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Curiculum Vitae

Nama : Dr.dr.Hasyim Kasim SpPD,KGH,FINASIM

Tempat/Tgl Lahir : Makassar 24 oktober 1959

Keluarga: seorang Istri, 2 putri/2 putra

Pendidikan : SD-SMA makassar,FKUH 1987,SP2 interna 1996, S3.

2013

Jabatan: -

Direktur penunjang medik RSUH

Ketua Divisi Ginjal Hipertensi Dep.Penyakit Dalam

Koordinator pendidikan SP 1 Penhy.Dalam

Sekertaris Alumni FKUH

Pengurus IDI wilayah Sulsel bidang Hukum

Ketua Alumni FKUH angkatan 1979/Dapur seni

Ketua PAPDI sulsel

Pengurus PERDOKHI

Management Hipertensive in

Primary Care

Hasyim Kasim

Introduction

Hypertension is a major health problem throughout the

world because of its high prevalence and its association

with increased risk of cardiovascular disease the prevalence of hypertension averages 26%

The higher the blood pressure, the greater the chance of

myocardial infarction, heart failure, stroke and kidney

disease

Individuals who are normotensive at age 55 years have a 90% lifetime risk for developing hypertension

For individuals aged 4070 years, each increment of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic

blood pressure doubles the risk of cardiovascular disease

Hypertension
Hypertension

Common, Responsible for the majority of

office visits Number one reason for drug prescription

Simple and cheap detection

Established treatment

Significant preventable outcomes

Observational studies suggest detection & treatment suboptimal

Health care professionals should know the blood pressure of all

of their patients and clients.

To screen for hypertension To assess cardiovascular risk To monitor antihypertensive treatment

Health care professionals should know the blood pressure of all of their patients and clients. •

Office Blood Pressure Measurement

Correct methods for office blood pressure measurement

Before measurement

Timing

  • 1 Avoiding coffee food, smoking, decongestants

hour

30 minutes

Avoiding exercise

  • 5 Sitting calmly

minutes

During measurement

Body position

Seated, back supported, legs uncrossed, feet flat on floor, and relaxed

Arm

Supported, using the arm higher value

Cuff

At heart level, using appropriate sized one

Measurement

Taking two measurement, spaced 1-2 minutes apart, and additional maesurement if needed,

For initial readings, take the blood pressure in both arms and

subsequently measure it in the arm with the highest reading

Other

No talk during the procedure, No acute anxiety, stress or pain, Bladder and bowel

comfortable, No tight clothing on arm or forearm, Quiet room with comfortable

temperature, Patient should stay silent prior and during the procedure

Blood Pressure Assessment:

Patient position

X
X
Blood Pressure Assessment: Patient position X

Health consequences of high blood pressure may include

Coronary artery disease Heart attack Heart disease Congestive heart failure Stroke Kidney damage Vision loss Erectile dysfunction in males

The common risk factors for hypertension include the following

Family history of high blood pressure

Poor diet and having too much salt in your diet History of smoking and second-hand smoke

exposure

The common risk factors for hypertension include the following • Family history of high blood pressure

Drinking too much alcohol

Lack of physical activity Having diabetes Being overweight or obese

African American race

What are the symptoms of hypertension?

normally will not experience symptoms.but Severe headache Nosebleeds/epstaxix Changes in vision Nausea or vomiting Shortness of breath Confusion Chest pain

Blood pressure can be measured via the following methods

1) Manually,

2) with an automated machine, 3) Ambulatory blood pressure monitoring,

4) Home blood pressure monitoring.

Ambulatory blood pressure monitoring is indicated in

Suspected white-coat hypertension Apparent drug resistance

Hypotensive symptoms with antihypertensive medication

Episodic hypertension Autonomic dysfunction

Manual blood pressure measurement

  • 1. Check the condition of the device and the cuff size to ensure the reading is accurate.

  • 2. Make sure patient is relaxed and has been seated comfortably for 5 minutes in a chair (not exam table) with feet on the floor and arm supported at heart level.

  • 3. Have the patient relax and sit with their arm slightly bent on the same level as

their heart and resting comfortably on a table or other flat surface.

  • 4. Place the inflatable blood pressure cuff securely on the upper arm (approximately one inch above the bend of the elbow).

  • 5. Close the pressure valve on the rubber inflating bulb, and pump the bulb rapidly to inflate the cuff.

  • 6. If using a stethoscope, place the earpieces in your ears and the bell of the stethoscope over the artery, just below the cuff.

  • 7. Now slowly release the pressure by twisting or pressing open the pressure

valve, located on the bulb. Listen through the stethoscope and note on the dial

when you first start to hear a pulsing or tapping soundthis is the systolic blood pressure.

