Jimmy Eko Budi Hartono

Departemen Neurologi
FK UNDIP/RSDK
Semarang
Tekanan darah arteri yang tinggi dan
menetap

The continuous relationship between the level of blood
pressure and cardiovascular risk makes any numerical
definition and classification of hypertension arbitrary.
1




1
2003 European Society of Hypertension-European Society of Cardiology guidelines for the
management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063.
Systolic Blood Pressure
BP when the heart contracts and expels the
blood into the arteries. This is what gives rise to the
pulse, known as the maxima
(Tekanan darah maksimal ketika darah
dipompakan dari ventrikel kiri)
Diastolic blood pressure
While the heart is filling between two
contractions, the blood in the main arteries flows
towards the smallest arteries: the blood pressure in
the main arteries then falls to the minima
(Tekanan darah pada saat jantung relaksasi)
Penderita duduk tenang
di kursi sedikitnya 5
menit, dengan posisi kaki
di lantai dan lengan pada
posisi setinggi jantung

Pengukuran dilakukan
sedikitnya dua kali
What are Korotkoff sounds?
Korotkoff sound represents arterial oscillation resulting from
distension of the arterial wall with each cardiac impulse due to
partial occlusion of artery by the cuff.
Low pitch sound
Five phases are
PHASE 1 - CLEAR TAPPING SOUND (SBP)
PHASE II - ONSET OF SWISHING SOUND OR SOFT MURMUR
PHASE III- LOUD SLAPPING SOUND
PHASE IV - SUDDEN MUFFLING OF SOUND
PHASE V - DISAPPEARANCE OF SOUND / PHASE OF SILENCE (DBP)
"Tap - Murmur - Slap - Muffle - Silence"
It was described by Nikolai Korotkoff, a Russian surgeon in 1905
JNC VII
Classification of Hypertension
SBP(mmHg) DBP (mmHg)
Normal < 120 and < 80
Pre-hypertension 120-139 or 80-89
Stage 1 140 - 159 or 90-99
Stage 2 > 160 or > 100
SBP = systolic blood pressure
DBP = diastolic blood pressure
>140/90 without compelling indication

>130/80 with compelling indication
diabetes and chronic renal disease
JNC VII
the reduction of cardiovascular and renal
morbidity and mortality
BP Target
Normal : 140 / 90 mm Hg
Diabetes or chronic kidney disease : 130 / 80 mm Hg
JNC. VII, 2003
Goal of Hypertension Therapy
Target Organ Damage
Heart
LVH
Angina / prior MI
Prior Coronary
Revascularization
Heart Failure
Brain
Stroke or TIA
Chronic Kidney Disease
Peripheral Arterial Disease
Retinopathy.
Major Risk Factors
Smoking
Dyslipidemia
Diabetes mellitus
Age ( men > 55 years
and women > 65 years )
Family history of CVD
Men < 55 years or
Women < 65 years

JNC. VII, 2003
Component of Cardiovascular Risk Stratification
in Patient with Hypertension
Impaired
NO synthase
Ang II and mechanisms of atherosclerosis
Jacoby DS, Rader DJ. Arch Intern Med. 2003;163:1155-64.

IL-6
MCP-1
PDGF
LOX-1
PAI-1
TF
TGF-
VCAM
ICAM
ARB ?
Lipid oxidation
Thrombosis
Inflammation
Proliferation fibrosis
Adhesion
Endothelial
dysfunction
Angiotensin II
SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin-
converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker;
CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Not at goal blood pressure
Without compelling indications
Stage 1 hypertension
(SBP 140159 or DBP 9099 mm Hg)
Thiazide-type diuretic for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Stage 2 hypertension
(SBP 160 or DBP 100 mm Hg)
Two-drug combination for most
(usually thiazide-type diuretic and
ACEI or ARB or BB or CCB).
Lifestyle modifications
Not at goal blood pressure (<140/90 mm Hg)
(<130/80 mm Hg for those with diabetes or chronic kidney disease)
Initial drug choices
With compelling indications
Drugs for compelling indications
Other antihypertensive drugs
(diuretic, ACEI, ARB, BB, CCB) as
needed.
Modified from Chobanian AV, et al. JAMA 2003;289:2560-2572.
Diuretic -blocker
ACE
Inhibitor
Angiotensin
II Blocker
Calcium
Antagonists
Aldosterone
Antagonist
Heart Failure

Post Heart Attack

High CAD Risk

Diabetes Mellitus

Chronic Renal
Disease

Recurrent Stroke

New studies
Menurunkan berat badan
Mempertahankan berat badan normal
BMI: 18.5 24.9
Menurunkan tekanan darah: 5-20 mmHg
Mengurangi berat badan : 10 kg
DASH Eating Plan
Dietary Approaches to Stop Hypertension
Buah
Sayur
Diet rendah lemak
Hipertensi urgensi : penurunan tekanan
darah dilakukan dalam waktu 24 jam
Hipertensi emergensi : penurunan tekanan
darah dilakukan sesegera mungkin
Perlu diingat bahwa penurunan tekanan
darah hanya diizinkan 20%-25% dari saat
onset
Steal phenomenon
The intracerebral steal
phenomenon (ISP) is a paradoxical
vasodilatory response that reduces
the cerebral blood flow to the
impaired perfusion area.

