Академический Документы
Профессиональный Документы
Культура Документы
HYPERTENSION IN FIRST
LEVEL HEALTH FACILITIES
Hypertension
More Than Just High BP
A complex syndrome in which neurohumoral and
metabolic abnormalities influence development
and progression of vascular disease and clinical
events
A complex inherited syndrome of cardiovascular risk factors
Hypertension Syndrome
High BMI
Physical inactivity
Alcohol
Indoor smoke from solid fuels
Iron deficiency
0
Attributable Mortality
WHO 2000 Report. Lancet. 2002;360:1347-1360.
Hypertension
8X
ris
k
6
4
2
0
1X
risk
115/75
2X
risk
135/85
4X
ris
k
155/95
175/105
CIRCADIAN RHYTHM
JNC 6 (1997)
JNC 7 (2003)
Optimal
Normal
Normal
< 130 and < 85
Prehypertension
High-normal
120-139 or 80-89
Hypertension
130-139 or 85-89
Stage 1
Stage 1
140-159 or 90-99
140-159 or 90-99
Stage 2
160-179 or 100-109
Stage 2
Stage 3
JNC VI. Arch Intern Med. 1997;157:2413-2446. JNC 7. JAMA. 2003; 289(19):2560
Elevated BP
Vascular Dysfunction
A Proposed Future Paradigm
Endothelial
Dysfunction
Vascular
Dysfunction
Elevated BP
Target Organ
Damage
LVH
Renal
Damage
MI
Angina
Pectoris
Stroke
Myocardial
infarction
Myocardial
ischaemia
STROKE
CAD
Atherosclerosis
LVH
Risk factors
smoking, HYPERTENSION,
cholesterol, diabetes
Sudden Death
Arrhythmia &
loss of muscle
Remodelling
Ventricular
dilatation
Congestive
heart failure
Death
2mm Hg
decrease in
mean SBP
7% reduction
in risk of
ischemic heart
disease
10% reduction in
risk of stroke
mortality
Rank
Cause
2020
% Rank
Cause
1
2
3
8.2
7.2
6.7
1
2
3
5.9
5.7
5.1
4
5
6
7
8
9
10
Major depression
Ischemic heart disease
Cerebrovascular disease
Tuberculosis
Measles
Road traffic accidents
Congenital abnormalities
3.7
3.4
2.8
2.8
2.7
2.5
2.4
4 Cerebrovascular disease
5 COPD
6 Lower respiratory infections
7 Tuberculosis
8 War
9 Diarrhoeal diseases
10 HIV
4.4
4.2
3.1
3.0
3.0
2.7
2.6
Vascular Disease:
-Atherosclerosis
-Arteriosclerosis
Left Ventricular
Hypertrophy
Independent Predictor of:
Myocardial infarction
Stroke
Heart Failure
Total Mortality
Sudden Death
LVH
Diastolic
Dysfunction
Hypertension
Smoking
Dyslipidemia
Diabetes
Normal LV
Structure
and Function
CHF
MI
Systolic
Dysfunction
LV
Remodeling
Subclinical LV
Dysfunction
LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure.
Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796.
Overt Heart
Failure
CV Complications of Untreated
Hypertension (N=500)
50
50
45
40
35
Event 30
rate 25
(%) 20
18
15
16
12
8
10
5
0
2
Renal
Failure
Stroke
Enceph
MI
Angina
CHF
Stage 2+
Stage 1
20
25
20
Cumulative
15
Incidence
(%)
10
Normotensive 15
0
40
10
10 12 14 16
40
Stage 2+
Normotensive
2
10 12 14 16
30
Stage 2+
Stage 1
10
Stage 1
20
Normotensive
10
30
Cumulative
Incidence 20
(%)
10
12
14
2
Time (y)
Normotensive
4
10
12
14
Population-Attributable Risks
for Development of CHF
AP
DM 5%
6%
LVH
4%
VHD
7%
MI
34%
Men
Women
HTN
39%
DM
12%
AP
5%
HTN
59%
LVH
5%
VH
D
8%
MI
12%
Normotensive
BP <140/90 mmHg
Hypertensive
BP >160/95 mmHg
Age at examination
Kannel et al. 1972
S
m
o
k
i
n
g
D
Dys
ia
elial
b
ndot h
E
e
t
n
e
s
Ross. N Engl J Med. 1999;340:115-126.
matio
Inflam
H
yp
er
t
CV
Disease
tress
en
si
on
D
ys
lip Stress & Inflammation
Oxidative
id
em
ia
LDL
BP
Diabetes
Smoking
Oxidative Stress
Endothelial Dysfunction and Smooth Muscle
Activation
NO Local Mediators Tissue ACE, AII
Endothelin
Catecholamines
Vasoconstriction
PAI-1, Platelet
VCAM/ICAM
Aggregation,
Cytokines
Tissue Factor
Thrombosis
Inflammation
Proteolysis
Inflammation
Growth Factors
Cytokines
Matrix
HYPERTENSION:
THERAPEUTIC ISSUES
30% No Rx
Younger
Male
Hispanic
0-1 visits/y
20% Rxd
Most on 1-2 meds
Men
AA, age, CKD,
obese
2 visits/y
Public education
Active screening
Improved access
to care
Therapeutic
efficiency
Therapeutic
inertia
adherence
MMWR 2011; 60:103
MANAGEMENT OF
HYPERTENSION
Non-pharmacological/ lifestyle
Pharmacological
No diabetes
Optimal treated BP pressure
Audit Standard
Diabetes
<140/85
<150/90
<130/80
<140/80
Audit standard reflects the minimum recommended levels of blood pressure control.
