Hipertensi dan Masalah disekitarnya

Lukman Muliadi

Apakah itu Hipertensi?

Hipertensi atau Tekanan Darah Tinggi adalah suatu keadaan dimana tekanan darah di atas normal (>140 mmHg untuk
sistolik dan >90 mmHg untuk diastolik)

Hipertensi bisa menyerang anak-anak atau orang dewasa, namun umumnya pada orang dewasa di atas 35 tahun

BP CLASSIFICATION
ESH-ESC & WHO-ISH 2003 BP Classification Optimal Normal High normal Grade 1 Hypertension (mild) Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension Systolic BP <120 / <80 120-129 / 80-84 130-139 / 85-89 140-159 / 90-99 160-179 /100-109 > 180 / >110 Isolated Systolic Hypertension Diastolic BP <120/<80 120-129 /80-84 130-139 / 85-89 140-159 / 90-99 >160 / >100 Stage 1 Hypertension Stage 2 Hypertension JNC VII Bp Classification Normal Prehypertension

> 140

< 90

Hypertension Syndrome Its More Than Just Blood Pressure (Tidak hanya tekanan darah yang meningkat)
Decreased Arterial Compliance

Obesity

Endothelial Dysfunction Abnormal Glucose Metabolism

Abnormal Lipid Metabolism

Accelerated Atherogenesis LV Hypertrophy and Dysfunction

Hypertension

Neurohormonal Dysfunction

Abnormal Insulin Metabolism

Renal-Function Changes Blood-Clotting Mechanism Changes

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

The Metabolic Syndrome : The Iceberg Concept

Hypertension Linked To Chronic Renal Disease Among 332,544 Men Screened for MRFIT
250 250 200 200

150 150 100 100 5050 00

180 160-179 140-159 130-139 120-129 <120 110 100-109 90-99 85-89 80-84

<80

Systolic BP (mm Hg)

Adapted from Klag MJ, et al. N Engl J Med. 1996;334(1):13-18. Massachusetts Medical Society

Apa Penyebab Hipertensi ?

90-95% hipertensi tidak diketahui penyebabnya 5-10% disebabkan penyakit lain :
Gangguan ginjal Gangguan pembuluh darah Ganguan hormonal: hypertiroidi

- obat obatan : NSAID,Steroid, kontrasepsi hormonal

hipertensi
(patogenesis)
TEKANAN DARAH = CURAH JANTUNG x RESAISTENSI PERIFERA

Hipertensi
Preload K ontraktilitas

Peningkatan CJ

Peningkatan RP
Hipertrofi struktural

Konstriksi Fungsional

Volume Cairan

Redistribusi Cairan

Retensi Na Ginjal As upan Na ekses

Luas Filtrasi Gg genetik

hiperaktif S.Simpatis Stress

RAS

Gangguan membran sel Gg Genetik

Hiper insulinemi

Obesitas

EDF

Perkembangan alamiah hipertensi esential tanpa terapi

HEREDITER - LINGKUNGAN Umur 0 30 tahun PRE-HIPERTENSI 20 40 tahun 30 50 tahun

Normotensi

HIPERTENSI DINI

HIPERTENSI (KLINIS)

TANPA KOMPLIKASI

DENGAN KOMPLIKASI

Hipertensi Maligne

Jantung Hipertrofi Gagal Infark

P.Darah Besar Aneurisma Diseksi

Otak Iskemia Trombosis Perdarahan

Ginjal Sklerosis Gagal Ginjal

Gambar 1. Perkembangan alamiah hipertensi esential tanpa terapi

Blood Pressure rises with age

In the elderly, one out of two is hypertension
70 60 50 % 40 30 20 10 0 18-29 30-39 40-49 50-59 60-69 70-79 80+

Age Group

Prevalence of Hypertension by age in USA

Kannel-W. Cardioprotection and Antihypertensive Therapy, Am. J. Cardiol 1996 ; 77

Levels of Risk Associated with Smoking, Hypertension and Hypercholesterolaemia

Hypertension (SBP 195 mmHg)

x3
x4.5

x9 x16

.x1,6 Smoking

x6

x4
Serum cholesterol level (8.5 mmol/L, 330 mg/dL)

Poulter N et al., 1993

Systolic BP is a better indicator of CAD risk than diastolic blood pressure (DBP)
MRFIT*: CAD death and BP
Age-adjusted CAD death rate per 10,000 person-years
100 90 80 70 60 50 40 30 20 10 0

Systolic BP

DBP

Systolic BP 130 DBP 80

150 90

*Multiple Risk Factor Intervention Trial. Adapted from Neaton et al, Arch Intern Med, 1992.

