Yusra Pintaningrum

WHO 1999

JNC VII

ETIOLOGY

MECHANISM OF PRIMARY

HEMODYNAMIC SUBTYPE

Neurohormonal control of blood pressure

Blood pressure = Cardiac output (CO) x Peripheral resistance (PR)

Hypertension = Increased CO and/or Increased PR

Preload

Fluid volume

Renal sodiumretention

Contractility

Fluid volume

Vasoconstriction

Sympatheticnervoussystem

Renin-angiotensin-aldosterone

system

Geneticfactors

Excesssodiumintake

(Adapted from Kaplan, 1994)

Acute neurohormonal effects on blood pressure homeostasis

Acute neurohormonal effects on blood pressure homeostasis

Heart rate and cardiac output

Perfusion

Sodium and water retention

Blood pressure

RAA SNS

Chronic neurohormonal effects on vascular structure

Chronic neurohormonal effects on vascular structure

Myocardial hypertrophy

Perfusion

Glomerular hypertention and hypertrophy

Vascular hypertrophy

RAA SNS

Haemodynamic Transition from Hyperkinetic to Typical Essential Hypertension

Cardiaccompliance

Beta adrenergicresponsiveness

Strokevolume Heart rate

CARDIAC OUTPUT

Wall/lumenratio

Endothelialdamage

Vaso-constriction Vasodilation

VASCULAR RESISTANCE

HEART RESISTANCE ARTERIOLES

PATOPHYSIOLOGY

The factors affecting cardiac output: - sodium intake, renal function, & mineralocorticoids - the inotropic effects occur via extracellular fluid volume augmentation - an increase in heart rate and contractility

Peripheral vascular resistance is dependent upon the sympathetic nervous system, humoral factors, and local autoregulation

(Sharma, 2003)

NEURAL MECHANISM

VASCULAR MECHANISM

HORMONAL MECHANISM

Diagnosis Approach

"The Goal is to Get to Goal!”

Hypertension -PLUS- Diabetes or Renal Disease

< 140/90 mmHg < 130/80 mmHg

Patients should return for follow-up and adjustment of medications every 1-2 months until the BP goal is reached

Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

Stage 2 HTN (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 HTN (SBP 140–159 or DBP 90–99 mmHg)

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or

combination.

Without Compelling Indications

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

Follow-up and Monitoring

Patients should return for follow-up and adjustment of medications every 1-2 months until the BP goal is reached

After BP at goal and stable, follow-up visits at 3- to 6-month intervals More frequent visits for stage 2 HTN or with

complicating comorbid conditions Continue to encourage self BP monitoring

Serum potassium and creatinine monitored 1–2 times per year

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314