths

*

*

*

* p


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Gaede P, et al. N Engl J Med2003;348:383-393

Steno-2: Patients who reached intensive-

treatment goals at a mean of 7.8 years

HbA1c


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Steno-2: Composite CV endpoints

Primaryco

mposite

endpoin

t*(%)

0

0 3612 966048 847224

60

30

40

20

10

50

Intensive therapy

BP 132/73 mmHg

Conventional therapy

BP 146/78 mmHg

Months of follow-up

p=0.007

Hazard ratio=0.47

(95% CI, 0.24 to 0.73; p=0.008)

Gaede P, et al. N Engl J Med2003;348:383-393

* Primary composite endpoint = composite of death from cardiovascular causes,nonfatal myocardial infarction, nonfatal stroke, revascularization and amputation


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Treatment of Hypertension in MS

Some anti-hypertensives (diuretics, beta-blockers) worsen glycemic controland may

not be suitable for long-term use in MS

Drugs of choice in MS may beACE-inhibitors,

and possibly ARBs

ACE-inhibitors (and ARBs) are free of potentially

diabetogenic side-effects and seem to have

pleiotropic antidiabetic properties

Use of ACE-inhibitors with beta-blockers and/or

diuretics may cancel out the diabetogenic effects

of the latter

Adapted from www.biophoenic.com


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In patients with metabolic syndrome diagnosticprocedures should include a more in-depth

assessment of subclinical organ damage.

In all individuals with metabolic syndrome intense

lifestyle measures should be adopted.

When there is hypertensiondrug treatmentshould

start with a drug unlikely to facilitate onset to

diabetes.Therefore ablocker of the renin-

angiotensin system should be usedand followed, if

needed, by the addition of a calcium antagonists or

a low-doze thiazide diuretics.It appears desirable

to bring BP to the normal range.

CONCLUTIONS (1)


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Lack of evidence from specific clinical trialsprevents firm recommendations on use of

antihypertensive drugs in all metabolic

syndrome subjects with a high normal BP.

There is some evidence thatblocking the renin-angiotensin system may also delay incident

hypertension.

CONCLUTIONS ( 2 )


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Dr. Trisulo, HT Dan Metabolik Sindrome