You are on page 1of 39

HYPERTENSION

SYAIFUL AZMI
Subdivision of Nephrology, Faculty of Medicine
Andalas University
Padang

Buku pegangan.
HARRISON

: INTERNAL MEDICINE

SUPARTONDO : ILMU OENYAKIT DALAM


NORMAN KAPLAN : CLINICAL
HYPERTENSION

Section 1: Definition and Classification


of Hypertension

Definition and classification of


hypertension: ESH/ESC 2003
Hypertension is defined 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

When a patients systolic and diastolic blood pressures fall into different
categories, the higher category should apply

ESH/ESC Guidelines 2003


J Hypertens 2003;21:1011-1053

Definition and classification of


hypertension: JNC VII
Hypertension is defined as blood pressure 140/90 mmHg
Category

Systolic
(mmHg)

Diastolic
(mmHg)

<120

and <80

Pre hypertension

120-139

or 80-89

Stage 1 hypertension

140-159

or 90-99

Stage 2 hypertension

160

or 100

Normal

JNC VII. JAMA 2003;289:2560-2572

Definition and classification of


hypertension: WHO/ISH 1999/2003
Hypertension is defined 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

When a patients systolic and diastolic blood pressures fall


into different categories, the higher category should apply

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

Section 2: Prevalence of Hypertension

Prevalence of hypertension*:
North America and Europe
80
Prevalence (%)

70
60

Men
Women
Total

50
40
30
20
10
0

* BP 140/90 mmHg or treatment with antihypertensive medication

Wolf-Maier K, et al. JAMA 2003;289:2363-2369

Prevalence (%)

Prevalence of hypertension: Asia


80
70
60
50
40
30
20
10
0

Men
Women
Total

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 Pacific 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:
Other countries
80
Prevalence (%)

70
60

Men
Women
Total

50
40
30
20
10
0

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,


Obese, TGT dan DM di SumBar 2005
N
O

1
2
3
4
5
6
7
8

KOTA

POPULASI
(%)

OBESE
(%)

TGT
(%)

DM
(%)

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 : Classification of
hypertension

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


Hypertension

Table Cardiovaskuler risk factors


Major Risk Factors
Hypertension*
Cigarette* (body mass index 30 kg/m2)
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 filtration rate
* Components of the metabolic syndrome

JNC VII 2003

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 HIPERTENSI
(bila tdk dikendalikan)

Kerusakan pada Organ Target


LVH
Gagal
Jantung
PJK
Retinopati
(buta)

Stroke
Penyakit Ginjal
khronik
Gagal Ginjal
Terminal

Section 5 : Pathophysiology and


Pathogenesis 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
( Kaplan N, 2002 )

Renin-angiotensin-aldosterone system
Angiotensinogen

(-)
Renin

Bradykinin

Angiotensin I
Angiotensinconverting
enzyme

Angiotensin II

BP

BP, blood pressure

Inactive kinins

AT1

Vasoconstriction
Aldosterone secretion
Catecholamine release
Proliferation
Hypertrophy

AT2

Vasodilation
Inhibition of cell growth
Cell differentiation
Injury response
Apoptosis
Ellis ML, et al. Pharmacotherapy 1996;16:849-860;
Carey RM, et al. Hypertension 2000;35:155-163

Section 6 : Diagnosis of Hypertension

SYMPTOMS
Headache
Nocturia
Palpitation
Dizziness
Tinitus
Epistaxis
Kaplan N , 2002

PHYSICAL EXAMINATION

25

TABLE. IMPORTANT ASPECTS OF THE PHYSICAL


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
ROUTINE LAB WORK UP
RISK FACTORS : BLOOD SUGAR, LIPID

PROFILE, ELECTROLYTES.

