HYPERTENSION

Taufan Adi Nugroho

Batasan Hipertensi1. Bila tekanan sistolik >= 140 mmHg, dan atau tekanan diastolik >= 90 mmHg, atau sedang mendapat obat antihipertensi. 2. Dilakukan dua kali atau lebih pengukuran pada dua kali atau lebih kunjungan.

Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension

140–159 or 90–99

Stage 2 Hypertension

>160 or >100

BP Classification

SBP mmHg

DBP mmHg

WHO/ISH 2003.

ESC/ESH 2003 .

Classification of blood pressure levels of the British Hypertension Society

Brit Med J 2004 328:634-40.

Category Systolic blood pressure Diastolic blood pressure (mmHg) (mmHg) Optimal <120 <80Normal <130 <85High-normal 130–139 85–89

HypertensionGrade 1 (mild) 140–159 90–99Grade 2 (moderate) 160–179 100–109Grade 3 (severe) 180 110

Isolated Systolic Hypertension Grade 1 140 - 159 <90Grade 2 >160 <90

AUSTRALIA 2003

BP Measurement TechniquesMethod Brief Description

In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring

Indicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.

JNC 7 2003

Office BP Measurement Use auscultatory method with a properly calibrated and validated

instrument.

Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.

Appropriate-sized cuff should be used to ensure accuracy.

At least two measurements should be made.

Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

JNC 7 2003

……… sphygmomanometer

Patient should be seated and relaxed, preferably for several minutes prior to the measurement and in a quiet room.

Appropriate cuff size.

Average the readings. If the firsty two readings differ by more than 10 mmHg systolic or 6 mmHg diastolic or if the initial readings are high, take several readings after five minutes of quiet rest, until consecutive readings do not vary by greater than these amounts.

Ideally, patients should not take caffeine-containing beverages or smoke for at least two hours before blood pressure is measured, …………………..

How to measure blood pressure accurately

Australia, 2004

Box 2 Procedures for blood pressure measurement

When measuring blood pressure, care should be taken to ……….. to sit for several minutes in a quiet room before

beginning blood pressure measurements.

Take at least two measurements spaced by 1-2 min, ………….

Use a standard bladder ……. but have a larger and a smaller bladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of the patient.

Use phase I and V …………….

Measure blood pressure in both arms at first visit to detect possible differences ……………………..

Measure blood pressure 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients,……………..

Measure heart rate by pulse palpation (30 s) after the second measurement in the sitting position.

ESC/ESH 2003

HIPERTENSIHIPERTENSI

Tekanan Darah :Tekanan Darah :

• Rata-rata dari 2 kali pemeriksaan• Pengukuran pada waktu yang berbeda• Pengukuran pada waktu duduk

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TD kekuatan darah ketika melewati dinding arteri

Jenis Hipertensi Hipertensi Resisten Hipertensi Emergensi Hipertensi Urgensi Berdasarkan Penyebab Hipertensi Primer idiopatik 90-95% Hipertensi Skunder Sistemik

Prevalensi Hipertensi USA 50 Juta dari total

Penduduk ( 1 dari 4 orang

dewasa) Indonesia Baliem 0,65% Sukabumi 28,6%

Etiology

Primary hypertension 95% of all cases

Secondary hypertension 5% of all cases Chronic renal disease – most common

CVD Risk Factors Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD

(men under age 55 or women under age 65)

*Components of the metabolic syndrome.

Identifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Target Organ Damage Heart

• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure

Brain• Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

Origin Origin CategoryCategory

Large arteries Large arteries Loss of complianceLoss of compliance(Dissecting) aneurysm(Dissecting) aneurysmPeripheral occlusive arterial disease Peripheral occlusive arterial disease

KidneyKidney NephrosclerosisNephrosclerosis

Categories of hypertensive end-organ damage

Birkenhäger and de Leeuw (1992)Birkenhäger and de Leeuw (1992)

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Hipertensi & Kerusakan Organ Target

Laboratory Tests Routine Tests

• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,

and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and

low-density lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

TreatmentOverview

Goals of therapy

Lifestyle modification

Pharmacologic treatment• Algorithm for treatment of hypertension

Classification and management of BP for adults

Followup and monitoring

Goals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons >50 years of age.

