HYPERTENSION

SEPTRIYANTO DIRGANTARA, M.Si., Apt

Batasan Hipertensi
1. Bila tekanan sistolik >= 140 mmHg, dan
atau tekanan diastolik >= 90 mmHg,
atau sedang mendapat obat
antihipertensi.

2. Dilakukan dua kali atau lebih

pengukuran pada dua kali atau lebih
kunjungan.
Blood Pressure Classification
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80

Prehypertension 120139 or 8089

Stage 1 140159 or 9099

Hypertension

Stage 2 >160 or >100

Hypertension
WHO/ISH 2003.
ESC/ESH 2003 .
 Classification of blood pressure levels of the
British Hypertension Society

Category Systolic blood pressure Diastolic blood pressure

(mmHg) (mmHg)

Optimal <120 <80

Normal <130 <85
High-normal 130139 8589

Hypertension
Grade 1 (mild) 140159 9099
Grade 2 (moderate) 160179 100109
Grade 3 (severe) 180 110

Isolated Systolic Hypertension

Grade 1 140 - 159 <90
Grade 2 >160 <90

Brit Med J 2004 328:634-40.

AUSTRALIA 2003
 BP Measurement Techniques
Method Brief Description
In-office Two readings, 5 minutes apart,
sitting in chair. Confirm elevated
reading in contralateral arm.
Ambulatory BP Indicated for evaluation of white-
monitoring coat HTN. Absence of 1020% BP
decrease during sleep may indicate
increased CVD risk.
Self-measurement Provides information on response
to therapy. May help improve
adherence to therapy and evaluate
white-coat HTN.
JNC 7 2003
 Office BP Measurement
Use auscultatory method with a properly calibrated and validated
instrument.
Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made.
Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.

JNC 7 2003
How to measure blood pressure accurately

sphygmomanometer
Patient should be seated and relaxed, preferably for several
minutes prior to the measurement and in a quiet room.
Appropriate cuff size.
Average the readings. If the firsty two readings differ by more than 10
mmHg systolic or 6 mmHg diastolic or if the initial readings are high, take
several readings after five minutes of quiet rest, until consecutive
readings do not vary by greater than these amounts.
Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
..
Australia, 2004
 Box 2 Procedures for blood pressure measurement

When measuring blood pressure, care should be taken to

.. to sit for several minutes in a quiet room before
beginning blood pressure measurements.

Take at least two measurements spaced by 1-2 min, .

Use a standard bladder . but have a larger and a smaller

bladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of the
patient.
Use phase I and V .

Measure blood pressure in both arms at first visit to detect

possible differences ..

Measure blood pressure 1 and 5 min after assumption of

the standing position in elderly subjects, diabetic patients,
..

Measure heart rate by pulse palpation (30 s) after the

second measurement in the sitting position.
 HIPERTENSI

Tekanan Darah :

Rata-rata dari 2 kali pemeriksaan

Pengukuran pada waktu yang berbeda
Pengukuran pada waktu duduk

12
 TD kekuatan darah ketika melewati
dinding arteri
Jenis Hipertensi
Hipertensi Resisten
Hipertensi Emergensi
Hipertensi Urgensi
Berdasarkan Penyebab
Hipertensi Primer idiopatik 90-95%
Hipertensi Skunder Sistemik
Prevalensi Hipertensi

USA 50 Juta dari total

Penduduk
( 1 dari 4 orang
dewasa)

Indonesia Baliem 0,65%

Sukabumi 28,6%
Etiology

Primary hypertension
95% of all cases
Secondary hypertension
5% of all cases
Chronic renal disease most common
 CVD Risk Factors
Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)

*Components of the metabolic syndrome.

 Identifiable
Causes of Hypertension
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
 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
 Categories of hypertensive
end-organ damage

Origin Category
Large arteries Loss of compliance
(Dissecting) aneurysm
Peripheral occlusive arterial disease

Kidney Nephrosclerosis

Birkenhger and de Leeuw (1992)

OBAT ANTIHIPERTENSI
Hipertensi & Kerusakan Organ Target

21
 Laboratory Tests
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
Optional tests
Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
 Treatment
Overview
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Classification and management of BP for adults
Followup and monitoring
 Goals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients

with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons >50 years of age.