Hypertensive crises can present as
hypertensive urgency or as a
hypertensive emergency.

Hypertensive Urgency

Is a situation where the blood pressure is severely
elevated (180 or higher for systolic pressure or
110 or higher for diastolic pressure)
but there is no associated organ damage.
Symptoms :
Severe headache
Shortness of breath
Nosebleeds
Severe anxiety
Hypertensive Emergency

When blood pressure reaches levels that are damaging organs.
Hypertensive emergencies generally occur at blood pressure
levels exceeding 180 systolic OR 120 diastolic.

The consequences can be severe and include
Stroke
Loss of consciousness
Memory loss
Heart attack
Damage to the eyes and kidneys
Loss of kidney function
Aortic dissection
Angina (unstable chest pain)
Pulmonary edema (fluid backup in the lungs)
Eclampsia
Hypertensive encephalopathy is a neurological dysfunction
induced by malignant hypertension.
It describes cerebral conditions, typically reversible, caused by
sudden and sustained severe elevation of blood pressure.
Hypertensive encephalopathy occurs in :
Eclampsia
acute nephritis
crises in essential hypertension
Symptoms :
headache
restlessness
nausea
disturbances of consciousness
seizures
retinal hemorrhage
papilledema
Coma
Preventif primer : pada stroke prone person
Fase akut : saat onset stroke (target organ)
Preventif sekunder : 10 hari pasca stroke
Antihypertensive Therapy
Antihypertensive therapy should
Lower blood pressure effectively
Have a favourable safety profile
Reduce cardiovascular morbidity and mortality

Five drug categories
Diuretics
Beta-blockers
ACE inhibitors
Calcium channel blockers
Angiotensin-receptor blockers
Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice.
Eur Heart J 2003; 24: 1601-10.
Reduction of cardiovascular and renal
morbidity and mortality.
1

The primary focus should be on achieving the
systolic BP goal.
Systolic BP and diastolic BP to targets < 140/90
mmHg = decrease in CVD complications.
In patients with hypertension with diabetes or renal
disease, the BP goal is < 130/80 mmHg
1

1
JNC - VII Report, JAMA , 2003;289:2560-2572
Diuretics, beta-blockers, calcium antagonists, ACE-
inhibitors, angiotensin receptor antagonists)
disesuaikan untuk terapi awal dan pemeliharaan
Pertimbangan :
Pengalaman penderita terdahulu
Beaya
Profil risiko, kerusakan target organ,
adanya penyakit kardiovaskular, penyakit
ginjal atau diabetes
Yang disukai penderita

Preparat long acting pemberian sekali sehari
dengan efikasi 24 jam merupakan dasar pilihan
Class Drug (Trade Name)
Usual dose range in mg/day
(daily frequency)
Thiazide diuretics Chlorothiazide (Diuril)
Chlorthalidone (Generic)
Hydrochlorothiazide
(Microzide, HydroDIURIL)
Polythiazide (Renese)
Idapamide (Lozol)
Metolazone (Mykrox)
Metalozano (zaroxylyn)
125 - 500 (1)
12.5 - 25 (1)
12.5 - 50 (1)

2 - 4 (1)
1.25 2.5 (1)
0.5 1.0 (1)
2.5 5 (1)
Loop diuretics Bumetanide (Bumex)
Furosemide (Lasix)
Torsemide (Demadex)
0.5 2 (20 )
20 80 (2)
2.5 10 (1)
Potassium-sparing
diuretics
Amiloride (Midamor)
Triamterene (Dyrenium)
5 10 (1-2)
20 100 (1-2)
Aldosterone
receptor blockers
Eplerenone (Inspra)
Spironolactone (Aldactone)
50 100 (1-2)
25 50 (1-2)
JNC VII, 2003
1
Class Drug (Trade Name)
Usual dose range in
mg/day (daily
frequency)
Beta-blockers Atenolol (Tenormin)
Betaxolol (Kerlone)
Bisoprolol (Zebeta)
Metoprolol (Lopressor)
Metoprolol extended release (Toprol
XL)
Nadolol (Corgard)
Propranolol (Inderal)
Propranolol long-acting (Inderal LA)
Timolol (Blocadren)
25 100 (1)
5 20 (1)
2.5 10 (1)
50 100 (1-2)
50 100 (1)