Sign and Symptoms Essential HTN is usually - asymptomatic - undetected for many years - headache, BP elevated systolic beyond 200 mmHg or BP rising rapidly (can occur in malignant HTN)

Symptomatic associated with malignant HTN Headache Blurred vision Chest pain Breathlessness Nausea, vomiting Anxiety, confusion, coma Seizures

Consequences of Malignant HTN

End Organ ComplicationsAorta Aortic disectionBrain Hipertensive encepahlopathy Cerebral Infarction or HaemmorhargeHeart Cardiac failure Myocardial ischemic or infarctionKidney Renal failure HaematuriaGastrointestinal Anorexia,nausea,vomiting,abdominal painPlacenta EclampsiaOther Micro-angiopathic haemolytic anemia

Consequences of hypertension Cardiac disease Left ventricular failure Angina Myocardial infarction

Cerebrovascular disease Transient ischemic attacks Stroke Multi-infarct dementia Hypertensive encephalopathy

Consequences of hypertension

Vascular disease Aortic aneurysm Occlusive peripheral vascular disease Arterial dissection

Others Progressive renal failure Hypertensive retinopathy

Risk of Hypertension

Advancing age Positive family history of premature

cardiovascular disease Smoking Hypercholesterolemia

Hypertension is thought to account for :- One–half of all deaths due to stroke- Up to one quarter of coronary heart

disease deaths

Isolated Systolic hypertension increase the risk of :

stroke and coronary heart disease by about 40%

cardiovascular death by about 50% heart failure by about 50%

Aetiology of hypertension Essential hypertension (primer/idiopathic hypertension remain uncertain (genetic and environmental factors contribute to development of

hypertension)

Secondary hypertension

Secondary hypertension

Renal parenchymal disease, causes : - the glomerulonephritides - diabetic nephropathy - analgesic nephropathy - adult polycystic kidney disease Renal artery stenosis Primary hyperaldosteronism Phaeochromocytoma

Secondary hypertension Aortic coarctation Cushing’s syndrome Drug induced hypertension - the oral contraception pill - steroids - NSAID - immunosuppressive - sympathomimetics - anabolic steroids - erythropoieti n - monoamin oxidase inhibitors Thyrotoxicosis Rare monogenic syndrome

Clinical assesment of hypertension Sign and symptoms Pointers to secondary hypertension Features of malignant hypertension End organ damage Hypertensive nephropathy Left ventricular hypertrophy Hypertensive retinopathy

Grades of hypertension retinopathyGrade Features

I Mild narrowing or sclerosis of the retinal arteriole, no symptoms, Good general health

II Venous compression at artriovenous crossing (A-V nipping) no symptoms, good general health

III Retinal oedema, cotton wool spots, hemmorhages, often symptoms

IV All abovePapiloedema,SymptomaticCardiac and renal function often impaired, reduced survival

Treatment Non Pharmacotherapy (lifestyle modification) Pharmacotherapy

Tujuan:

ANGKA KESAKITAN KERUSAKAN ORGAN TARGET ANGKA KEMATIAN

Pengobatan

Sasaran PengelolaanSasaran Pengelolaan

Menilai gaya hidup dan identifikasi faktor risiko kardiovaskular lain atau gangguan yang menyertai yang dapat mempengaruhi prognosis & pengobatan

Mengetahui penyebab tekanan darah yang tinggi

Menilai adanya kerusakan organ dan penyakit kardiovaskular

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Strategi Penatalaksanaan HipertensiJNC: Preventif Deteksi Evaluasi Pengobatan

JNC VI, 1997

Preventif Untuk mencegah atau memperlambat terjadinya

Hipertensi

Merupakan solusi jangka panjang masalah hipertensi Mencegah terjadi komplikasi

Dapat menghentikan atau mengurangi biaya pengobatan dan komplikasi

NHBPEP Working Group Report on Primary Prevention of Hypertension

Preventif

Upaya preventif primer: Terhadap individu yang potensial

hipertensi:TD normal tinggi

Riwayat keluarga hipertensiObesitas

Konsumsi tinggi garamKurang aktifitas

Konsumsi tinggi alkohol

Diharapkan prevalensi Hipertensi turun

Intervensi Preventif PrimerTerbukti Efektif

Turunkan BB Kurangi Garam Kurangi Alkohol Olah Raga

Efektif terbatas

Manajemen Stres Kalium Minyak Ikan (Fish oil) Kalsium Magnesium Serat Cegak makronutrien

