dr.

Cholid T Tjahjono,MKes,SpJP
Fakultas Kedokteran
Universitas Brawijaya
Malang
Hipertensi
Definisi, klasifikasi
Prevalensi
Komplikasi
Faktor kontribusi

Update pada VII
th
report of the JNC

Obat-obatan yang menurunkan
tekanan darah




Klasifikasi Tekanan Darah
Klasifikasi SBP (mmHg) DBP (mmHg)
______________________________________________________

Normal <120 and <80

Prehypertension 120139 or 8089

Hypertension >140/90
Stage 1 Hypertension 140159 or 9099

Stage 2 Hypertension >160 or >100
_____________________________________________
Hipertensi esensial

Pada 9095% kasus, penyebabnya
tidak diketahui = Hipertensi esensial

Pengobatan simtomatik yaitu
menurunkan tekanan darah.
No real cure yet.
Penyebab hipertensi
sekunder yang bisa dikenali
Sleep apnea
Dipicu obat atau berhubungan dengan obat
Penyakit ginjal kronik (Chronic kidney disease)
Aldosteronisme primer
Penyakit Renovaskular
Chronic steroid therapy dan Cushings syndrome
Pheochromocytoma
Coarctation of the aorta (koarktasio aorta)
Penyakit tiroid atau paratiroid
Prevalensi
Tinggi di Amerika : 50% orang
dewasa, 60% kulit putih, 71% of
African Americans, 61% Mexican
Americans diatas usia 60 tahun

Lebih banyak pada laki-laki daripada
perempuan

Prevalensi tertinggi pada orang tua
perempuan African-American
Komplikasi
Sistem kardiovaskular
CNS (Central Nervous system)
Sistem ginjal (Renal system)
Kerusakan retina (Retinal
damage)
Penyakit arteri perifer
Target Organ Damage
Jantung (Heart)
Left ventricular hypertrophy
Penyakit arteri koroner
Infark miokardium
Gagal jantung (Heart failure)
Otak (Brain)
Stroke atau transient ischemic attacks
Penyakit ginjal kronik (Chronic kidney
disease), gagal ginjal (kidney failure)
Retinopathy

Faktor kontribusi
Obesitas
Stress
Kurang olah raga
Diet (excess dietary salt)
Minum alkohol
Merokok
National Heart Lung Blood Institute National
High Blood Pressure Education Program

The Seventh Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure (JNC 7, 2003)

http://www.nhlbi.nih.gov/guidelines/hypertension/index.ht
m


Mengapa perlu ada Guidelines
untuk Hipertensi?

50 juta orang dengan hipertensi di Amerika
10 tahun yang lalu 1:4 secara
keseluruhan, separuhnya berusia > 60

Hanya 1 dari 2 orang yang mendapatkan
pengobatan untuk menurunkan tek darah.
Hanya 1 pada 4 orang berusia 18-74 tahun
yang tek darahnya terkontrol <140/<90 di
Amerika
Sasaran Baru tek darah

<140/<90 dan lebih rendah jika pasien
toleran
<130/<80 pada diabetics
<130/<85 pada gagal jantung
<130/<85 pada gagal ginjal
<125/<75 pada gagal ginjal dengan
proteinuria>1.0 g/24 jam

Penekanan pada Guidelines
terkini

JNC, WHO/ISH, BHS,
Canada, and More

Strategi pengobatan yang agresif
berdasarkan profil medik pasien

Mengobati mencapai sasaran
Based upon the average of > 2 properly
measured readings at each of > 2 visits (at least
3 to 6 visits, spaced over a period of weeks to
months)
Apply to adults on no antihypertensive
medications and who are not acutely ill.
If there is a disparity in category between the
systolic and diastolic pressures, the higher value
determines the severity of the hypertension.
Treatment Overview
Sasaran terapi
Modifikasi gaya hidup
Pengobatan farmakologik
Algoritme untuk pengobatan
hipertensi
Klasifikasi dan tatalaksana tekanan
darah pada dewasa
Follow-up dan monitoring

