MANAGEMENT OF

HYPERTENSION
Dharmeizar

Divisision of Nephrology and Hypertension, Dept. Internal Medicine, FMUI -Cipto

Mangunkusumo Hospital
• The prevalence of hypertension = 31.7%
(Riskesdas, 2007); 25.8% (Riskesdas, 2013)

• Increased risk of cardiovascular,

cerebrovascular, and renal events

• BP-target must be achieved

Prevalence of controlled BP J Hypertension 26 (Suppl 4): S1-S14, 2008
Definition and Classification of Hypertension
ESH 2013
Category Systolic (mmHg) Diastolic (mmHg)

Optimal <120 and <80

Normal 120–129 and/or 80–84
High normal 130–139 and/or 85–89
Grade 1 hypertension 140–159 and/or 90–99
Grade 2 hypertension 160–179 and/or 100–109
Grade 3 hypertension ≥180 and/or ≥110
Isolated systolic hypertension ≥140 and <90

JNC 8 (same with classification of JNC 7)

Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-00
Stage 2 hypertension ≥160 or ≥100
Eur Heart J. 2013 Jul;34(28):2159-219
Eur Heart J. 2013 Jul;34(28):2159-219
 Out of office BP measurement

• BP measurements away from the medical

environment  more reliable

• Commonly assessed by HBPM or ABPM

Eur Heart J. 2013 Jul;34(28):2159-219
Initiation of antihypertensive
drug treatment
• Grade 2 and 3 hypertension
• Total CV risk as high (OD, DM, CVD, or CKD)
even grade 1 hypertension)
• Remain grade 1 hypertension with low to
moderate risk after lifestyle
• Elderly with SBP ≥ 160 mmHg
• Younger than 80 years with SBP 140-159 mmHg
and treatment will tolerated

ESH, 2013
Initiation of antihypertensive
drug treatment
• Age ≥ 60 years with BP ≥150/ ≥90 mmHg (grade A)
• Age < 60 years with DBP ≥ 90 mmHg (age 30-59
years = grade A, age 18-29 years= grade E)
• Age < 60 years with SBP ≥ 140 mmHg (grasde E)
• Age ≥ 18 years with DM, without CKD, with BP ≥
140/>90 mmHg (grade E)
• Age ≥ 18 years with CKD, with or without DM, with
BP ≥140/>90 mmHg (grade E)

JNC 8, 2014
Eur Heart J. 2013 Jul;34(28):2159-219
BP Target
• Age ≥ 60 years, BP target < 150/< 90 mmHg
• Age < 60 years, BP target < 140/<90 mmHg
• Age ≥ 18 years, with DM, without CKD, BP target
< 140/ <90 mmHg
• Age ≥ 18 years with CKD, with or without DM, BP
target < 140/<90 mmHg

JNC 8, 2014
Adoption of Lifestyle changes
Recomendations Class a Level b,d Level b,e Ref. c
Salt restriction to 5-6 per day is I A B 339,
recommended 344-
346,351
Moderation of alcohol consumption to I A B 339,
no more than 20-30 g of ethanol per 354,355
day in men and to no more than 10-20 g
of ethanol per day in women is
recommended
Increased consumption of vegetables, I A B 339,356-
fruits, and low-fat dairy products is 358
recommended
Reduction of weight to BMI of 25 km/m2 I A B 339,
and of waist circumference to <102 cm 363-365
in men and < 88 cm in women is
recommended, unless contraindicated
Regular exercise, i.e at least 30 min of I A B 339,
moderate dynamic exercise on 5 to 7 369,373,
days per week is recommended 376
It is recommended to give all smokers I A B 384-386
advice to quit smoking and to offer
assistance
Eur Heart J. 2013 Jul;34(28):2159-219
 Lifestyle Modifications To Prevent and Manage Hypertension
Approximate SBP Reduction
Modification Recommendation
(Range)†
Maintain normal body weight
Weight reduction 5-20 mmHg/10 kg
(body mass index 18.5-24.9 kg/m2).
Consume a diet rich in fruits,
vegetables, and low-fat dairy
Adopt DASH eating plan 8-14 mmHg
products with a reduced content of
saturated and total fat.
Reduced dietary sodium intake to
no more than 100 mmol per day
Dietary sodium reduction 2-8 mmHg
(2.4 g sodium or 6 g sodium
chloride).
Engage in regular aerobic physical
activity such as brisk walking (at
Physical activity 4-9 mmHg
least 30 minutes per day, most days
of the week).
Limit consumption to no more than
2 drinks (eg, 24 oz beer, 10 oz wine,
Moderation of alcohol or 3 oz 80-proof whiskey) per day 2-4 mmHg
consumption in most men and to no more than 1
drink per day in women and lighter
weight persons.
JNC VII, 2003
Antihypertensive drugs
1. Diuretics
2. β-blockers
3. ACE-Is
4. ARBs
5. Calcium antagonists
6. Renin inhibitors
7. Centrally active agents and α-receptor
blockers
Eur Heart J. 2013 Jul;34(28):2159-219
Eur Heart J. 2013 Jul;34(28):2159-219
Treatment strategies and
choice of drugs
1. Diuretics, β-blockers, CCB, ACE-I, and ARB are
suitable and recommended for initiation and
maintenance, as mono or combination
therapy (IA)
2. Some agents considered in specific conditions
(IIC)
3. Two-drug combination may be considered in
high baseline BP or high CV risk (IIC)