Deteksi Dilakukan di fasilitas kesehatan dengan

alat ukur yang standar dan cara yang benar

Pasien diberitahu tentang makna TDnya Pasien dianjurkan melakukan

pemeriksaan periodik sesuai dengan TD pertama

Diharapkan ditemukan kasus tahap awal

Evaluasi Mencari penyebab hipertensi

(sekunder)

Memeriksa adanya kerusakan organ target dan penyakit lain

Mencari faktor risiko

Mengetahui respon pengobatan, efek samping dan kepatuhan pasien

WHO-ISH Guidelines for Management of Hypertension: Stratification of Cardiovascular Risk

Blood Pressure (mm Hg)

Grade 1 Grade 2 Grade 3

Mildhypertension

Moderatehypertension

Severehypertension

Other risk factors anddisease history

SBP 140–159or DBP 90–99

SBP 160–179or DBP 100–109

SBP 180or DBP 110

I No other risk factors Low risk Med risk High risk

II 1–2 risk factors Med risk Med risk Very high risk

III 3 or more risk factors or TOD or diabetes

High risk High risk Very high risk

IV ACC Very high risk Very high risk Very high risk

TOD = Target-organ damageACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH Guidelines. J Hypertens 1999;17:151-183.

BP TARGETS:

WITHOUT COMPLICATION : <140/80 mmHg

DIABETES : < 130/80 mmHg

CKD : < 130/80 mmHg

PROTEINURIA > 1 g/d : <125/75 mmHg

Lifestyle ModificationModification Approximate SBP

reduction(range)

Weight reduction 5–20 mmHg/10 kg weight lossAdopt DASH eating plan

8–14 mmHg

Dietary sodium reduction

2–8 mmHg

Physical activity 4–9 mmHgModeration of alcoholconsumption

2–4 mmHg

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

Type Dynamic exercise- Walking- Cycling- Non-competitive swimming

Time - 45-60 minutes

Intensity - Moderate

Frequency - Four or five times per weekFI

T

T

Treatment of Hypertension Diuretic ACE-Inh ARB Beta blocker Alpha blocker Direct renin inhibitor

Treatment Algorithm for Adults with Systolic-Diastolic Hypertension without another compelling indication

TARGET <140/90 mmHg

Beta-blocker

Long-actingDHP-CCBARBThiazide

Lifestyle modificationtherapy

ACE-I

INITIAL TREATMENT AND MONOTHERAPY

Alpha-blockeras initial

monotherapy

Indications for PharmacotherapyStrongly consider prescription if:

Average DBP equal or over 90 mmHg and:Hypertensive Target-organ damage (or CVD) orIndependant cardiovascular risk factors

Elevated systolic BP Cigarette smoking Abnormal lipid profile Strong family history of premature CV disease Truncal obesity Sedentary Lifestyle

– Average DBP equal or over 80 mmHg and diabetes

Diuretics

-blockers AT1 receptor blockers

Ca Antagonistα-blockers

ACE Inhibitors

2003 Guidelines for Management of Hypertension, J of Hypertension 2003

C.I. : Verapamil + ßBlocker ESH-ESC 2003

JNC 7: Management of Hypertension by Blood Pressure Classification

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB = calcium channel blocker.Chobanian AV et al. Chobanian AV et al. JAMA. JAMA. 2003;289:2560-2572.2003;289:2560-2572.

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

BP ClassificationLifestyle Modification

Initial Drug TherapyWithout Compelling

IndicationWith Compelling

Indication

Normal<120/80 mm Hg

Prehypertension120-139/80-89 mm Hg

Stage 1 hypertension140-159/90-99 mm Hg

Stage 2 hypertension≥160/100 mm Hg

Encourage

Yes

Yes

Yes

No drug indicated Drug(s) for the compelling indications

Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination

2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB)

Diabetes

Chronic kidney disease

Recurrent stroke prevention

Compelling Indications for Individual Drug Classes

Compelling Indication

Initial Therapy Options

Clinical Trial Basis

NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

PROGRESS

THIAZ, BB, ACE, ARB, CCB

ACEI, ARB

THIAZ, ACEI

JNC 7 2003