170 100 mm Hg

190 110

210 120

BP directly correlates with risk of stroke

MRFIT: elevated systolic BP confers increased risk of stroke
9

Relative risk of stroke

8 7 6 5 4 3 2 1 0

Systolic BP DBP

Systolic BP DBP

<112 <71

11271-

11876-

12179-

12581-

12984-

13286-

13789-

14292-

151 98

mm Hg

Adapted from He and Whelton, J Hypertens, 1999.

Elevated systolic BP interacts with diabetes to increase CVD risk

MRFIT: men with diabetes and elevated systolic BP are at greater risk of CVD than those without diabetes
Patients with diabetes

300
CVD deaths per 10,000 person-years

250
Patients without diabetes

200

150

100

50

0
<120 120-139 140-159 160-179 180-199 Systolic BP (mm Hg)
Stamler et al, Diabetes Care, 1993.

200

Importance of blood pressure control

It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors,

achieving a sustained 12-mmHg

reduction in SBP over 10 years will

prevent 1 death
for every 11 patients treated.
JNC VII 2003

Millimetres matter

For individuals 40-70 years of age, each increment of 20 mmHg in systolic BP or

10 mmHg in diastolic BP doubles the risk

of CVD across the entire BP range from 115/75 to 185/115 mmHg

BP, blood pressure; CVD, cardiovascular disease

JNC VII. JAMA 2003;289:2560-2572

Millimetres matter

A 2-mmHg reduction in DBP would result in a 6% reduction in the risk of CHD and a 15% reduction in the risk of stroke and TIAs
DBP, diastolic blood pressure; CHD, coronary heart disease; TIA, transient ischaemic attack
Cook NR, et al. Arch Intern Med 1995;155:701-709

Relative importance of SBP and DBP as predictors of CHD risk as a function of age
1.0 0.5 0.0 p=0.008 Favours DBP 45 55 Age (years)

Favours SBP

(SBP) (DBP) -0.5 * -1.0 -1.5

25

35

65

75

* The difference between SBP and DBP proportional hazard regression coefficients, ie, (SBP) - (DBP), was estimated for each age group SBP, systolic blood pressure; DBP, diastolic blood pressure; CHD, coronary heart disease

Franklin SS, et al. Circulation 2001;103:1245-1249

Natural history of coronary heart disease

Myocardial Infarction Arrhythmia

Myocardial Ischemia
Coronary Artery Disease LV Hypertrophy Atherosclerosis

Remodelling

Sudden Death

Ventricular Dilatation

Heart Failure

Risk factor :
Hypertension Hyperlipidemia Diabetes Insulin resistance

Death
Dzau & Braunwald , 1991

Kidney
Renal Insufficiency ESRD / Gagal Gnjal

Heart
Left Ventricular Hypertrophy
Chronic Heart Failure Myocardial Infarction Congestive Heart Disease Arrhythmia

Hypertension

Brain
Stroke

Vessel
Arteriosclerosis Peripheral Vascular Disease Coronary Heart Disease

The pioneers
Vasodilation treatment with fever-producing or antimalarial agents : Fries 1940s:
This was the first time we had seen reversal of the signs of malignant hypertension following an antihypertensive drug. It was an exciting experience
Page

1949 :

I need hardly say this an unpleasant treatment butconsidering the danger of the diseaseto the life of the patient it is a small price to pay for the benefits

Year
1935 1937 19371941

Blood pressure
162/98

A case of untreated hypertension

Complications Treatment

136/78 (age 53) Phenobarbital Low salt and low fat diet/massages/digitalis

170-180/90-100

1941

188/105

Cardiac enlargement Probable lacunnar infarcts

CHF Renal failure Cerebral haemorrhage-death, age 63

1944 19441945 April12, 1945

186/108 180-230/110-126

Pengukuran Tekanan Darah

Contoh tekanan darah Normal : 120/80 mmHg

Tinggi : >140/>90 mmHg

Pengukuran Tekanan Darah

Ada 2 angka yang terukur dalam pengukurang tekanan darah :
Sistolik (tekanan ketika jantung memompa) Diastolik (tekanan ketika jantung menerima darah kembali)
Sistolik (tekanan yang lebih tinggi) saat ini dianggap LEBIH BERPERAN dalam menyebabkan komplikasi: PJK, stroke dan gagal ginjal