History

Physical Examination

Recommended diagnostic testing

12 lead electrocardiogram

Complete blood count

Basic metabolic profile (serum sodium, potassium, creatinine with estimated/measured glomerular filtration rate, calcium)

Lipid profile (total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, triglycerides) after 9 to 12 hour

fast

Fasting blood glucose or Hemoglobin A1c

Thyroid-stimulating hormone (TSH)

Urinalysis

Urinary albumin excretion or albumin/creatinine ratio

Chest X-ray

Heart Echocardiogram

Heart Echocardiogram

The classification of blood pressure and hypertension WHO-ISH, WSH-ESC, BSH, JNC-7

WHO-ISH, ESH-ESC,

BP

 

BP

JNC VII

 

BSH BP Classification

(mmHg)

(mmHg)

Bp Classification

Optimal

<120 / <80

 

<120/<80

Normal

 

Normal

120-129 / 80-84

 

120-129 /80-84

Prehypertension grade 1

 

High normal

130-139 / 85-89

 

130-139 / 85-89

Prehypertension grade 2

 

Grade 1 Hypertension (mild)

140-159 / 90-99

 

140-159 / 90-99

Stage 1 Hypertension

 

Grade 2 Hypertension

160-179 /100-

 

>160 / >100

Stage 2

 

(moderate)

109

Hypertension

Grade 3 Hypertension

> 180 / >110

 

(severe)

Isolated Systolic Hypertension

> 140 /

 

< 90

Isolated Systolic Hypertension

 
     

Stages of hypertension

A meta-analysis of prospective observational studies found a direct correlation between

CVD deaths and SBP down to a threshold of

115 mm Hg .

As many as 39% of male and 23% of female patients have an SBP between 130 and 139

mm Hg and are at increased risk of developing

HTN

Interview guide to assess medication adherence

Actions to Improve Medication Adherence

Blood pressure treatment goals based on

patients age, DM , and CKD status

**Adapted from the 8th report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

a Recommendation informed by the following trials: HYVET, Syst-Eur, SHEP, JATOS, VALISH, and CARDIO-

SIS.6-11

b Recommendation informed by the following trials: HDFP, Hypertension-Stroke Cooperative, MRC,

ANBP, and VA Cooperative.12-17 c Recommendation informed by the following trials: SHEP, Syst-Eur, UKPDS, and Accord-BP. 18-21

d Recommendation informed by the following trials: AASK, MDRD, and REIN-2.

lifestyle modifications

Lifestyle Recommendations for Hypertension: Dietary

High in:

Fresh fruits Fresh vegetables • Low fat dairy products • Dietary and soluble fibre Plant protein

Dietary Sodium

Less than 2300mg / day

(Most of the salt in food is hiddenand comes from processed food)

Dietary Potassium

Daily dietary intake >80 mmol

Low in:

Saturated fat and cholesterol Sodium

No conclusive studies for hypertension Calcium supplementation
No conclusive studies for hypertension
Calcium supplementation
No conclusive studies for hypertension Magnesium supplementation
No conclusive studies for hypertension
Magnesium supplementation

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

F

I

T

T

Frequency

- Four to seven days per week

Intensity

- Moderate

Time

- 30-60 minutes

Type

Cardiorespiratory Activity

  • - Walking, jogging

  • - Cycling

- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

Non-pharmacological Treatment
Non-pharmacological Treatment
Non-pharmacological Treatment Intervention Expected systolic blood Pressure reduction (range) Weight Reduction Maintain ideal body mass index

Intervention

Recommendation

Expected systolic blood Pressure reduction (range)

Weight Reduction

Maintain ideal body mass index (20-23 kg/m 2 )

5-10 mmHg per 10 kg

weight loss

DASH eating plan Consume diet rich in fruit, vegetables,

8-14 mmHg

low-fat dairy products with reduced

All put together reduce SBP by

content of saturated and total fat

Dietary sodium restriction

Reduce dietary sodium intake to

20 to 55 mmHg

<100 mmol/day (<2.4 g sodium or

<6 g sodium chloride)

2-8 mmHg

Physical Activity

Engage in regular aerobic

physical activity

4-9 mmHg

Alcohol

moderation

Men < 21 units per week Women < 14 units per week

2-4 mmHg

BP Treatment Initiation Algorithm for Adults < 60 years

The two drug initiation therapy strategy involves initiating therapy with two different antihypertensive drugs, either as 2 separate

drugs or a single pill combination. When considering adding additional medications, begin adding from within the

four classes of first-line medications:

thiazides, ACEI, ARBs, and CCB.

Consider secondary causes of hypertension if patient requires more than three antihypertensive medications from three different classes.

Refer to Appendix A for evaluation of secondary causes of hypertension.