40 120 (1)
40 160 (2)
60 180 (1)
20 40 (2)
Beta-blockers with
intrinsic
sympothiometic
activity
Acebutolol (Sectral)
Penbutolol (Levatol)
Pindolol (Generic)
200 800 (2)
10 40 (1)
10 40 (2)
Combined alpha-and
beta-blockers
Carvedilol (Coreg)
Labetalol (Normodyne, Trandate)
12.5 50 (2)
200 800 (2)
Oral antihypertensive drugs
2
JNC VII, 2003
Class Drug (Trade Name)
Usual dose range in mg/day
(daily frequency)
ACE inhibitors Benazepril (Lotensin)
Captopril (Capoten)
Enalarpil (Vasotec)
Fasinopril (Monopril)
Lisinopril (Prinvil, Zestril)
Moexipril (Univasc)
Perindropril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)
10 -40 (1-2)
25 100 (2)
2.5 40 (1-2)
10 40 (1)
10 40 (1)
7.5 30 (1)
4 8 (1-2)
10 40 (1)
2.5 20 (1)
1 4 (1)
Angiotensin II
antagonist
Candesartan (Atacand)
Eprosartan (Tevetan)
Irbesartan (Avapro)
Losartan (Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan (Diovan)
8 32 (1)
400 800 (1-2)
150 300 (1)
25 100 (1-2)
20 40 (1)
20 80 (1)
80 320 (1)
JNC VII, 2003
3
Class Drug (Trade Name)
Usual dose range in
mg/day (daily
frequency)
Calcium channel
blockers- non-
Dihydropyridines
Diltiazem extended release
(Cardizem CD, Dilacor XR, Tiazac)
Diltiazem extended release (Cardizem
LA)
Verapamil immediate release (Calan,
Isoptin SR)
Verapamil Coer (Covera HS, Verelan
PM)
180 420 (1)
120 540 (1)
80 320 (1)

120 360 (1-2)

120 360 (1)
Calcium channel
blockers-
Dihydropyridines
Amlodipine (Norvasc)
Felodipine (Plendil)
Isradipine (Dynacirc SR)
Nicardipine sustained release (Cardene
SR)
Nifedipine long-acting (Adalat CC,
Procardia XL,
Nisoldipine (Sular)
2.5 10 (1)
2.5 20 (1)
2.5 10 (2)
60 120 (2)

30 60 (1)

10 40 (1)
4 Oral antihypertensive drugs
JNC VII, 2003
Class Drug (Trade Name)
Usual dose range in
mg/day (daily
frequency)
Alpa
1
, blockers Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin (Hytrin)
1 16 (1)
2 20 (2 3)
1 20 (1 2)
Central alpha
2
agonist
and other centrally acting
drugs
Clonidine (Catapres)
Clonidine patch (Catapres-TTS)
Methyldopa (Aldoment
1
)
Reserpine (generic)
Guanfacine (generic)
0.1 0.8 (20
0.1 0.3 (1 wkly)
250 1.000 (2)
0.05 0.25 (1)
0.5 2 (1)
Direct vasodilators Hydralazine (Apresoline)
Minoxidil (Loniten)
25 100 (2)
2.5 80 (1-2)
JNC VII, 2003
5
Contraindications
Class Conditions favouring the use Compelling Possible
Diuretics
(thiazides)
Congestive heart failure; elderly
hypertensive ; isolated systolic
hypertension ; hypertensives of
African origin
Gout Pregnancy
Diuretics (loop) Renal insufficiency ; congestive
heart failure
Diuretics (Anti-
aldosterone)
Congestive heart failure ; post-
myocardial infarction
Renal failure ;
hyperkalemia
-Blockers Angina pectoris ; post-
myocardial infarction ;
congestive heart failure (up-
titration); pregnancy ;
tacthyarrhythmias
Asthma ; chronic
obstructive
pulmonary
disease ; A-V
block (grade 2 or
3)
Peripheral
vascular disease ;
glucose intolerance
; athletes and
physically active
patients.
Calcium
antagonists
(dihydropyridines)
Elderly patients ; isolated
systolic hypertension; angina
pectoris ; peripheral vascular
diseases ; carotid atherosclerosis
pregnancy
Tachyarrhythmias
; congestive heart
failure
Journal of Hypertension 2003, Vol. 21 No. 6
1
Contraindications
Class Conditions favouring the use Compelling Possible
Calcium
antagonists
(verapamil,
diltiazem)
Angina pectoris ; carotid
atherosclerosis;
supraventricular tachycardia
A-V block
(grade 2 or 3) ;
congestive heart
failure
Angiotension-
converting
enzyme (ACE)
inhibitors
Congestive heart failure ; LV
dysfunction ; post-myocardial
infarction ; non-diabetic
nephropathy ; type 1 diabetic
nephropathy proteinuria.
Pregnancy ;
hyperkalemia ;
bilateral renal
artery stenosis
Angiotension
II receptors
antagonists
(AT
1
-blockers)
Type 2 diabetic nephropathy ;
diabetic microalbuminuria ;
protenuria ; left ventricular
hypertrophy ; ACE-inhibitor
cough
Pregnancy;
hyperkalemia ;
bilateral renal
artery stenosis
-Blockers Prostatic hyperplasia (BPH);
hyperlipidemia
Orthostatic
hypotension
Congestive heart
failure
Indication and contraindications for the major classes of antihypertensive drugs
Journal of Hypertension 2003, Vol. 21 No. 6
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