Tehnik Pengukuran Tekanan Darah

1. Pasien harus tenang / relaks, tangan ditopang, lengan baju longgar 2. Sebaiknya jam setelah makan / merokok 3. Cuff sesuai lingkar lengan 4. Manometer harus tegak lurus. Air raksa dipompa sampai denjut hilang, diturunkan pelahan : 2-3 mm/detik. 5. Bunyi pertama = TDS, bunyi hilang = TDD 6. Hipertensi ringan diulang setelah 1 minggu

Perubahan Tekanan Darah Terkait Aktivitas

Aktivitas
Rapat Bekerja Jalan Berpakaian Telepon Makan Kerja tulis menulis Membaca Nonton TV Relaks Tidur

TDS(mmHg)
+20.2 +16.0 +12.0 +11.5 +9.5 +8.8 +5.9 +1.9 +0.3 0.0 -10.0

TDD(mmHg)
+15.0 +13.0 +9.2 +5.5 +7.2 +9.6 +5.3 +2.2 +1.1 0.0 -7.6

Faktor Risiko Hipertensi

Tidak dapat dimodifikasi
Usia lanjut Keturunan

Dapat dimodifikasi
Kegemukan Asupan garam berlebih Kurang bergerak/beraktivitas Stress Merokok

Proof of Benefit

1960s to 1980s several major clinical trials establish the facts that early treatment of hypertension would prevent complication and prolong life
VAS, USPHS, HDFP

Benefits of therapy :
Complications Control No. % Treated No. % % Improvement

Total morbid events

Total mortality Cerebrovascular events ; fatal & nonfatal Fatal coronary events

563
342 140 79

9.0
5.4 2.2 1.2

417
252 76 46

6.6
4.1 1.2 0.7

27
24 50 42

Data from a subset of patients in VACS, USPHCS, HDFP, AustS, Oslo Study

Relative risk reduction of fatal events and combined fatal and nonfatal events in patients on active treatment versus placebo or no treatment

S-D hypertension Risk reduction

Mortality all cause cardiovascular noncardiovascular Fatal and non fatal events stroke coronary - 42% - 14% <0.001 <0.01 -14% -21% -1%

SIS-hypertension Risk reduction P

P
<0.01 <0.001 ns -13% -18% -1%

<0.02 <0.01 ns

- 30% - 23%

<0.001 <0.001

ESH-ESC 2003

BP Control Rates
Trends in awareness, treatment, and control of high blood pressure in adults ages 1874
National Health and Nutrition Examination Survey, Percent II 197680 51

Awareness

Treatment Control

31 10

II (Phase 1) 198891 73 55 29

II (Phase 2) 199194 68 54 27

19992000 70

59 34

Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC6.

% Patients with controlled BP world-wide

< 140 / 90 mmHg USA Canada 27 % 22% < 160 / 95 mmHg Finland Spain Australia 20,5% 20% 19%

England 6%

France 24%

Germany Scotland 22,5% 17,5%

India 9%

> 65 yr only

European heart journal suppl B vol 2 ,March 2000

Goals of treatment
JNC VII ( 2003 ) :
@ < 140 / 90 mmHg or < 130 / 80 mmHg for those with Diabetes or Chronic Kidney disease. @ Achieve SBP goal especially in persons >50 years of age.

ESH ( 2003 ) :
@ At least below 140 / 90 mmHg ( lower values if tolerated ) @ Below 130 / 80 mmHg in Diabetics. @ Keeping in mind, however, that systolic below 140 mmHg may be difficult to achieved in elderly( more flexible )

Goals BP
BP Threshold & Target BP (mmHg) Low and medium risk >140/90 <140/90

High risk
DM

<160/90

<140/90
<130/<80

JNC 7 - WHO/ISH ESH-ESC, 2003

Multiple antihypertensive agents are needed to achieve target BP

Trial

Number of antihypertensive agents Target BP (mmHg) 1 2 3 4 DBP <85 DBP <75 MAP <92 DBP <80 MAP <92 SBP <135/DBP <85

UKPDS ABCD MDRD HOT AASK IDNT

ALLHAT SBP <140/DBP <90

DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure

Bakris GL, et al. Am J Kidney Dis 2000;36:646-661; Lewis EJ, et al. N Engl J Med 2001;345:851-860; Cushman WC, et al. J Clin Hypertens 2002;4:393-404