Despite best practice, the Audit Standard will not be achievable in all treated hypertensives.
For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by
~10/5 is recommended.
Without Compelling
Indications
Stage 1
Hypertension (SBP
140-159 or DBP 9099 mmHg) Thiazidetype diuretics for
most. May consider
ACEI, ARB, BB, CCB,
or combination
With Compelling
Indications
Stage 2 Hypertension
(SBP 160 or DBP 100
mmHg) Two-drug
combination for most
(usualy Thiazide-type
diuretics ACEI, ARB, BB,
CCB)
Lifestyle Modifications
Modification
Weight reduction
814 mmHg
28 mmHg
Physical activity
49 mmHg
Moderation of alcohol
consumption
24 mmHg
Non-pharmacological interventions
Measures that lower blood pressure:
weight
salt intake
alcohol consumption
physical exercise
fruit & vegetable consumption
Stop smoking
saturated fat, poly- & mono-unsaturates
oily fish consumption
total fat intake
BHS Guidelines 1999
Lifestyle measures
Maintain normal weight for adults (body mass index 20-25
kg/m2)
Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g
Na+/day)
Limit alcohol consumption to 3 units/day for men and 2
units/day
for women
Engage in regular aerobic physical exercise (brisk walking
rather
than weight lifting) for 30 minutes per day, ideally
on most of days
of the week but at least on three days of
the week
Consume at least five portions/day of fresh fruit and
vegetables
Reduce the intake of total and saturated fat
ACE-inhibitor
Angiotensin receptor
blocker
(Alpha-blocker)
CCB
Arteriodilation
Peripheral oedema
Effective in low-renin patients
Reduces cardiac ischaemia
BP
Synergistic
BP reduction
Complementary
clinical benefits
CCB
RAS activation
No renal or CHF
benefits
ACEi/ARB
Venodilation
Attenuates peripheral oedema
Effective in high-renin patients
No effect on cardiac ischaemia
BP
Synergistic
BP reduction
Complementary
clinical benefits
ACEi/ARB
RAS blockade
CHF and renal
benefits
CCB
RAS activation
No renal or CHF
benefits
Calcium antagonist
One drug:
Younger, non-black
Older, black
C or D
Two drugs: (A or B) + (C or D)
Three drugs: (A or B) + C + D
Diuretic
A or B
ie et al. In: Opie LH, editor. Drugs for the Heart. 3rd ed. 1991:4273; White et al. Clin Pharmacol Ther.
86;39:4348; Gustaffson. J Cardiovasc Pharmacol. 1987;10:S121S131.
Opie et al. In: Opie LH, editor. Drugs for the Heart. 3rd ed. 1991:4273; White et al. Clin Pharmacol Ther.
1986;39:4348; Gustaffson. J Cardiovasc Pharmacol. 1987;10:S121S131; Messerli et al. Am J Cardiol.
2000;86:11821187.
Aldo Ant
CCB
ARB
ACEI
BB
Compelling
Indication*
Diuretic
Recommended
Drugs
Clinical trial basis
Heart Failure
Postmyocardial
Infarction
Diabetes
Recurrent Stroke
Prevention
PROGRESS
Possible
indications
Beta-blockers
MI,
Angina
Heart failure
CCBs
(dihydropyridine)
CCBs
(rate limiting)
Elderly, ISH
Angina
Angina
Elderly
Class of drug
Thiazide/thiazide- Elderly
like diuretics
ISH
Heart failure
2 o stroke
prevention
Caution
Compelling
contraindications
Heart failure,
PVD,
Diabetes
(except with
CHD)
-
Asthma/COPD,
Heart block
Combination
with betablockade
Heart block
Heart failure
Gout
Obat
HL
Onset
Durasi
PPT
Bioav
(%)
Lisinopril
12 jam
1-6 jam
24 jam
6-8 jam
25
Ramipril
13-17
jam
4 jam
24 jam
2-4 jam
50-60%
Perindopril
3-10
jam
1,5 jam
24 jam
1 jam
75 %
Trandolapril
6-10
jam
4 jam
24 jam
1 jam
80 %
Enalapril
1,3 jam
1-4 jam
12-24
jam
1 jam
60 %
Losartan
1,5-2
jam
6 jam
24 jam
11,5jam
25%
Valsartan
6-9 jam
2 jam
6-8 jam
2-4 jam
25 %
ThankYou