ESH, 2013
Treatment strategies and
choice of drugs
4. The combination of the RAS is not
recommended and should be discouraged
(IIIA)
5. Other drug combinations should be considered
and probably are beneficial. Combinations that
have been successfully used in trials may be
preferable (IIC)
6. Combination of two antihypertensive drugs at
fixed dose in a single tablet may be
recommended (IIB)
ESH, 2013
JNC 8, JAMA 2014 Feb 5, 311(5):507-20
JNC 8, JAMA 2014 Feb 5, 311(5):507-20
JNC 8, JAMA 2014 Feb 5, 311(5):507-20
Klasifikasi hipertensi dalam kehamilan
(HDP: hypertensive disorders of pregnancy)

TD ≥ 140/≥ 90 mmHg, pada 2 kali pemeriksaan

pada lengan yang sama dengan jarak waktu
paling sedikit 15 menit
• 1. Preeklamsi – Eklamsi
• 2. Hipertensi kronik (preexisting Hypertension)
• 3. Preeklamsi – Eklamsi superimposed hipertensi
kronik
• 4. Hipertensi Gestasional
Klasifikasi hipertensi dalam kehamilan
(HDP: hypertensive disorders of pregnancy)

• 1. Preeklamsi – Eklamsi
• Preeklamsi adalah hipertensi yang ditemukan pada kehamilan diatas
20 minggu yang disertai oleh proteinuria atau adanya disfungsi organ
target. Tekanan darah pasien pre-eklamsi sebelum 20 minggu
normal. Bila pada pasien tersebut ditemukan juga kejang, maka
disebut eklamsi

• 2. Hipertensi Kronik (preexisting hypertension)

• Bila hipertensi ditemukan pada kehamilan dibawah 20 minggu atau
tetap menetap setelah 12 minggu postpartum, maka disebut
hipertensi kronik
Klasifikasi hipertensi dalam kehamilan
(HDP: hypertensive disorders of pregnancy)

• 3. Preeklamsi-eklamsi superimposed hipertensi kronik

• Ialah hipertensi kronik yang pada perkembangannya memburuk yang
ditandai oleh ditemukannya proteinuria atau tanda-tanda lain dari
preeklamsi seperti peningkatan enzim hati serum, atau penurunan
trombosit darah.

• 4. Hipertensi Gestasional
• Bila ditemukan hipertensi pada kehamilan diatas 20 minggu, tanpa
disertai oleh proteinuria atau tanda-tanda lain dari preeklamsi, maka
disebut hipertensi gestasional.
• Perlu diperhatikan, pada sebagian hipertensi gestasional dengan
berjalannya waktu, akan berkembang menjadi preeklamsi atau
hipertensi menetap setelah postpartum.
Berdasarkan nilai TD, dibedakan atas:

a. Hipertensi Ringan : TDS 140-149 mmHg, dan atau

TDD 90-99 mmHg
b. Hipertensi Sedang : TDS 150-159 mmHg, dan atau
TDD 100-109 mmHg
c. Hipertensi Berat : TDS ≥ 160 mmHg, dan atau TDD ≥
110 mmHg
Pengobatan hipertensi dalam
kehamilan

 Pada hipertensi ringan dan moderat perlu

diperhatikan adanya penyakit komorbid dan
keluhan pasien
 Bila terdapat DM, CAD, LVH, sakit kepala,
gangguan penglihatan  dapat dimulai
pengobatan
 Perlu kontrol secara teratur
www.uptodate.com, 2015
Tatalaksana hipertensi dalam
kehamilan
• PREEKLAMSI
Terapi definitif adalah terminasi kehamilan
Belum ada kesepakatan mengenai berapa nilai
TD untuk memulai terapi dengan obat
antihipertensi
Umumnya pengobatan antihipertensi dimulai
saat TDS ≥ 150 mmHg, dan atau TDD ≥ 100
mmHg. Atau bila terdapat tanda-tanda
keterlibatan otak, dan jantung
Tatalaksana hipertensi dalam
kehamilan
Obat-obat yang digunakan pada preeklamsi:
1. Labetalol
2. Hidralazin
3. CCB
4. Nitrogliserin
J Obstet Gynaecol Can. 2014;307:416-438
J Obstet Gynaecol Can. 2014;307:416-438
Target TD pada preeklamsi

TDS 135-150 mmHg, TDD 80-100 mmHg

Penurunan MAP tidak melebihi 25% dalam 2
jam pertama, setelah itu perlahan-lahan
diturunkan dengan target TD 135-150/80-100
mmHg
Tatalaksana hipertensi dalam
kehamilan
• HIPERTENSI KRONIK

• Hipertensi ringan (TD <150/100 mmHg) tanpa kerusakan organ

target tidak diberikan obat antihipertensi oleh karena risiko pada
ibu dan fetus tidak bertambah

• Hipertensi sedang (TD < 150-159/100-109 mmHg) = belum jelas

apakah terjadi peningkatan risiko pada ibu dan fetus

• Bila TD ≥160/ ≥ 110 mmHg, diberikan obat antihipertensi

Target TD pada hipertensi kronik

Tanpa kerusakan organ target = 140-150 / 90-110

mmHg
Dengan kerusakan organ target = < 140/90
mmHg
J Obstet Gynaecol Can. 2014;307:416-438
J Obstet Gynaecol Can. 2014;307:416-438