ESHESC: Algorithm for Treatment of Hypertension

Choose between
Mild BP elevation Low/moderate CV risk Conventional BP target Marked BP elevation High/very high CV risk Lower BP target

Low-dose single agent

Low-dose 2-drug combination

Not at BP goal
Full dose of single agent Switch to different agent at low dose Full dose of 2-drug combination Add a third drug at low dose

Not at BP goal
23 drug combination at full dose Full-dose single agent
Full doses of 23-drug combination
Task Force for ESHESC. J Hypertens 2007;25:110587

TOD = target organ damage

Updated UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension

55 years or black patients at any age CCB or thiazide-type diuretic

<55 years Step 1 ACEI (or ARB*)

Step 2

ACEI (or ARB*) + CCB or ACEI (or ARB*) + thiazide diuretic

Step 3

ACEI (or ARB*) + CCB + diuretic Add further diuretic therapy, -blocker, or -blocker. Consider seeking specialist advice

Step 4

Management of Hypertension (JNC VII)

BP Classification Lifestyle modification Initial Drug Therapy (-) compelling (+) compelling Indication indication

Normal PreHypertension Stage 1 Hypertension Stage 2 Hypertenssion

Encourage Yes Yes

No AHD indicated AHD (s) for the compelling indications AHD(s) for the compelling indications. Other AHD as needed. AHD(s) for the compelling indications. Other AHDs (D.ACEI,ARB,BB.CCB)

Thiazide-type D for most, may consider other AHD.

Yes

2-AHDs combination for most (usually thiazide-type D and ACEI or ARB or BB or CCB

Modified from JNC VII

Treatment initiation: ESH/ESC 2003

Blood pressure
Other risk factors and disease history No other risk factors Normal High normal Grade 1 Grade 2 Grade 3

No BP intervention

No BP intervention

Lifestyle changes for several months, then drug treatment if preferred by the patient and resources available Lifestyle changes for several months, then drug treatment

Lifestyle changes for several months, then drug treatment

Immediate drug treatment and lifestyle changes

1-2 risk factors

Lifestyle changes

Lifestyle changes

Lifestyle changes for several months, then drug treatment

Immediate drug treatment and lifestyle changes

3 or more risk factors, target organ damage, or diabetes

Associated clinical conditions

Lifestyle changes

Drug treatment and lifestyle changes

Drug treatment and lifestyle changes

Drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053

ESHESC Recommendations for Combining BP-lowering Drugs and Availability as Single-pill Combinations
Diuretics

-blockers

Angiotensin receptor blockers (ARBs)

a-blockers

Calcium channel blockers (CCBs)

Angiotensin-converting enzyme (ACE) inhibitors

Available as a single-pill combination Less frequently used/combination used as necessary Task Force for ESHESC. J Hypertens 2007;25:110587

Mitos-mitos di seputar Hipertensi

Tekanan darah diastolik (angka yang lebih rendah) lebih penting dari sistolik
FAKTA:
Tekanan darah sistolik dan diastolik samasama penting, bahkan pada usia lanjut, tekanan darah sistolik lebih harus dikontrol

Mitos-mitos di seputar Hipertensi

Pada orang tua, sudah biasa tekanan darahnya tinggi, sehingga tidak perlu diobati (100 + umur mmHg adalah wajar)
FAKTA:
Baik orang muda maupun orang tua, tekanan darah HARUS di bawah 140/90 mmHg untuk mencegah komplikasi

Mitos-mitos di seputar Hipertensi

Jika saya minum obat hipertensi dan tekanan darah saya terkontrol baik, obat tersebut tidak perlu diminum lagi
FAKTA:
Tekanan darah terkontrol tsb. karena disebabkan oleh obat. Jika obat dihentikan maka tensi akan meningkat kembali. Hipertensi tidak dapat disembuhkan, hanya dapat dikendalikan. Jadi obat hipertensi harus terus diminum sesuai instruksi dokter

Mitos-mitos di seputar Hipertensi

Jika kita pusing-pusing dan leher terasa kaku, itu berarti tensi kita sedang naik. Jika tidak terasa apa-apa, tensi kita normal
FAKTA:
Hipertensi itu penyakit yang umumnya tidak bergejala. Untuk mengetahui apakah tensi kita naik atau tidak hanyalah mengukur dengan tensi meter. Periksalah tekanan darah secara teratur untuk mengetahui berapa tekanan darah kita.

