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