LAB OF TARGET ORGAN DEMAGE


PLASMA INSULIN, PLASMA RENIN
ACTIVITY

FUNDUSCOPY EXAMINATION :
RETINOPATHY

CARDIAC ASSESSMENT : LVH, ARYTHMIA


CEREBRAL ASSESSMENT :
ENCEPHALOPATHY
RENAL ASSESSMENT

Section 7 : Treatment Guidelines

Table Lifestyle modifications to manage hypertension *


Modification

Recommendation

Approximate SBP
Reduction (range)

Weight reduction

Maintain normal body weight (body mass


index 18.5-24.9 kg/m2)

5-20 mmHg/10 kg weight


loss23-24

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 mmHg25-26

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 mmHg25-27

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 mmHg26-27

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 mmHg30

DASH, Dietary Approaches to Stop Hypertension.


*
For overall cardiovascular risk reduction, stop smoking.

The effects of implementing these modifications are dose and time dependent, and could be greater for some
individuals

JNC VII 2003

THE IDEAL ANTIHYPERTENSIVE AGENT

- Effectively reduces BP
- Maintains BP control over 24 hours with
once-a-day dosing
- Effective in all hypertensive patients
- No adverse effects
- No negative metabolic side effects

History of antihypertensive drugs

Effectiveness and general tolerability


1940s

1950

1960s

1957

Alphablockers

Direct
vasodilators
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids

1970s

Thiazide
diuretics

Central 2
agonists

Calcium
antagonistsnon-DHPs

1980s

ARBs
ACE
inhibitors

Calcium
antagonistsDHPs

Betablockers
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker

1990s

2000

Multiple antihypertensive agents


are needed to achieve target BP
Trial

Number of antihypertensive agents


Target BP (mmHg) 1
2
3
4

UKPDS

DBP <85

ABCD

DBP <75

MDRD

MAP <92

HOT

DBP <80

AASK

MAP <92

IDNT

SBP <135/DBP <85

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

Main classes of antihypertensive drugs


Diuretics
Inhibit the re absorption of salts and water from kidney
tubules into the bloodstream

Calcium-channel antagonists
Inhibit influx 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
classes
RECOMMENDED DRUGS+
CLINICAL TRIAL BASIS+

COMPELLING INDICATION
DIURETIC
Heart failure

Postmyocardial infarction

BB

ACEI

ARB

High coronary disease risk

Diabetes

Chronic Kidney disease

Recurrent stroke prevention

CCB

ALDO ANT

ACC/AHA Heart Failure Guideline,40 MERIT-HF, 41 COPERNICUS,42 CIBIS,43 SOLVD,44 AIRE,45


TRACE,44 ValHEFT,47 RALES48

ACC/AHA post-MI Guideline,49


BHAT,50 SAVE,51 Capricorn,52
EPHESUS,53

ALLHAT,33 HOPE,34 ANBP2,36


LIFE,32 CONVINCE31

NKF-ADA Guideline,31,32 UKPDS,34


ALLHAT33
NKF Guideline,22 captopril Trial,55
RENALL,56 IDNT,57 REIN,58 AASK59
PROGRESS35

JNC VII , 2003

Compeling indications for antihypertensive drugs are based on benefits from outcome studies or existing
clinical guidelines; the compelling indications is managed in parallel with the BP
+ Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB,angiotensin receptor blicker;
Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker
Conditions for which trials demonstrate benefit of specific classes of antihypertensive drugs.

Treatment initiation: JNC VII

Lifestyle
modification

Normal

Prehypertension

Stage 1
hypertension

Stage 2
hypertension

Encourage

Yes

Yes

Yes

Initial drug therapy


Without
compelling
indication

No antihypertensive drug
indicated

Thiazide-type
Two-drug
diuretics for most; combination for
may consider
most (usually
ACE-I, ARB, BB,
thiazide-type
CCB, or
diuretic and
combination
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


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

SBP, systolic blood pressure; DBP, diastolic blood pressure;


BP, blood pressure

JNC VII. JAMA 2003;289:2560-2572

Diuretik : Hati hati pada :


- gangguan elektrolit
- dislipidemia
Beta bloker hati hati pada :
- Asma bronkhial / spasme bronkhus
- Diabetes melitus