Sign and Symptoms
Essential HTN is usually
- asymptomatic
- undetected for many years
- headache, BP elevated systolic
beyond 200 mmHg or BP rising
rapidly (can occur in malignant
HTN)
Symptomatic associated with
malignant HTN
Headache
Blurred vision
Chest pain
Breathlessness
Nausea, vomiting
Anxiety, confusion, coma
Seizures
 Consequences of Malignant HTN
End Organ Complications

Aorta Aortic disection

Brain Hipertensive encepahlopathy
Cerebral Infarction or Haemmorharge
Heart Cardiac failure
Myocardial ischemic or infarction

Kidney Renal failure

Haematuria
Gastrointestinal Anorexia,nausea,vomiting,abdominal
pain
Placenta Eclampsia
Other Micro-angiopathic haemolytic anemia
 Consequences of hypertension

Cardiac disease
Left ventricular failure
Angina
Myocardial infarction

Cerebrovascular disease
Transient ischemic attacks
Stroke
Multi-infarct dementia
Hypertensive encephalopathy
Consequences of hypertension

Vascular disease
Aortic aneurysm
Occlusive peripheral vascular disease
Arterial dissection

Others
Progressive renal failure
Hypertensive retinopathy
Risk of Hypertension

Advancing age
Positive family history of premature
cardiovascular disease
Smoking
Hypercholesterolemia
Hypertension is thought to account for :
Onehalf of all deaths due to stroke
Up to one quarter of coronary heart
disease deaths
Isolated Systolic hypertension increase
the risk of :
stroke and coronary heart disease by
about 40%
cardiovascular death by about 50%
heart failure by about 50%
Aetiology of hypertension
Essential hypertension
(primer/idiopathic hypertension
remain uncertain
(genetic and environmental factors
contribute to development of
hypertension)

Secondary hypertension
Secondary hypertension

Renal parenchymal disease, causes :

- the glomerulonephritides
- diabetic nephropathy
- analgesic nephropathy
- adult polycystic kidney disease
Renal artery stenosis
Primary hyperaldosteronism
Phaeochromocytoma
Secondary hypertension
Aortic coarctation
Cushings syndrome
Drug induced hypertension
- the oral contraception pill
- steroids
- NSAID
- immunosuppressive
- sympathomimetics
- anabolic steroids
- erythropoieti n
- monoamin oxidase inhibitors
Thyrotoxicosis
Rare monogenic syndrome
Clinical assesment of hypertension
Sign and symptoms
Pointers to secondary hypertension
Features of malignant hypertension
End organ damage
Hypertensive nephropathy
Left ventricular hypertrophy
Hypertensive retinopathy
 Grades of hypertension retinopathy
Grade Features
I Mild narrowing or sclerosis of the retinal
arteriole, no symptoms,
Good general health
II Venous compression at artriovenous
crossing (A-V nipping) no symptoms,
good general health
III Retinal oedema, cotton wool spots,
hemmorhages, often symptoms
IV All above
Papiloedema,Symptomatic
Cardiac and renal function often
impaired, reduced survival
Treatment
Non Pharmacotherapy
(lifestyle modification)
Pharmacotherapy
Pengobatan

Tujuan:

ANGKA KESAKITAN
KERUSAKAN ORGAN TARGET
ANGKA KEMATIAN
 Sasaran Pengelolaan
Menilai gaya hidup dan identifikasi faktor
risiko kardiovaskular lain atau gangguan
yang menyertai yang dapat
mempengaruhi prognosis & pengobatan
Mengetahui penyebab tekanan darah
yang tinggi
Menilai adanya kerusakan organ dan
penyakit kardiovaskular

40
Strategi Penatalaksanaan
Hipertensi
JNC:
Preventif
Deteksi
Evaluasi
Pengobatan
JNC VI, 1997
Preventif
Untuk mencegah atau memperlambat terjadinya
Hipertensi

Merupakan solusi jangka panjang masalah hipertensi

Mencegah terjadi komplikasi

Dapat menghentikan atau mengurangi biaya

pengobatan dan komplikasi

NHBPEP Working Group Report on Primary Prevention of Hypertension

Preventif

Upaya preventif primer:

Terhadap individu yang potensial
hipertensi:
TD normal tinggi
Riwayat keluarga hipertensi
Obesitas
Konsumsi tinggi garam
Kurang aktifitas
Konsumsi tinggi alkohol

