HYPERTENSION

HYPERTENSION
SYAIFUL AZMI
Subdivision of Nephrology, Faculty of Medicine
Andalas University
Padang
Buku pegangan.
Buku pegangan.
HARRISON : INTERNAL MEDICINE
SUPARTONDO : ILMU OENYAKIT DALAM
NORMAN KAPLAN : CLINICAL
HYPERTENSION
Section 1: Defnition and Classifcation
Section 1: Defnition and Classifcation
of Hypertension
of Hypertension
Defnition and classifcation of
Defnition and classifcation of
hypertension: ESH/ESC 2003
hypertension: ESH/ESC 2003
Hypertension is defned as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Optimal <120 <80
Normal 120-129 80-84
High normal 130-139 85-89
Grade 1 hypertension (mild) 140-159 90-99
Grade 2 hypertension (moderate) 160-179 100-109
Grade 3 hypertension (severe) 180 110
Isolated systolic hypertension 140 <90
ESH/ESC Guidelines 2003
J Hypertens 2003;21:1011-1053
When a patients systolic and diastolic blood pressures fall into diferent
categories, the higher category should apply
Defnition and classifcation of
Defnition and classifcation of
hypertension: JNC VII
hypertension: JNC VII
Hypertension is defned as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Normal <120 and <80
Pre hypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 or 100
JNC VII. JAMA 2003;289:2560-2572
Defnition and classifcation of
Defnition and classifcation of
hypertension: WHO/ISH 1999/2003
hypertension: WHO/ISH 1999/2003
Hypertension is defned as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Optimal <120 <80
Normal <130 <85
High-normal 130-139 85-89
Grade 1 hypertension (mild)
Subgroup: borderline
140-159
140-149
or 90-99
90-94
Grade 2 hypertension (moderate) 160-179 or 100-109
Grade 3 hypertension (severe) 180 or 110
Isolated systolic hypertension
Subgroup: borderline
140
140-149
<90
<90
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992; 1999 WHO/ISH Guidelines for the
Management of Hypertension. J Hypertens 1999;17:151-183
When a patients systolic and diastolic blood pressures fall
into diferent categories, the higher category should apply
Section 2: Prevalence of Hypertension
Section 2: Prevalence of Hypertension
Prevalence of hypertension*:
Prevalence of hypertension*:
North America and Europe
North America and Europe
0
10
20
30
40
50
60
70
80
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Wolf-Maier K, et al. JAMA 2003;289:2363-2369
* BP 140/90 mmHg or treatment with antihypertensive medication
Prevalence of hypertension: Asia
Prevalence of hypertension: Asia
0
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30
40
50
60
70
80
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Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol
1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacifc J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
Prevalence of hypertension:
Prevalence of hypertension:
Other countries
Other countries
0
10
20
30
40
50
60
70
80
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Ordunez P, et al. Pan Am J Public Health 2001;10:226-231;
Cubillos-Garzon LA, et al. Am Heart J 2004;147:412-417; Amad S, et al. J Hum Hypertens 1996;10:S31-S33
TABEL 4 Prevalensi Hipertensi Pada Populasi,
TABEL 4 Prevalensi Hipertensi Pada Populasi,
Obese, TGT dan DM di SumBar 2!
Obese, TGT dan DM di SumBar 2!
N
O
KOTA POPULASI
(%)
OBESE
(%)
TGT
(%)
DM
(%)
1
2
3
4
5
6
7
8
P.Panjang
Bt.Sangkar
Solok
Pariaman
Payakumbuh
Painan
Bukittinggi
Padang
22.3
23.4
26.1
22.9
19.1
16.0
26.6
11.8
22.4
23.4
24.6
22.2
17.6
17.7
37.6
12.0
26.3
32.5
33.3
35.6
326.6
36.4
38.2
25.3
33.3
42.2
41.2
40.0
18.4
29.4
28.6
23.1
RERATA 21.1 22.2 30.4 30.0
Section 3 : Classifcation of
Section 3 : Classifcation of
hypertension
hypertension
CLASSIFICATION
CLASSIFICATION
PRIMARY ( 90 % )
SECUNDARY ( 10 % )
renovascular hypertension
renal parenchymal hypertension
hypertension with pregnancy
pheochromocytoma
primary aldosteronemia
drug induced or related causes
JNC 7 2003, Caplan, clinical hypertension 2002
Section 4 : Risk factors of
Section 4 : Risk factors of
Hypertension
Hypertension
Table Cardiovaskuler risk factors
Table Cardiovaskuler risk factors
Major Risk Factors

Hypertension*
Cigarette* (body mass index 30 kg/m
2
)
Physical inactivity
Dislipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR < 60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women under age 65)
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
GFR, glomerular fltration rate
* Components of the metabolic syndrome JNC VII 2003
Risk factors
Risk factors
Gender
Race
Age
Family history
Cigarette smoking
Obesity ( BMI 30 Kg/m2 )*
Physical activity
Dyslipidemia*
Diabetes Mellitus*
Microalbuminuria
* componen of metabolic syndrome