Lifestyle Modifications
(Modifikasi gayahidup)
Menurunkan berat badan sampai normal
BMI (<25kg/m
2
): 5-20 mmHg/10kg loss
Rencana makan dengan DASH: 8-14
mmHg
Reduksi garam diet : 2-8 mmHg
Meningkatkan aktivitas fisik : 4-9 mmHg
Reduksi konsumsi alkohol : 2- 4 mmHg


DASH Diet

Dietary

Approaches

to

Stop

Hypertension
Menekankan: buah, sayuran,
makanan rendah lemak, dan
mengurangi garam

Termasuk whole grains,
poultry, ikan, nuts

Mengurangi jumlah daging
merah, gula dan total
kolesterol dan saturated fat
Sacks FM et al: NEJM 344;3-10, 2001
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 Hypertension
(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 Hypertension
(SBP 140159 or DBP 9099 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Renal
function
Blood
volume
Venous
tone
Venous
return
Heart
rate
Nervous
control
Muscular
responsiveness
Myocardial
contractility
Stroke
volume
Cardiac
output
CNS
factors
Renin
release
Angiontensin II
formation
Intrinsic vascular
responsiveness
Peripheral
resistance
Nervous
control
Renal
function
Mean arterial
pressure
Faktor-faktor yang
mengendalikan
the Mean Arterial Pressure
Mean Arterial Pressure
= Tekanan arteri rata-rata
MAP = CO

CO = HR X SV

SNS Blood volume
Heart contactility
Venous tone







X PVR

myogenic tone
vascular responsivenes
nervous control

vasoactive metabolites
endothelial factors
circulating hormones

CO= Cardiac output; PVR: peripheral vascular resistance; HR=heart rate;
SV: stroke volume; SNS: sympathetic nervous system


Klasifikasi obat antihipertensi

Diuretik
Obat yang mempengaruhi
fungsi adrenergik
Vasodilators
Obat yang mempengaruhi
Renin Angiotensin System
(RAS)
The cardiovascular risk profile of the
patient
Coexisting disorders
Target organ damage
Interactions with other drugs used for
concomitant conditions
Tolerability of the drug
Cost of the drug
Reduce cardiac output
-adrenergic blockers
Ca
2+
Channel blockers
Dilate resistance vessels
Ca
2+
Channel blockers
Renin-angiotensin system blockers

1
adrenoceptor blockers
Nitrates
Reduce vascular volume
Diuretics
Direct vasodilators

BLOCKERS
Calsium Antagonist
+
BLOCKERS
HYDRALAZINE
Symphatetic
Activity
Cardiac
Output
Renin
PERIPHERAL
VASCULAR
RESISTENCE
Thiazids
ACE-i
ARBs
Renin inhibitors
Condition Preferred drugs Other drugs that can
be used
Drugs to be
avoided
Asthma CCBs -blockers/ARB/Diuretics/
ACE-i
-blockers

Diabetes
mellitus
-blockers/ACE-i/
ARB
CCBs Diuretics/
-blockers

High
cholesterol
levels
-blockers ACE-i/ARB/ CCB -blockers/
Diuretics

Elderly
patients
CCBs -blockers/ACE-i/
ARB/- blockers

BPH - blockers

-blockers/ ACE-i/ ARB/
Diuretics/ CCBs
Initial Drug Choices
Drug(s) for the
compelling
indications
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB, CCB)
as needed
With Compelling Indications
Stage 2 Hypertension
(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 Hypertension
(SBP 140159 or DBP
9099 mmHg)
Thiazide-type
diuretics for most.
May consider ACEI,
ARB, BB, CCB, or
combination
Without Compelling Indications
Not at Goal BP
Optimize dosages or add additional drugs
until goal BP is achieved.
Consider consultation with hypertension
specialist.
JNC 7 Medication Algorithm
Class of
drugs
Main side-effects Contraindications/
Special Precautions
Diuretics
(e.g. HCT)
Electrolyte
imbalance,
level of total and
C-LDL,, glucose
levels, UC, C-
HDL
Hypersensitivity, Anuria
-blockers
(e.g. atenolol)
Impotence,
Bradycardia,
fatique
Hypersensitivity, Bradycardia,
Conduction disturbances,
Diabetes, Asthma, Severe
cardiac failure
Class of drugs Main side-effects Contraindications/
Special Precautions
CCB (e.g.
Amlodipine,
Diltiazem)
Pedal edema,
Headache
Non-DHP CCBs (e.g diltiazem)
Hypersensitivity, Bradycardia,
Conduction disturbances, CHF, LV
dysfunction.
DHP CCBsHypersensitivity
-blockers (e.g.
Doxazosin)
Postural hypotension Hypersensitivity
ACE-inhibitors
(e.g. Lisinopril)
Cough, Hypertension,
Angioneurotic edema
Hypersensitivity, Pregnancy,
Bilateral renal artery stenosis
A-II RB Headache, Dizziness