Management of secondary causes of hypertension should be coordinated with the

primary care provider and appropriate specialist.

Strategies to Dose Antihypertensive Drugs

Initiating Pharmacologic Therapy

First visit.

(1)

  • 1. Patients with SBP ≥180 mmHg and/or DBP ≥110 mmHg, with or without macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD (GFR<60 mL/min/1.73 m2) require immediate management (non- pharmagological & pharmacological treatment)

  • 2. If SBP is between 160179 mmHg and/or DBP 100109 mmHg with macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD (GFR<60 mL/min/1.73 m2) require immediate management (non- pharmagological & pharmacological treatment)

  • 3. If SBP is between 160179 mmHg and/or DBP 100109 mmHg, without

macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD (GFR<60 mL/min/1.73 m2) a second visit within 1-2 week should be scheduled

for confirmation of HTN. Non-pharmacological treatment should be initiated.

  • 4. If average BP levels is within stage 1 range, a second visit within 3-4 weeks should be scheduled for the assessment of HTN. Non-pharmacological treatment should be initiated.

Criteria for Diagnosis of Hypertension (2)

Second Visit.

  • 1. Patients with macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD (GFR<60 mL/min/1.73 m2) if SBP is ≥140 mmHg and/or DBP is ≥90 mmHg, pharmacological treatment should be initiated

  • 2. Patients without macrovascular TOD, DM, or CKD and SBP is between ≥140159 mmHg and/or DBP ≥90–99 mmHg, third visit within 2-4 week should be scheduled for confirmation of HTN

Third Visit

  • 1. If SBP is ≥140 mmHg and/or DBP is ≥90 mmHg, pharmacological treatment

should be initiated.

Commonly used hypertension medications

Aspects of the treatment plan that should be emphasized with the

patient

The unique role of each drug

The importance of taking the drug as directed and making sure that they are refilled

How often the drug should be taken

Aspects of the treatment plan that should be emphasized with the patient • The unique role

When to

avoid taking the drug (e.g., before a meal, with other medications, etc.)

Any possible side effects Suggest ways to manage side effects

Emphasize danger of not taking medications as prescribed

Address possible adherence issues that may arise

Pertinent lab tests to order at follow-up

Indications and contraindications of antihypertensive drugs

Indications and contraindications of antihypertensive drugs Shin et al. Clinical Hypertension (2015) 21:2
Considerations in the individualization of antihypertensive treatment
Considerations in the individualization of antihypertensive
treatment
Considerations in the individualization of antihypertensive treatment
Considerations in the individualization of antihypertensive treatment
Considerations in the individualization of antihypertensive
treatment
Considerations in the individualization of antihypertensive treatment
Considerations in the individualization of antihypertensive
treatment
Considerations in the individualization of antihypertensive treatment

Resistant Hypertension

Blood pressure that remains above goal (<140/90

mmHg in non-complicated patients & <130/80 mmHg in

high risk patients) in spite of the concurrent use of of three antihypertensive agent of different classes

Ideally, one of the three agents should be diuretic and

all agents should be prescribed at optimal dose

amounts

Includes patient whose blood pressure is controlled with use of more than three medications

In a compliant patient

Refer/consult with appropriate specialists when necessary.

Initial systolic BP ≥ 180 Initial diastolic BP ≥ 110

Abnormal lab results Total cholesterol ≥ 200 LDL cholesterol ≥

130 or ≥ 100 in a patient with diabetes HDL ≤ 40 Triglycerides

≥ 200 Creatinine ≥ 1.4 for women or ≥ 1.5 for men

Potassium ≤ 3.5 mEq or ≥ 5.5 mEq

Positive microalbuminuria

Extreme complications/side effects of therapy.

Patient does not respond to therapy.

Patient is pregnant.

Patient is ≤ 18 years old.

Patient has an abnormal ECG.

Patient has any abnormal physical examination findings.

Suspect secondary causes of HT

Abrupt onset of symptomatic hypertension Stage 2 hypertension Hypertensive crisis Sudden loss of blood pressure control after many years of stability on drug therapy Drug resistant hypertension Individuals with no family history of HT

Differential diagnosis for secondary causes of HT

Guidelines for the physician to improve antihypertensive drug compliance

Educate the patient about hypertension and its treatment with clear

and accepted goals. Need to continue treatment, control does not mean cure, one cannot tell if BP is elevated by feeling or symptoms-> BP must be measured

Keep the treatment as simple and cheap as possible (using long-acting once-daily dosing) with written information.

Combine efficient and well tolerated drugs in the same pill (fixed-dose combination)

Treat to target.

Lifestyle modifications are effective in preventing HT,

treating hypertension and reducing cardiovascular risk.

Combinations of both lifestyle changes and drugs are generally necessary to achieve target blood pressures