JNC 7 2003
Bahaya
Bahaya
HIPERTENSI
HIPERTENSI
(bila tdk dikendalikan)
(bila tdk dikendalikan)

Kerusakan pada Organ Target
Kerusakan pada Organ Target
Stroke
Stroke
Retinopati
Retinopati
(buta)
(buta)
4
LH
LH
4
!aga"
!aga"


#antung
#antung
4
P#K
P#K
Penyakit !in$a"
Penyakit !in$a"
khronik
khronik
4
!aga" !in$a"
!aga" !in$a"


Ter%ina"
Ter%ina"
Section 5 : Pathophysiology and
Section 5 : Pathophysiology and
Pathogenesis of Hypertension
Pathogenesis of Hypertension
PATHOPHYSIOLOGY OF HYPERTENSION
PATHOPHYSIOLOGY OF HYPERTENSION
Several hypothesis exists of the original pathogenesis
of hypertension
- Excess Na intake
- Renal Na retention
- RAS
- Stress & sympathetic activity
- Peripheral resistance
- Endothelial dysfunction
- Obesity
- Insulin resistance
Pathogenesis hipertensi
( Kap"an N& '((' )
Angiotensinogen
Angiotensin I
Angiotensin II
Ellis ML, et al. Pharmacotherapy 1996;16:849-860;
Carey RM, et al. Hypertension 2000;35:155-163
AT
AT
1 1
AT
AT
2 2
Vasoconstriction
Aldosterone secretion
Catecholamine release
Proliferation
Hypertrophy
Vasodilation
Inhibition of cell growth
Cell diferentiation
Injury response
Apoptosis
BP
(-)
Renin-angiotensin-aldosterone system
Renin-angiotensin-aldosterone system
Renin Renin
Angiotensin- Angiotensin-
converting converting
enzyme enzyme
Bradykinin
Inactive kinins
5"1 0lood pressure
Section 6 : Diagnosis of Hypertension
Section 6 : Diagnosis of Hypertension
SYMPTOMS
SYMPTOMS
Headache
Nocturia
Palpitation
Dizziness
Tinitus
Epistaxis
Kaplan N , 2002
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
25
TABLE. IMPORTANT ASPECTS OF THE PHYSICAL
TABLE. IMPORTANT ASPECTS OF THE PHYSICAL
EXAMINATION
EXAMINATION
ACCURATE MEASUREMENT OF BLOOD PRESSURE
GENERAL APPEARANCE : DISTRIBUTION OF BODY FAT,
SKIN LESSION,MUSCLESTRENGTH.
FUNDUSCOPY.
NECK : PALPATION AND AUSCULTATION OF CAROTIDS, THYROID.
HEART : SOUND, RHYTHM, SIZE.
LUNG : RALES.
ABDOMEN : RENAL MASSES, BRUIT OVER AORTA OR RENAL
ARTERIES, FEMORAL PULSES, WAIST CIRCUMFERENCE.
EXTREMITIES : PERIPHERAL PULSES, EDEMA.
NEUROLOGIC ASSESSMENT, INCLUDING COCNITIVE
FUNCTION.
LABORATORY TEST
LABORATORY TEST
ROUTINE LAB WORK UP
RISK FACTORS : BLOOD SUGAR, LIPID
PROFILE, ELECTROLYTES.
LAB OF TARGET ORGAN DEMAGE
PLASMA INSULIN, PLASMA RENIN
ACTIVITY
FUNDUSCOPY EXAMINATION :
FUNDUSCOPY EXAMINATION :


RETINOPATHY
RETINOPATHY
CARDIAC ASSESSMENT : LVH, ARYTHMIA
CEREBRAL ASSESSMENT :
ENCEPHALOPATHY
RENAL ASSESSMENT
Section 7 : Treatment Guidelines
Section 7 : Treatment Guidelines
Table Lifestyle modifcations to manage hypertension * Table Lifestyle modifcations to manage hypertension *
DASH, Dietary Approaches to Stop Hypertension.
* For overall cardiovascular risk reduction, stop smoking.
The efects of implementing these modifcations are dose and time dependent, and could be greater for some individuals
JNC VII 2003
Modifcation Recommendation Approximate SBP
Reduction (range)
Weight reduction Maintain normal body weight (body mass
index 18.5-24.9 kg/m
2
)
5-20 mmHg/10 kg weight
loss
23-24
Adopt DASH eating plan Consume a diet rich in fruits, vegetables,
and lowfat dairy products with a reduced
content of saturated and total fat
8-14 mmHg
25-26
Dietary sodium reduction Reduce dietary sodium intake to no more
than 100 mmol per day (2.4 g sodium or
6 g sodium chloride)
2-8 mmHg
25-27
Physical activity Engage in regular aerobic physical
activity such as brisk walking (at least 30
min per day, most days of the week0
4-9 mmHg
26-27
Moderation of alcohol
consumption
Limit consumption to no more than 2
drinks ( 1 oz or 30 mL ethanol; e.g., 24
oz beer, 10 oz wine, or 3 oz 80-proof
whiskey) per day in most men and to no
more than 1 drink per day in women and
lighter weight persons
2-4 mmHg
30
THE IDEAL ANTIHYPERTENSIVE AGENT
THE IDEAL ANTIHYPERTENSIVE AGENT
-Efectively reduces BP
-Maintains BP control over 24 hours with once-
a-day dosing
-Efective in all hypertensive patients
-No adverse efects
-No negative metabolic side efects
History of antihypertensive drugs
History of antihypertensive drugs
Direct
vasodilators
Alpha-
blockers
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids
Central
2