Hypersensitivity, Pregnancy,
Bilateral renal artery stenosis
BP
Classification
SBP
(mm HG)
DBP
(mm HG)
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1
hypertension
140-159 or 90-99
Stage 2
hypertension
160 or 100
National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the
Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.
Not at goal blood pressure (<140/90 mm HG)
(<130/80 mm HG for those with diabetes or chronic kidney disease)
Initial drug choices
Drug(s) for compelling
indications
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB)
as needed.
With compelling
indications
Lifestyle modifications
Stage 2 Hypertension
(SBP >160 or DBP >100 mm HG)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB).
Stage 1 Hypertension
(SBP 140159 or DBP 9099 mm HG)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.0
Without compelling
indications
Not at goal
blood pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the
Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.
Acute life-threatening increase in BP

Hypertensive urgency: severe
hypertension (usually SBP > 180 and DBP
> 120 mmHg) without acute target organ
damage (TOD)

Hypertensive emergency : severe HTN +
TOD
Untreated essential hypertension
Sudden withdrawal / non-adherence to
antihypertensive drug therapy
Increase in sympathetic tone (stress, drugs)
Renovascular hypertension, renal parenchymal
diseases, pheochromocytoma, or primary
hyperaldosteronism.
Pressure damages vascular endothelium
Platelets and fibrin activate
Encephalopathy
AMI (acute myocardial infarction)/USA
(Unstable angina)
Nephropathy
Aortic dissection (Diseksi aorta)
LV failure (gagal ventrikel kiri)/cardiac
decompensation (gagal jantung)
Eclampsia
Medical history (Riwayat medik)
Physical examination (Pemeriksaan fisik)
Laboratory evaluation (evaluasi laboratorium)
serum
urine
Profil pengobatan
Riwayat pemakaian obat
Fundoscopy
EKG, CXR (chest X ray= foto thoraks), head CT
(CT scan kepala), echocardiography
Urinalysis: protein, RBC (red blood
cells), casts
Cardiac enzymes- CKMB, troponins
Electrolytes, BUN (blood urea nirogen) ,
creatinine
Toxicology screen
EKG, echo, angiography, X-ray
Thyroid, cortisol, BG (blood gas
analysis)
LFTs (liver function tests)

Time frame - consider risk level
BP goal
Urgency: gradual; DBP to 110 in 24-48 hours
Emergency: MAP < 20 to 25% in 1 to 2 hours
Drug selection
Route
Widening neurologic deficits
Retinal ischemia: blindness
Acute myocardial infarction
Deteriorating renal function
End-stage
heart
disease
Heart
failure
ACE inhibition
Angiotensin receptor blockade
GISSI-3
ISIS-4
AIRE
SAVE
SOLVD-Prevention
TRACE
CHARM-Preserved
OPTIMAAL
VALIANT
SOLVD-Treat
CHARM-Added
CHARM-Alternative
ELITE II
Val-HeFT
CONSENSUS
HOPE
EUROPA
ALLHAT
ANBP2
ASCOT
INVEST
LIFE
VALUE
Adapted from: Dzau V, et al. Am Heart J. 1991;121:1244-1263.
Ventricular
dilation
Remodeling
LV
Dysfunction
Arrhythmia
Myocardial
Infarction
Coronary
thrombosis
Myocardial
ischemia
CAD
Athero-
sclerosis
LVH
Hypertension
45