Hipertensi = Silent Killer

Sebagian besar hipertensi TIDAK bergejala Tekanan darah tinggi bisa merusak organorgan tubuh yang berhubungan erat dengan pembuluh darah Hipertensi adalah penyebab utama STROKE, SERANGAN JANTUNG DAN GAGAL GINJAL Hipertensi dapat dikontrol untuk mencegah komplikasi tersebut

Dont wait to treat hypertension

Awaiting overt signs and symptoms of coronary disease before treatment is no longer justified. In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.
William B. Kannel, MD
Department of Medicine Boston University Medical Center

Menunnggu sampai gejala dan tanda penyakit jantung koroner timbul baru diberi terapi sudah tidak benar . Pada beberapa keadaan, timbulnya atau telah adanya gejala justru menggambarkan kegagalan tindakan medis, bukan saat baru mulai terapi.
William B. Kannel, MD Department of Medicine Boston University Medical Center

Kannel, Atherosclerosis and Coronary Artery Disease, 1996.

10 kewajiban penderita hipertensi

1. 2. 3. 4. Mengukur tekanan darah secara teratur Jangan lupa mengkonsumsi obat sesuai aturan dokter Mengontrol berat badan Tidak mengkonsumsi garam berlebih (menghindari makanan bergaram tinggi) 5. Makan makanan rendah lemak 6. Berhenti merokok 7. Berkonsultasi dengan dokter secara teratur 8. Latihan fisik sesuai anjuran dokter 9. Menjalani kehidupan secara normal dan sehat 10. Menganjurkan keluarga (orang tua, kakak, adik, paman, anak dll) untuk memeriksakan tekanan darah secara teratur (risiko keturunan)

Obat-obat yang ideal

Efektif menurunkan tekanan darah Efek samping minimal Diminum sekali sehari Efek penurunan tekanan gradual Memiliki drug holiday protection (melindungi pasien yang lupa minum obat) Tidak perlu memilih obat yang penurunan tekanan darahnya cepat (kecuali kasus emergency)

Tips untuk mengurangi berat badan

Kurangi makanan yang digoreng Kurangi mentega, minyak dan lemak Kurangi porsi makanan Kurangi daging dan pilihlah ayam atau ikan (kulit ayam disingkirkan) Konsumsi buah dan sayuran lebih banyak Konsumsi susu yang rendah lemak Aktivitas fisik 30-60 menit 3-6 kali seminggu

Tips untuk mengurangi asupan garam

Kurangi jumlah garam dalam masakan Tambahkan bumbu dan penyedap untuk mengimbangi rasa masakan Kurangi kripik kentang dan jagung asin, hot dogs, ikan asin, burger yang banyak mengandung garam Tambahkan konsumsi buah dan sayur segar dan bukan kalengan Perhatikan LABEL kandungan garam dalam makanan

Obat-obat anti-hipertensi
Bersikap sabar dalam menjalani pengobatan, tidak mengharapkan terapi yang ajaib yang cepat menurunkan tekanan darah Memberi kesempatan pada tubuh untuk menyesuaikan dengan obat yang mungkin memerlukan waktu untuk mengendalikan tekanan darah Obat diminum sesuai dengan anjuran dokter. Tidak menghentikan pengobatan sendiri atau merubah dosis dan segera mengunjungi dokter jika ditemukan adanya efek samping

Obat-obat anti-hipertensi
Diuretik Beta bloker Antagonis kalsium ACE inhibitor Alfa bloker Angiotensin II antagonis Central agonist dan vasodilator Anti Renin

Development of Antihypertensive Therapies

Effectiveness

Tolerability
1940s 1950
Direct vasodilators Peripheral sympatholytics Ganglion blockers Veratrum alkaloids

1957

1960s

1970s

1980s

1990s
ARBs

2005+
Renin Inh

ACE Alpha blockers inhibitors Thiazide diuretics Central alpha2 DHP CCBs agonists Non-DHP CCBs

The primary goal of treatment is to achieve maximum reduction in total CV risk, through treatment of Beta blockers elevated BP and all associated reversible risk factors DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker. ESH/ESC 2007

AMLODIPINE
Obat yang mempunyai masa kerja panjang dari generasi kedua antagonis kalsium Mempunyai waktu paruh 35-48 jam T/P Ratio >50% Dosis sekali sehari Menurunkan tekanan darah secara gradual