Diharapkan prevalensi Hipertensi turun

Intervensi Preventif Primer
Terbukti Efektif
Efektif terbatas

Turunkan BB Manajemen Stres

Kurangi Garam Kalium
Kurangi Alkohol Minyak Ikan (Fish oil)
Olah Raga Kalsium
Magnesium
Serat
Cegak makronutrien
Deteksi
Dilakukan di fasilitas kesehatan
dengan alat ukur yang standar dan
cara yang benar
Pasien diberitahu tentang makna
TDnya
Pasien dianjurkan melakukan
pemeriksaan periodik sesuai dengan
TD pertama

Diharapkan ditemukan kasus tahap

awal
Evaluasi
Mencari penyebab hipertensi
(sekunder)

Memeriksa adanya kerusakan organ

target dan penyakit lain

Mencari faktor risiko

Mengetahui respon pengobatan, efek

samping dan kepatuhan pasien
 WHO-ISH Guidelines for Management
of Hypertension: Stratification of
Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1 Grade 2 Grade 3
Mild Moderate Severe
hypertension hypertension hypertension
Other risk factors and SBP 140159 SBP 160179 SBP 180
disease history or DBP 9099 or DBP 100109 or DBP 110
I No other risk factors Low risk Med risk High risk
II 12 risk factors Med risk Med risk Very high risk
III 3 or more risk factors High risk High risk Very high risk
or TOD or diabetes
IV ACC Very high risk Very high risk Very high risk

TOD = Target-organ damage Guidelines subcommittee. WHO-ISH

ACC = Associated clinical conditions Guidelines. J Hypertens 1999;17:151-183.
BP TARGETS:

WITHOUT COMPLICATION : <140/80 mmHg

DIABETES : < 130/80 mmHg

CKD : < 130/80 mmHg

PROTEINURIA > 1 g/d : <125/75 mmHg

 Lifestyle Modification
Modification Approximate SBP
reduction
(range)
Weight reduction 520 mmHg/10 kg weight loss

Adopt DASH 814 mmHg

eating plan
Dietary sodium 28 mmHg
reduction
Physical activity 49 mmHg
Moderation of 24 mmHg
alcoholconsumption
Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four or five times per week

I Intensity - Moderate

T Time - 45-60 minutes

Type Dynamic exercise

T - Walking
- Cycling
- Non-competitive swimming

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
Treatment of Hypertension
Diuretic
ACE-Inh
ARB
Beta blocker
Alpha blocker
Direct renin inhibitor
Treatment Algorithm for Adults with Systolic-
Diastolic Hypertension without another
compelling indication

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Long-acting Beta-
Thiazide ACE-I ARB DHP-CCB blocker

Alpha-blocker
as initial
monotherapy
Indications for
Pharmacotherapy
Strongly consider prescription if:
Average DBP equal or over 90 mmHg and:
Hypertensive Target-organ damage (or CVD) or
Independant cardiovascular risk factors
Elevated systolic BP
Cigarette smoking
Abnormal lipid profile
Strong family history of premature CV disease
Truncal obesity
Sedentary Lifestyle

Average DBP equal or over 80 mmHg and

diabetes
 Diuretics

-blockers AT1 receptor

blockers

-blockers Ca Antagonist

ACE Inhibitors

2003 Guidelines for Management of Hypertension, J of Hypertension 2003

C.I. : Verapamil + Blocker ESH-ESC 2003

JNC 7: Management of Hypertension by
Blood Pressure Classification
Initial Drug Therapy
Lifestyle Without Compelling With Compelling
BP Classification Modification Indication Indication

Normal Encourage
<120/80 mm Hg

Prehypertension Yes No drug indicated Drug(s) for the

120-139/80-89 mm Hg compelling indications

Stage 1 hypertension Yes Thiazide-type diuretics Drug(s) for the compelling

140-159/90-99 mm Hg for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Stage 2 hypertension Yes 2-drug combination for most
160/100 mm Hg (usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta
blocker; CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed
 Compelling Indications for
Individual Drug Classes
Compelling Initial Therapy Clinical Trial
Indication Options Basis

Diabetes THIAZ, BB, ACE, NKF-ADA

ARB, CCB Guideline, UKPDS,
ALLHAT
NKF Guideline,
Chronic kidney ACEI, ARB Captopril Trial,
disease RENAAL, IDNT,
REIN, AASK

Recurrent stroke THIAZ, ACEI PROGRESS

prevention
JNC 7 2003
THANK YOU