agonists
Calcium
antagonists-
non-DHPs
Beta-
blockers
Thiazide
diuretics
Calcium
antagonists-
DHPs
ARBs
1940s 1950 1957 1960s 1970s 1980s 1990s 2000
ACE
inhibitors
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
Efectiveness and general tolerability
AASK MAP <92
Target BP (mmHg)
Multiple antihypertensive agents
are needed to achieve target BP
Number of antihypertensive agents
1
UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
Trial
2 3 4
65"1 diastoli$ 0lood pressure7 (8"1 !ean arterial pressure7
S5"1 systoli$ 0lood pressure
IDNT SBP <135/DBP <85
ALLHAT SBP <140/DBP <90
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
Main classes of antihypertensive drugs
Main classes of antihypertensive drugs
Diuretics
Inhibit the re absorption of salts and water from kidney
tubules into the bloodstream
Calcium-channel antagonists
Inhibit infux of calcium into cardiac and smooth muscle
Beta-blockers
Inhibit stimulation of beta-adrenergic receptors
Angiotensin-converting enzyme (ACE) inhibitors
Inhibit formation of angiotensin II
Angiotensin II receptor blockers (ARBs)
Inhibit binding of angiotensin II to type 1 angiotensin II
receptors
Clinical trial and guideline basis for compelling indications for individual drug Clinical trial and guideline basis for compelling indications for individual drug
classes classes
RECOMMENDED DRUGS
+
COMPELLING INDICATION CLINICAL TRIAL BASIS
+
DIURETIC BB ACEI ARB CCB ALDO ANT
Heart failure ACC/AHA Heart Failure Guide-
line,
40
MERIT-HF,
41
COPERNI-
CUS,
42
CIBIS,
43
SOLVD,
44
AIRE,
45

TRACE,
44
ValHEFT,
47
RALES
48
Postmyocardial infarction ACC/AHA post-MI Guideline,
49
BHAT,
50
SAVE,
51
Capricorn,
52
EPHESUS,
53
High coronary disease risk ALLHAT,
33
HOPE,
34
ANBP
2
,
36
LIFE,
32
CONVINCE
31
Diabetes NKF-ADA Guideline,
31,32
UKPDS,
34
ALLHAT
33
Chronic Kidney disease NKF Guideline,
22
captopril Trial,
55
RENALL,
56
IDNT,
57
REIN,
58
AASK
59
Recurrent stroke prevention PROGRESS
35

JNC VII , 2003
Co!peling indi$ations 9or anti+ypertensi#e drugs are 0ased on 0ene9its 9ro! out$o!e studies or e:isting
$lini$al guidelines7 t+e $o!pelling indi$ations is !anaged in parallel wit+ t+e 5"
; 6rug a00re#iations7 8CEI1 angiotensin $on#erting en<y!e in+i0itor7 8=51angiotensin re$eptor 0li$>er7
8ldo 8?*1 aldosterone antagonist7 551 0eta30lo$>er7 CC51 $al$iu! $+annel 0lo$>er
@ Conditions 9or w+i$+ trials de!onstrate 0ene9it o9 spe$i9i$ $lasses o9 anti+ypertensi#e drugsA
Treatment initiation: JNC VII
Treatment initiation: JNC VII
Normal
Pre-
hypertension
Stage 1
hypertension
Stage 2
hypertension
Lifestyle
modifcation
Encourage Yes Yes Yes
Initial drug therapy
Without
compelling
indication
No antihypertensive drug
indicated
Thiazide-type
diuretics for most;
may consider
ACE-I, ARB, BB,
CCB, or
combination
Two-drug
combination for
most (usually
thiazide-type
diuretic and
ACE-I or ARB
or BB or CCB)
With
compelling
indications
Drug(s) for compelling
indications
Drug(s) for compelling indications;
other antihypertensive drugs
(diuretics, ACE-I, ARB, BB, CCB)
as needed
ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII. JAMA 2003;289:2560-2572
Goals of treatment: JNC VII
Goals of treatment: JNC VII
The SBP and DBP targets are
<140/90 mmHg
The primary focus should be on achieving the
SBP goal
In patients with hypertension and diabetes or
renal disease, the BP goal is <130/80 mmHg
JNC VII. JAMA 2003;289:2560-2572
SBP, systolic blood pressure; DBP, diastolic blood pressure;
BP, blood pressure
Diuretik : Hati hati pada :
- gangguan elektrolit
- dislipidemia
Beta bloker hati hati pada :
- Asma bronkhial / spasme bronkhus
- Diabetes melitus