Pharmacokinetics: Olmesartan Olmesartan medoxomil is a prodrug, which is hydrolyzed to its active metabolite, olmesartan Absolute bioavailability 25.6% Time to Cmax ~2 hours t1/2 ~10-15 hours Dual elimination:
40% renal 60% hepatobiliary
Schwocho LR, et al. J Clin Pharmacol 2001;41:515-527; Laeis P, et al. J Hypertens 2001;19(Suppl 1):S21-S32

Pharmacokinetics: Summary (cont.) Not metabolized by cytochrome P450 system; interactions with drugs metabolized by CYP450 unlikely Can be administered with or without food No dosage adjustment necessary for the elderly or in patients with renal or hepatic impairment
BUT not recommended for patients with severe renal or hepatic impairment
Schwocho LR, et al. J Clin Pharmacol 2001;41:515-527; Laeis P, et al. J Hypertens 2001;19(Suppl 1):S21-S32; von Bergmann K, et al. J Hypertens 2001;19(Suppl 1):S33-S40

Olmesartan may give more prolonged AT1 blockade than irbesartan or valsartan
p vs placebo <0.0001 0.005 0.028 0.058 (NS) 0.002 0.004 0.036

p vs olmesartan

Change from predose to 24 hours in mean PRA (ng/mL/h)

4 3.16 3 2 1 0 0 Placebo Olmesartan 40 Irbesartan 300 mg mg Valsartan 160 mg 1.78 1.19

n=20

1.84

PRA, plasma renin activity

Valsartan 320 mg

Jones M, et al. Presented at ASH 2006; Abstract P-195

Results at Week 2 (cont.)

Change in SeSBP
Losartan 50 mg/d Valsartan 80 mg/d

Olmesartan 20 mg/d
0 -2 Change in BP (mmHg)

Irbesartan 150 mg/d

-4
-6 -8

-10
-12 -14 -13.0

-8.9 **

-9.2 **
-10.8 *

* p0.05 ** p0.005

n=588

SeSBP, seated systolic blood pressure; BP, blood pressure

Oparil S, et al. J Clin Hypertens 2001;3:283-291

Results at Week 8

Change in SeDBP
Losartan 50 mg/d Valsartan 80 mg/d

n=588
Irbesartan 150 mg/d

Olmesartan 20 mg/d

Change in BP (mmHg)

-4

-8 -8.2 **

-7.9 ** -9.9 *

-12 * p<0.05 ** p<0.0005

-11.5

40%

46%

16%

SeDBP, seated diastolic blood pressure; BP, blood pressure

Oparil S, et al. J Clin Hypertens 2001;3:283-291; Brunner HR. J Hypertens 2003;21(Suppl 2):S43-S46

Compliance at 1 year with antihypertensive treatment

70 Compliance at 1 year (%) 60 50 40 30 20
* p<0.007 vs ACE inhibitors

64 * 58 50 43

38

10
0 Diuretics Beta- blockers CCBs ACE inhibitors ARBs

ACE, angiotensin-converting enzyme; CCB, calcium-channel blocker; ARB, angiotensin II receptor blocker

Bloom BS, et al. Clin Ther 1998;20:671-681

ACEI + CCB
Less peripheral oedema Less cough Potentiation of the BP lowering effect Greater reduction of CV events Greater organ protection Antiinflamatory vasc effect Anti atherogenic properties Anti diabetogeniceffects Neutral effects on lipid profile and uric acid

Take home messages

Kenalilah tekanan darah anda Kendalikanlah dengan :
Mengkonsumsi obat sesuai anjuran dokter Rajin berkonsultasi pada dokter Mengurangi asupan garam Mengendalikan berat badan Berhenti merokok - Olah raga teratur

Summary
Regardless of the blood pressure level, all patients should adopt appropriate lifestyle modifications A low dose of a diuretic should be considered as the first choice of therapy for the majority of patients without a compelling indication for another class of drug
2003 WHO/ISH Statement on Hypertension. J Hypertens 2003;21:1983-1992

Summary
Specific drug classes may differ in their effects Main benefits are due to BP lowering Drugs are not equal in adverse-event profiles Major drug classes are suitable for initiation and maintenance of therapy Choice of drug will be influenced by patient experience and preference, and cost and risk profile Long-acting drugs that provide once-daily, 24-hour efficacy are preferable

BP, blood pressure

ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053

Thank You